On femoral rupture its anatomy, pathology, and surgery, with a new mode of operating, applicable to cases of strangulated herniae generally / [John Gay].

  • Gay, John, 1813-1885.
Date:
1848
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Licence: Public Domain Mark

Credit: On femoral rupture its anatomy, pathology, and surgery, with a new mode of operating, applicable to cases of strangulated herniae generally / [John Gay]. Source: Wellcome Collection.

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    deep thin edge of the crural arch, and the first portion of Gimbernat’s ligament, and the sheath of the vessels ; and may well be considered as the deep crural arch.” * (h)—Some delicate areolar tissue separates and assists in distinguishing these layers of the iliac fascia lata; and a considerable branch of the anterior crural nerve is seen. * For reasons which I am about to adduce, I believe that this ligamentous band, and not the falciform process of the fascia lata and its fibrous appendage, is the structure to which Mr. Hey directed especial attention, and termed the “ Femoral Ligamentat all events, that its importance demands for it a distinct recognition as such. In the Appendix to Part I. of a “ System of Dissections,” published by Mr. (afterwards Sir Charles) Bell in 1799, the existence of this structure was pointedly referred to; and in a second edition of that work in 1810, that acute anatomist gave a more definite account of it under the appellation of “ the Femoral Ligament,” a term which Mr. Hey had in the meantime given it. After a rather confused description of the sheath of the femoral vessels. Sir Charles says, “ The dissector endeavouring to push his finger up into the belly by the inside of the vessels of the thigh, feels the sharp edge of a ligament; and when he pushes his finger deep, and again withdraws it, the circular edge of this ligament can be seen.”—(Op. cit. p. 7.) And in a Clincical Lecture in 1832, published in the Medical Gazette, vol. x. p. 748, Sir Charles further says, in allusion to the operation for femoral rupture, “ All you divide is just the sharp edge of that tendinous arch which stretches across the upper part of the neck of the sac.” Mr. Hey was, however, the first to assign that amount of importance to this ligament, which has since been allowed most justly to belong to it. But as Mr. Hey does not appear to have insulated that structure, and thus to have gained a knowledge of its seat and relations sufficiently exact to render his account of it clear to other minds, some misapprehension appears to have arisen, and the terms “ the Femoral Ligament,” and “ Hey’s Ligament,” have been employed to designate parts, to which, in my opinion, they were not originally intended to apply. Mr. Hey says, “About three-eighths of an inch below Poupart’s ligament, there exists in the aponeurotic sheath (of the femoral vessels) another ligament, somewhat similar to Poupart’s, but smaller. It runs transversely, but does not descend obliquely, as this ligament does. On the contrary, it rather ascends as it approaches the symphysis of the ossa pubes, passing behind and decussating Poupart’s ligament.” Again, Mr. H. describes it as “formed in the fascia of the thigh, on the anterior layer of the aponeurotic sheath of the great vessels.” These descriptions cannot in any way be made to apply to the falciform process, or its edge, which neither exist “ in the aponeurotic sheath,” nor at the distance of “ three-eighths of an inch below Poupart’s ligament.” Mr. Hey further states, that “ a prolapsed intestine w'ould receive very little pressure from Poupart’s ligament in comparison of that which it must suffer from this inferior ligament, the structure and situation of which account clearly for the peculiar phenomena of femoral hernia.” (P. 154.) Now, if the falciform process be the ligament to which Mr. Hey alludes, the reverse of this statement in reference to the comparative amount of pressure which that and Poupart’s ligament would have to sustain, is nearer the truth. But it is not a little marvellous, that the reference to this strueture in Sir A. Cooper’s work, and particularly the note by which it is accompanied, did not have the effect of obtaining for Mr. Hey’s exposition a more critical examination, especially as the deeper and more subtle parts of the anatomy of femoral hernia were at that period engrossing the attention of some of the best surgeons. If sueh had been the case, I feel persuaded the views of the “ Femoral Ligament” of Hey, that now prevail, would not have been adopted. Sir A. Cooper has presented us with an account of this ligament, such as he gained as well from his own dissections, as from a conversation which he had respecting it with Mr. Hey; not having been, apparently, satisfied either with Mr. H.’s published account of it, nor with the plate by which it was meant to be illustrated. Sir Astley describes it as composed of a jiart of the falciform process, but adds in a note, that Mr. Hey “ did not mean to confine the term ‘ femoral ligament’ to the outer fascia alone, but extends it to the portion of the sheath behind the crural arch.—(Gp. cit. Lond. 1807, Part II., p. 2.) In the very masterly edition of that work by Mr. Key, it is still more definitely noticed “ as a