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Branches of Posterior Division of Femoral Nerve-stock-foto
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Anatomical Illustration of Obturator Canal-stock-foto
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. American practice of surgery ; a complete system of the science and art of surgery . may contain either 604 AMERICAN PRACTICE OF SURGERY. omentum or intestine. Cases are reported in which the hernial sac containedthe tubeS; ovaries, or the bladder. Diagnosis.—On account of the small and deeply buried sac the diagnosisof obturator hernia may be difficult or impossible except when strangulationoccurs. Palpation may give negative results except when made bimanuallythrough the vagina or the rectum. With the bladder and rectum previouslyemptied it is possible to detect a cord-like mass leading do-stock-foto
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. Abdominal hernia : its diagnosis and treatment. Operation for the cure of conj^ential lumbar hernia (Z.Ji/rf).—Flap composed of fascialata and aponeurotic part of gluteus maximus and medius. Stitches placed for suturing thisflap to the lumbar-fascia, to the external oblique muscle and to the latissimus dorsi muscleand for drawing the upper parts of the latissimus dorsi and external oblique together. Obturator Hernia.—Obturator hernia presents as anobscure, deep-seated swelling upon the thigh, below Scarpastriangle. It is rarely recognized until strangulation hasoccurred or until after death-stock-foto
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. The anatomy and surgical treatment of hernia. reserved. 20. Ramus of the pubis. 21. Nutritive vessels separated from the fem-oral vessels. 22. Obturator vessels and nerves seen behindthe posterior aponeurosis of the sheath. J. Muscular sheath of the first abductor. 2j, 2j. Nutritive vessels freed from the fem-oral artery. 24. Nerve branch of the same muscle fur-nished by the obturator. 2j. Trunk of the obturator nerve seen throughfrom behind the posterior sheath. K. Superior extremity of the layer of the vastusinternus. L. Superior extremity of the sartorius. jM. Aponeurosis of the anterior-stock-foto
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. The anatomy and surgical treatment of hernia. imbernats ligament as it passes tothe obturator foramen, and when this occurs it is very likely to be divided in theoperation for a strangulated femoral hernia. A delicate layer of connective tissue closes the femoral ring, and is described byM. Cloquet as the septum crurale. It is a slight protection to a hernial protrusion ; asmall lymphatic gland usually lies between it and the peritontEum. It is perforated bynumerous small openings for the passage of lymphatic vessels, and serves as much fortheir connection and support as for closure of the r-stock-foto
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. The anatomy and surgical treatment of hernia. ision inward is the very fre-quent disposition of the obturator artery, which oftenembraces very closely the neck of the sac upon theinner side. The division of this artery would beserious, because of the difficulty of securing it thusdeeply situated. However, it has frequently happened in my ex-perience that it seemed the wise procedure to divideonly the fibers of Gimbernats ligament, and it is oftensurprising to note that the division of a few of thesefibers is sufficient to double the capacity of the ring,and thereby liberate the imprisoned co-stock-foto
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. The anatomy and surgical treatment of hernia. l tumor is exceptional. Mr. Birkett, who has especially studied the subject, writes:* After passing alongthe obturator canal, the hernial tumor emerges upon the thigh, below the horizontalramus of the pubes to the inner side of the capsule of the hip-joint, behind and a little tothe inner side of the femoral artery and vein, and to the outer side of the tendon of theadductor longus. The tumor formed by the protrusion is covered by the pectineusmuscle. It may be distinguished, therefore, from crural hernia, by observing the relativepositions of th-stock-foto
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. The anatomy and surgical treatment of hernia. OBTURATOR, OR HERNIA OF THE FORAMEN OVALE. 155 In those cases in which either a fullness, slight hardness, tumefaction, or swellingexists, coupled with well-marked indications of obstruction or strangulation in somepart of the alimentary tube, the difficulty of diagnosis is not so very great; but howmuch embarrassment arises when those symptoms which betoken strangulated bowelexist and a tumor is nowhere to be felt, let the numerous cases on record attest inwhich the rupture has only been found after death! PLATE XLIII* Hernia of the Foramen Oval-stock-foto
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. The anatomy and surgical treatment of hernia. o the bone; and below, appeared the muscles and ligaments of the pelvis. PLATE XLV* Gives an internal view of the ischiatic hernia from Dr. Joness patient. The preparation is in theanatomical collection at St. Thomass Hospital. a. Section of the pubes. m. Obturator artery, which may be traced be- b. Spinous process of the ilium. fore the sac as far as the obturator foramen. c. Sacrum. n. Internal iliac vein. d. Iliacus internus muscle. o. Obturator vein passing behind the hernia e. Psoas muscle. to the obturator foramen, from which another/. Pyri-stock-foto
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. The anatomy and surgical treatment of hernia. ^^ay-sa^^. OBTURATOR, OR HERNIA OF THE FORAMEN OVALE. 159 Figure i. Thyroideal hernia. a. Symphysis pubis. b. Spine of the ilium. c. Abdominal muscles. d. Acetabulum. e. Tuberosity of the ischium. /. Ligament of the obturator, or thyroid fora-men. g. Crural artery. h. Artera circumflexa ilii. /. Spermatic vein. k. Obturator artery. /. Inguinal hernia drawn aside. m. Thyroideal hernia situated just behind thepubes. Figu7-e 2. Posterior view of the same preparation. a. Symphysis pubis. b. Tuberosity of the ischium. c. Sacro-sciatic ligaments. d. L-stock-foto
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. Surgery, its principles and practice . ports 366cases, of which 46 were hernia of the tube, without the ovary; 80, herniaof the ovary and tube; 176, hernia of the ovary without the tube or latternot mentioned; 43, hernia of the non-gravid uterus; 30, hernia of thepregnant uterus. Of the 46 cases of hernia of the tube without the ovary, 27 were ingui-nal and 14 femoral, 2 obturator, and in 3 the variety is not stated. The ages of the patients ranged between birth and forty-six years. Seventeen of the 27 cases of inguinal hernia recovered after operation;3 died. In 5 the hernia was found post--stock-foto
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. Surgery, its principles and practice . ped,the treatmentis limitedpractically tothis condition.It is wise tofirst make anincision in the femoral region and attempt to reduce the hernia by slightlyenlarging the obturator opening. This must be done with extreme care, andthe nicking or cutting of the opening should be made in an upward andinward direction to avoid injury to the obturator vessels which usually liejust to the outer side of the sac. In cases in which resection is necessary,it is better to do a median abdominal section, and after carefully pro-tecting the rest of the abdominal cavi-stock-foto
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. Surgery, its principles and practice . Fig. 66.A bony pelvis in which the obturator membrane (6) has been left in theright obturator foramen. The membrane entirely fills the foramen, withthe exception of an opening (a) which is designated as the obturator canal.It is through this opening that the obturator hernia escapes, the obturatorvessels and nerve being pushed to one side (Sultan). OBTURATOR HERNIA. 97. femoral and some cases of inguinal hernia, and recently employed in ob-turator hernia by Schwartzschild. Schwartzschild has lately used thismethod in a case of obturator hernia, strangul-stock-foto
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. Surgery, its principles and practice . essels. The ihe method OI operation m the cured sac of the obturator hernia has been !• .... • -< fi 1 opened and an intestinal coil is seen cases was: femoral incision m 13; lap- within. «, Pouparts ligament; 6, iiio- arotomy in 3; a combination of both Efrra^vliiT e, i^rmaLSl methods in one. An artificial anus was T^,,^i^l,^L£^^^Z.^^^-, estabhshed in 4 with 4 deaths; intestinal f obturator membrane; fc, adductor longus; /, lower stump oi the pectineus resection was done in 5 cases with 1 re- muscle.CO very. With regard to the diagnosis of obtura-stock-foto
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A system of surgery : theoretical and practical . atter escapes from the pelvis behind the horizontalramus of the pubes, and therefore Gimbernats ligament and the crural aperture canbe felt. The elevation of the integuments produced by an obturator hernia iscertainly in the locality of the crural apeiture; but the depth of the tumour isits striking feature, and the facility with which the crural aperture can be felt ispathognomonic of the relations of the protrusion. Crural hernia requires to be distinguished from other diseases which occur in thesame region. 1. From psoas abscess.—The history-stock-foto
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The practice of surgery . pon the mass and follow it up intothe sciatic notch in order to reduce and cure it. OBTURATOR HERNIA About 200 cases of obturator hernia have been reported. Thesehernise are found chiefly in old women, and are often associated withhernise in other regions. They appear as swellings at the upper por-tion of the adductor longus, internal to the femoral vessels. Make theexamination with the thigh flexed, adducted, and rotated outward.The diagnosis is not easy. The hernia has never been operated uponhitherto except when strangulated. The results of operation are un-favorab-stock-foto
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Operative surgery . are, within, Gimber-nats ligament, and without, the femoral vein (Fig. 1117), surrounded by its sheath. Throughout the course of thisthe femoral vein lies at the outerside. The distinctive coverings of thisprotrusion are the cribriform fascia,crural sheath, and septumcrurale. The importantvascular relations are thoseof the femoral vein andthe obturator artery. Taxis should be em-ployed with greater cau-tion and for a shorter timein femoral than in ingui-nal hernia, since the con-stricting influences aregreater, and the neck ofthe sac much smaller inthe former. The fact, is-stock-foto
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Operative surgery . e relations of the wound tothe dorsal position of the patient. The Results.—A general death rate of about 5U per cent follows opera-tions for strangulation. If prompt ac-tion be taken a much better outlook thanthis may be expected. Strangulated Obturator Hernia (Fig.1122).—The viscus in this instance fol-lows the course of the obturator vesselsin its escape from the pelvis, and liesbeneath the pectineus and obturatormuscles. It is usually small and maynot be detected during life. The incision for its relief is made overthe tumor at the inner side of and parallelto the femor-stock-foto
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Operative surgery . Fig. 1122.—The relation of an obtura-tor hernia to the obturator mem-brane and vessels, and to the bone. 914 OPERATIVE SURGERY. foramen, it will require much caution to divide it without implicating thesevessels. Abdominal section has been practiced in many instauces of relief. The Results.—The death rate is about 80 per cent with surgical treat-ment, owing, no doubt, to delay in detection and diagnosis. Strangulated ventral hernia is treated not unlike that of umbilical.Strangulated lumbar (Fig. 1123), ischiatic (Figs. 1124 and 1125), perineal, and diaphragmatic hernitB (p-stock-foto
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A text-book of clinical anatomy : for students and practitioners . Fig. 78.—Location of various forms of abdominal hernia; (diagrammatic). U,Umbilical hernia. D, Direct inguinal hernia. B, Indirect incomplete inguinal hernia.O, Complete or scrotal inguinal hernia. F, Femoral hernia. 241. - *.-*¥& Fig. 79.—View of inner aspect of anterior wall of abdomen to show internal orifices ofinguinal, femoral,, and obturator hernias. DA, Deep epigastric artery. E, Middle in-guinal fossa, corresponding externally to external abdominal ring. A direct inguinalhernia passes directly outward through this de-stock-foto
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A text-book of clinical anatomy : for students and practitioners . communicates with the joint. Pusfrom the hip-joint may escape through the anterior part of the capsulebetween the deep muscles here toward the surface. The head of thefemur cannot be felt except in very emaciated individuals. Just beneath the pectineus muscle is the obturator opening, throughwhich the obturator nerve and vessels emerge from the pelvis. Throughthis gap in the membrane closing the obturator foramen a hernia (seeFig. 79) may form and be very difficult to diagnose. The distributionof branches to the head of the bon-stock-foto
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Annual and analytical cyclopaedia of practical medicine . udes.The common forms are: inguinal, fem-oral, iimhiUcal, and ventral. The rareforms: diaphragmatic, lumbar, obturator,ischiatic, pudendal, perineal, properito-neal, and retroperitoneal. Distinction is often made between ex-ternal hernia, including all the varietiesabove mentioned, and internal hernia, bywhich latter is meant the protrusion ofa viscus through some anomalous pouchin the peritoneum. Surgical Anatomy.—A hernia consistsof a sac, the coverings of the sac, andcontents. The sac is always a prolon-gation of the parietal periton-stock-foto
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Annual and analytical cyclopaedia of practical medicine . 446 IIKIIXIA. KARE FORMS. HERPES. Winckel, who found 6 cases in 5600patients examined by him, recommendsa radical operation through the perinealtissues. Obtueatoe IIerxia.—This is a rarevariety of hernia, which protrudesthrough the obturator foramen betweenobturator externus and pectineus, push-ing before it the obturator fascia. Thefemoral artery and vein pass externallyand in front of it, the adductor longusforming the opposite wall. The obtura-tor artery and vein may lie to the inneror outer side of the hernia, especially feature, in-stock-foto
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. Modern surgery, general and operative. stricted bowel within it has been forced throughthe internal ring. By reduction en bissac is meant the forcing of a congenitalhernia into a congenital pouch or diverticulum. Reduction en masse is a rareaccident. Corner and Howitt (Annals of Surgery, vol. xlvii) collected 137cases of reduction en masse of strangulated hernia. Of these, no were males,113 were inguinal, 22 femoral, and 2 obturator hernia. No ventral or umbilicalcases are recorded. The accident is a very dangerous one.According to Corner and Howitt (Ibid.), the mortalityafter inguinal reduc-stock-foto
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. The anatomy and surgical treatment of abdominal hernia. IT French, del. inndalrs Llth EXPLANATION OF PLATE XIX. 413 q. Common trunk of the epigastric and obturator arteries. r. Obturator artery passing before and on the inner side ofthe neck of the sac, in its course to the obturator fora-men, and situated a little above the posterior edge of theexternal oblique muscle. s. Epigastric artery. An engraving of this preparation has been published in an in-genious Thesis on Crural Hernia, by Dr. James Sanders, Edin-burgh, 1805. PLATE XX. Shows three umbilical herniae, one of which is curious on a-stock-foto
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. The anatomy and surgical treatment of abdominal hernia. valis.)A view of a perineal hernia in the possession of Mr. Cutcliffe, of Barn-staple. Also a hernia congenita in the female, and a crural hernia sentme by Mr. Allan Burns, surgeon, of Glasgow. Fig. 1. Thyroideal hernia. a. Symphysis pubis. b. Spine of the ilium. c. Abdominal muscles. d. Acetabulum. e. Tuberosity of the ischium. /. Ligament of the obturator, or thyroid foramen. g. Crural artery. h. Artera circumflexa ilii. i. Spermatic vein. k. Obturator artery. /. Inguinal hernia drawn aside. m. Thyroideal hernia situated just behind t-stock-foto
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. The anatomy and surgical treatment of abdominal hernia. &??* d. > fjn-^dcl SmcZnu s Iiitii PLATE XX III.—Fig. 1. Gives an internal view of the ischiatic hernia, from Dr. Joness patient.The preparation is in the anatomical collection at Saint Thomass Hos-pital. a. Section of the pubes. b. Spinous process of the ilium. c. Sacrum. d. Iliacus internus muscle. e. Psoas muscle. /. Pyriformis muscle. g. Coccygeus muscle. h. Termination of the external iliac artery in the crural. i. Beginning of the crural vein. k. Trunk of the common iliac artery. /. Internal iliac artery. m. Obturator artery, w-stock-foto
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. The anatomy and surgical treatment of abdominal hernia. the ilium. c. Sacrum. d. Iliacus internus muscle. e. Psoas muscle. /. Pyriformis muscle. g. Coccygeus muscle. h. Termination of the external iliac artery in the crural. i. Beginning of the crural vein. k. Trunk of the common iliac artery. /. Internal iliac artery. m. Obturator artery, which may be traced before the sac as faras the obturator foramen. n. Internal iliac vein. o. Obturator vein passing behind the hernia to the obturator fora-men, from which another vein (p) is seen passing intothe iliac vein. q. Hernial sac. r. Its orifice-stock-foto
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. Anatomy, descriptive and applied. Anatomy. Figs. 474 and 475.—Variations in origin and course of the obturator artery. When the obturator artery arises at the front of the pelvis from the deep epigastric, it descends almost vertically to the upper part of the obturator foramen. The artery in this course usually lies in contact with the external iliac vein and on the outer side of the femoral ring (Fig. 474); in such cases it would not be endangered in the operation for femoral hernia. Occasionally, however, it curves inward along the free margin of Gimbernat's ligament (Fig. 475), and under-stock-foto