Lectures on Hernia and its Radical Cure
Authors: J. Wood
Journal: BMJ (1885)

Antatomy.-Varieties.-Tavis.-Operationfor Radical Cure.--Choice of Cases.-Review of the variouts MIethods of Attempting a Radical Citre of Hernia in Ancient and Modern Timnes.-Classifica-tion of Cases for Selection of Operation.-Conclusion.Anatomy of Crural Hernia.-In the hollow of the groin below the inner extremity of Poupart's ligament, and forming, with the deep and superficial abdominal rings, an inverted triang,le, of which it is the apex, lies the saphenous opening.Formed by the separation of the fascia lata into two layers, of which the outer or iliac part is advanced forwards by its attachment along the whole length of Poupart's ligament, and the inner or pubic portion, covering the sloping surface of the adductor and pectineus muscles, is attached to the pectineal line, and continued behind the sheath of the femoral vessels to be continuous with the ilio-psoas fascia, and connected with the capsule of the hip-joint; the saphenous opening presents an oval outline, looking forwards and a little dowvn- wards and inwards.The outer border curves sharply inwards in a falciform manner, lies in front of the femoral vessels, and is attached to and blended with Gimlbernat's ligament by a process about half an inch wide, Hey's ligament, important to surgeons, because it crosses the upper part of the crural canal, and may be the seat of strangulation.Below, the falciform edge passes under the saphena vein, which curves over it to join the common femoral vein, receiving, as it does so, the veins which accompany the superficial branches of the common femoral artery, nlamely, the two external pubic, the epigastric, and the circumflex iliac.The first two pass inwards, the next upwards, and the last outwards.They supply the numerous lymphatic glands which lie in two groups in this situation, the upper directed obliquely along Poupart's ligament above and invested by Scarpa's fascia, and the lower lying parallel and internal to the saphena vein.Nearly all the afferent ducts of these glands pass in a body through the saphenous opening, the inner part of the femoral sheath, and the crural ring, to join the deep iliac and lumbar glands.The saphenous opening is covered in by a layer of fascia connected with its borders, called, from the numerous holes which transmit these lymphatics and some of the vessels, the cribriform fascia.This is blended, superficially, with the deep layer of superficial fascia of the thigh, and, deeply, with the inner part of the sheath of the femoral vessels.By detaching Hey's ligament from Poupart's, and turning down the fascia lata and cribriform fascia, the sheath of the femoral vessels is brouaht to view.It is arranged in three compartments ; the outer for the common femoral artery, the middle one for the vein, and the inner one, smaller and funnel-shaped, is filled upi by the afferent lymphatic ducts.On clearing these, it is found that they are held in position by a thin horizontal layer of perforated fascia containing, a lymphatic gland, derived from, and continuous with, the subperitoneal fascia and fat of the iliac fossa, attached externally to the strong longitudinal septum, covering and protecting the femoral vein, and, internally, to Gimbernat's ligaments.This is the septum crurale of Cloquet, and is of little or no surgical importance.It the finger be pushed upward i4to the iliac fossa, it will pass through the crural ring.Arching over it, in front, will be felt a curved border, formed by the union of the fascia transversalis with the deep fibres of Poupart's ligament, the deep crural arch.This is the usual seat of strangulation in crural hernia.Outside is the femoral