Aciphex

Thomas C. Gerber, MD, PhD

• Professor of Medicine and Radiology
• Mayo Clinic College of Medicine
• Rochester, Minnesota
• Consultant in Cardiology
• Mayo Clinic
• Jacksonville, Florida

It consists of a mixture of dead epidermal cells and a fatty substance (secretion) from the fetal sebaceous glands gastritis red wine discount aciphex 20 mg mastercard. The vernix caseosa protects the delicate fetal skin from abrasions gastritis colitis diet purchase aciphex now, chapping gastritis diet åâðîôóòáîë order aciphex from india, and hardening that result from exposure to the amniotic fluid gastritis head symptoms buy aciphex on line. The fetuses are usually completely covered with fine downy hairlanugothat helps to hold the vernix caseosa on the skin gastritis diet âêîíòàêòå buy 20mg aciphex with mastercard. Brown fat forms during this period and is the site of heat production gastritis ultrasound generic aciphex 20mg line, particularly in the newborn infant. Brown fat is chiefly found at the root of the neck, posterior to the sternum, and in the perirenal area. By 20 weeks, the testes have begun to descend, but they are still located on the posterior abdominal wall, as are the ovaries in female fetuses. Integration link: Brown fat Twentyone to Twentyfive Weeks There is a substantial weight gain during this period, and the fetus is better proportioned. The skin is usually wrinkled and more translucent, particularly during the early part of this period. The skin is pink to red in fresh specimens because blood is visible in the capillaries. At 21 weeks, rapid eye movements begin and blinkstartle responses have been reported at 22 to 23 weeks. Although a 22 to 25week fetus born prematurely may survive if given intensive care. Integration link: Preterm birth page 101 page 102 ure 69 A 25weekold normal female newborn weighing 725 g. The lungs and pulmonary vasculature have developed sufficiently to provide adequate gas exchange. In addition, the central nervous system has matured to the stage where it can direct rhythmic breathing movements and control body temperature. Toenails become visible, and considerable subcutaneous fat is now present under the skin, smoothing out many of the wrinkles. This ends by 28 weeks, by which time bone marrow has become the major site of this process. Usually by the end of this period, the skin is pink and smooth and the upper and lower limbs have a chubby appearance. If a normalweight fetus is born during this period, it is premature by date as opposed to being premature by weight. Integration link: Pupillary light reflex Thirtyfive to Thirtyeight Weeks Fetuses born at 35 weeks have a firm grasp and exhibit a spontaneous orientation to light. As term approaches, the nervous system is sufficiently mature to carry out some integrative functions. After this, the circumference of the abdomen may be greater than that of the head. The fetal foot measurement is usually slightly larger than femoral length at 37 weeks and is an alternative parameter for confirmation of fetal age. A fetus adds approximately 14 g of fat per day during these last weeks of gestation. The thorax (chest) is prominent, and the breasts often protrude slightly in both sexes. The testes are usually in the scrotum in fullterm male infants; premature male infants commonly have undescended testes. Although the head is smaller at full term in relation to the rest of the body than it was earlier in fetal life, it still is one of the largest regions of the fetus. Approximately one third of those with a birth weight of 2500 g or less are actually small for gestational age. These "small for dates" infants may be underweight because of placental insufficiency (see Chapter 7). The placentas are often small or poorly attached and/or have undergone degenerative changes that progressively reduce the oxygen supply and nourishment to the fetus. The decline, particularly after full term (38 weeks), probably reflects inadequate fetal nutrition caused by placental changes. Approximately 12% of babies are born 1 to 2 weeks after the expected time of birth. Postmaturity Syndrome page 103 page 104 Prolongation of pregnancy for 3 or more weeks beyond the expected date of delivery occurs in 5% to 6% of women. Some infants in such pregnancies develop the postmaturity syndrome and have an increased risk of mortality. These fetuses have dry, parchmentlike skin, are often overweight, and have no lanugo, decreased or absent vernix caseosa, long nails, and increased alertness. Gases and nutrients pass freely to the fetus from the mother through the placental membrane (see Chapter 7). Glucose is a primary source of energy for fetal metabolism and growth; amino acids are also required. Insulin required for the metabolism of glucose is secreted by the fetal pancreas; no significant quantities of maternal insulin reach the fetus because the placental membrane is relatively impermeable to this hormone. Insulin, insulinlike growth factors, human growth hormone, and some small polypeptides (such as somatomedin C) are believed to stimulate fetal growth. Severe maternal malnutrition resulting from a poorquality diet is known to cause reduced fetal growth (see. The growth rate for fetuses of mothers who smoke cigarettes is less than normal during the last 6 to 8 weeks of pregnancy (see. On average, the birth weight of infants whose mothers smoke heavily during pregnancy is 200 g less than normal, and perinatal morbidity is increased when adequate medical care is unavailable. The effect of maternal smoking is greater on fetuses whose mothers also receive inadequate nutrition. Multiple Pregnancy Individuals of multiple births usually weigh considerably less than infants resulting from a single pregnancy (see. It is evident that the total metabolic requirements of two or more fetuses exceed the nutritional supply available from the placenta during the third trimester. Impaired Uteroplacental and Fetoplacental Blood Flow Maternal placental circulation may be reduced by conditions that decrease uterine blood flow. The net effect of these placental abnormalities is a reduction of the total area for exchange of nutrients between the fetal and maternal blood streams. It is very difficult to separate the effect of these placental changes from the effect of reduced maternal blood flow to the placenta. In some instances of chronic maternal disease, the maternal vascular changes in the uterus are primary and the placental defects are secondary. Repeated cases of this condition in one family indicate that recessive genes may be the cause of the abnormal growth. In recent years, structural and numerical chromosomal aberrations have also been shown to be associated with cases of retarded fetal growth. Corner, Renowned American Embryologist, 18881981 Perinatology is the branch of medicine that is concerned with the wellbeing of the fetus and newborn infant, generally covering the period from approximately 26 weeks after fertilization to 4 weeks after birth. The chorionic sac and its contents may be visualized by ultrasonography during the embryonic and fetal periods. Placental and fetal size, multiple births, abnormalities of placental shape, and abnormal presentations can also be determined. Ultrasound scans give accurate measurements of the biparietal diameter of the fetal cranium, from which close estimates of fetal age and length can be made. ures 612 and 614 illustrate how details of the fetus can be observed in ultrasound scans. Ultrasound examinations are also helpful for diagnosing abnormal pregnancies at a very early stage. Rapid advances in ultrasonography have made this technique a major tool for prenatal diagnosis of fetal abnormalities. Diagnostic Amniocentesis this is a common invasive prenatal diagnostic procedure, usually performed between 15 and 18 weeks gestation. The amniotic fluid volume is approximately 200 mL, and 15 to 20 mL can be safely withdrawn. Amniocentesis is relatively devoid of risk, especially when the procedure is performed by an experienced physician who is guided by realtime ultrasonography for outlining the position of the fetus and placenta. The common indications for amniocentesis are Advanced maternal age (38 years or older) Previous birth of a trisomic child. Spectrophotometric Studies Examination of amniotic fluid by this method may be used for assessing the degree of erythroblastosis fetalis, also called hemolytic disease of newborn. This disease results from destruction of fetal red blood cells by maternal antibodies (see Chapter 7). A needle is inserted through the lower abdominal and uterine walls into the amniotic cavity. Diagnostic Value of Chorionic Villus Sampling Biopsies of chorionic villi are used for detecting chromosomal abnormalities, inborn errors of metabolism, and Xlinked disorders. The rate of fetal loss is approximately 1%, slightly more than the risk from amniocentesis. Sex Chromatin Patterns Fetal sex can be determined by noting the presence or absence of sex chromatin in the nuclei of cells recovered from amniotic fluid. These tests were developed after it was discovered that sex chromatin was visible in nuclei of normal female cells but not in normal male cells. By use of a special staining technique, the Y chromosome can also be identified in cells recovered from the amniotic fluid surrounding male fetuses (see. Knowledge of fetal sex can be useful in diagnosing the presence of severe sexlinked hereditary diseases, such as hemophilia and muscular dystrophy. Cell Cultures and Chromosomal Analysis the prevalence of chromosomal disorders is approximately one in 120 liveborn infants. Fetal sex and chromosomal aberrations can be determined by studying the sex chromosomes in cultured fetal cells obtained during amniocentesis. These cultures are commonly done when an autosomal abnormality, such as occurs in Down syndrome, is suspected. Moreover, microdeletions and microduplications, as well as subtelomeric rearrangements, can now be detected with fluorescence in situ hybridization technology. Inborn errors of metabolism in fetuses can also be detected by studying cell cultures. Enzyme deficiencies can be determined by incubating cells recovered from amniotic fluid and then detecting the specific enzyme deficiency in the cells (see Chapter 20). The need for fetal blood transfusions is reduced nowadays owing to the treatment of Rhnegative mothers of Rhpositive fetuses with antiRh immunoglobulin. Fetal transfusion of platelets directly into the umbilical cord vein is carried out for the treatment of alloimmune thrombocytopenia. Also, fetal transfusion of drugs in a similar manner for the treatment of a few medical conditions in the fetus has been reported. Integration link: Rhesus blood group Molecular basis Fetoscopy Using fiberoptic lighting instruments, parts of the fetal body may be directly observed. It is possible to scan the entire fetus looking for congenital anomalies such as cleft lip and limb defects. The fetoscope is usually introduced through the anterior abdominal and uterine walls into the amniotic cavity, similarly to the way in which the needle is inserted during amniocentesis. Fetoscopy is usually carried out at 17 to 20 weeks of gestation, but with new approaches such as transabdominal thingauge embryofetoscopy, it is possible to detect certain anomalies in the embryo or fetus during the first trimester. Because of the risk to the fetus compared with other prenatal diagnostic procedures, fetoscopy now has few indications for routine prenatal diagnosis or treatment of the fetus. Biopsy of fetal tissues, such as skin, liver, kidney, and muscle, can be performed with ultrasound guidance. Moreover, the procedure permits treating the fetus directly, including the transfusion of packed red blood cells for the management of fetal anemia resulting from isoimmunization. Important advantages of magnetic resonance imaging are that it does not use ionizing radiation and that it has high softtissue contrast and resolution. Integration link: Fetal surgery Fetal Monitoring Continuous fetal heart rate monitoring in highrisk pregnancies is routine and provides information about the oxygenation of the fetus. There are various causes of prenatal fetal distress such as maternal diseases that reduce oxygen transport to the fetus. It is characterized by rapid body growth and differentiation of tissues and organ systems. An obvious change in the fetal period is the relative slowing of head growth compared with that of the rest of the body. By the beginning of the 20th week, lanugo and head hair appear, and the skin is coated with vernix caseosa. The eyelids are closed during most of the fetal period but begin to reopen at approximately 26 weeks. At this time, the fetus is usually capable of extrauterine existence, mainly because of the maturity of its respiratory system. Until approximately 30 weeks, the fetus appears reddish and wizened because of the thinness of its skin and the relative absence of subcutaneous fat. Fat usually develops rapidly during the last 6 to 8 weeks, giving the fetus a smooth, plump appearance. The fetus is less vulnerable to the teratogenic effects of drugs, viruses, and radiation, but these agents may interfere with growth and normal functional development, especially of the brain and eyes. The physician can now determine whether a fetus has a particular disease or a congenital anomaly by using various diagnostic techniques. Prenatal diagnosis can be made early enough to allow early termination of the pregnancy if elected. A 44yearold pregnant woman was worried that she might be carrying a fetus with major congenital anomalies.

Syndromes

• Are the stools an abnormal color (especially pale or clay-colored stools)?
• Bleeding after sex
• Temporary or permanent weakness, numbness, difficulty speaking
• Do repetitive movements with your wrist such as typing on a computer keyboard, using a computer mouse, playing racquetball or handball, sewing, painting, writing, or using a vibrating tool.
• Rotator cuff tear
• Lumbar puncture (spinal tap) with careful testing of walking before and after the spinal tap
• Cardiomyopathy (a problem where your heart becomes big and floppy and has problems pumping blood)
• Osteomyelitis
• Aging also causes the alveoli to lose their shape and become baggy.
• Peripheral artery disease

Arefiexia is most often encountered in disorders of lower motor neurones gastritis espanol cheap aciphex online amex, specifically radiculopathies gastritis how long buy aciphex 20mg mastercard, plexopathies gastritis medicine over the counter buy genuine aciphex, and neuropathies (axonal and demyeli nating) gastritis diet vs regular cheap aciphex 20 mg overnight delivery. It fails to react to light (refiex iridoplegia) chronic gastritis x ray purchase aciphex 10 mg without a prescription, but does constrict to accommodation (when the eyes converge) gastritis in english language aciphex 10mg amex. Since the light refiex is lost, testing for the accommodation reaction may be performed with the pupil directly illuminated: this can make it easier to see the response to accommodation, which is often dif ficult to observe when the pupil is small or in individuals with a dark iris. Although pupil involvement is usually bilateral, it is often asymmetric, causing anisocoria. The Argyll Robertson pupil was originally described in the context of neu rosyphilis, especially tabes dorsalis. A lesion in the tectum of the (rostral) midbrain proximal to the oculomotor nuclei has been suggested. Four cases of spinal myosis [sic]: with remarks on the action of light on the pupil. It is said that in organic weakness the hand will hit the face, whereas patients with functional weakness avoid this consequence. The term was invented in the nineteenth century (Hamilton) as an alternative to aphasia, since in many cases of the latter there is more than a loss of speech, including impaired pantomime (apraxia) and in symbolizing the relationships of things. Hughlings Jackson approved of the term but feared it was too late to displace the word aphasia. Cross References Aphasia, Apraxia Asomatognosia Asomatognosia is a lack of regard for a part, or parts, of the body, most typically failure to acknowledge the existence of a hemiplegic left arm. Asomatognosia may be verbal (denial of limb ownership) or nonverbal (failure to dress or wash limb). All patients with asomatognosia have hemispatial neglect (usually left), hence this would seem to be a precondition for the development of aso matognosia; indeed, for some authorities asomatognosia is synonymous with personal neglect. Attribution of the neglected limb to another person is known as somatoparaphrenia. The neuroanatomical correlate of asomatognosia is damage to the right supramarginal gyrus and posterior corona radiata, most commonly due to a cerebrovascular event. The predilection of asomatognosia for the left side of the body may simply be a refiection of the aphasic problems associated with left sided lesions that might be expected to produce asomatognosia for the right side. Asomatognosia is related to anosognosia (unawareness or denial of ill ness) but the two are dissociable on clinical and experimental grounds. The term has no standardized definition and hence may mean different things to different observers; it has also been used to describe a disorder characterized by inability to stand or walk despite nor mal leg strength when lying or sitting, believed to be psychogenic (although gait apraxia may have similar features). A transient inability to sit or stand despite normal limb strength may be seen after an acute thalamic lesion (thalamic astasia). Cross Reference Gait apraxia Astereognosis Astereognosis is the failure to recognize a familiar object, such as a key or a coin, palpated in the hand with the eyes closed, despite intact primary sensory modal ities. Description of qualities such as the size, shape, and texture of the object may be possible. There may be associated impairments of twopoint discrim ination and graphaesthesia (cortical sensory syndrome). Astereognosis was said to be invariably present in the original description of the thalamic syndrome by Dejerine and Roussy. Some authorities recommend the terms stereoanaesthesia or stereohypaes thesia as more appropriate descriptors of this phenomenon, to emphasize that this may be a disorder of perception rather than a true agnosia (for a similar debate in the visual domain, see Dysmorphopsia). Cross References Agnosia; Dysmorphopsia; Graphaesthesia; Twopoint discrimination Asterixis Asterixis is a sudden, brief, arrhythmic lapse of sustained posture due to involun tary interruption in muscle contraction. It is most easily demonstrated by observ ing the dorsifiexed hands with arms outstretched. These features distinguish asterixis from tremor and myoclonus; the phenomenon has previously been described as negative myoclonus or neg ative tremor. Unilateral asterixis has been described in the context of stroke, contralateral to lesions of the midbrain (involving corticospinal fibres, medial lemniscus), tha lamus (ventroposterolateral nucleus), primary motor cortex, and parietal lobe; and ipsilateral to lesions of the pons or medulla. Asynergia Asynergia or dyssynergia is lack or impairment of synergy of sequential muscular contraction in the performance of complex movements, such that they seem to become broken up into their constituent parts, socalled decomposition of move ment. Dyssynergy of speech may also occur, a phenomenon sometimes termed scan ning speech or scanning dysarthria. This is typically seen in cerebellar syndromes, most often those affecting the cerebellar hemispheres, and may coexist with other signs of cerebellar disease such as ataxia, dysmetria, and dysdiadochokinesia. Cross References Ataxia; Cerebellar syndromes; Dysarthria; Dysdiadochokinesia; Dysmetria; Scanning speech Ataxia Ataxia or dystaxia refers to a lack of coordination of voluntary motor acts, impairing their smooth performance. Ataxia is used most frequently to refer to a cerebellar problem, but sensory ataxia, optic ataxia, and frontal ataxia are also described, so it is probably best to qualify ataxia rather than to use the word in isolation. An International Cooperative Ataxia Rating Scale has been developed to assess the efficacy of treatments for cerebellar ataxia. These fibres run in the corticopontocerebellar tract, synapsing in the pons before passing through the middle cerebellar peduncle to the contralateral cerebellar hemisphere. Triple ataxia, the rare concurrence of cerebellar, sensory, and optic types of ataxia, may be associated with an alien limb phenomenon (sensory type). International Cooperative Ataxia Rating Scale for pharmacological assessment of the cerebellar syndrome. This syndrome is caused by lacunar (small deep) infarcts in the contralateral basis pons at the junction of the upper third and lower twothirds. It may also be seen with infarcts in the contralateral thalamocapsular region, posterior limb of the internal capsule (anterior choroidal artery syndrome), red nucleus, and the paracentral region (anterior cerebral artery territory). Sensory loss is an indica tor of capsular involvement; pain in the absence of other sensory features is an indicator of thalamic involvement. Athetosis often coexists with the more fiowing, dancelike movements of chorea, in which case the movement dis order may be described as choreoathetosis. Athetoidlike move ments of the outstretched hands may also been seen in the presence of sensory ataxia (impaired proprioception) and are known as pseudoathetosis or pseudo choreoathetosis. Cross References Chorea, Choreoathetosis; Pseudoathetosis; Pseudochoreoathetosis Athymhormia Athym(h)ormia, also known as the robot syndrome, is a name given to a form of abulia or akinetic mutism in which there is loss of selfautoactivation. Clinically there is a marked discrepancy between heteroactivation, behaviour under the infiuence of exogenous stimulation, which is normal or almost normal, and autoactivation. Left alone, patients are akinetic and mute, a state also known as loss of psychic selfactivation or pure psychic akinesia. It is associated with bilat eral deep lesions of the frontal white matter or of the basal ganglia, especially the globus pallidus. Athymhormia is thus environmentdependent, patients nor malizing initiation and cognition when stimulated, an important differentiation from apathy and akinetic mutism. The term is often applied to wasted muscles, usually in the context of lower motor neurone pathology (in which case it may be synonymous with amyotrophy), but also with disuse. Atrophy develops more quickly after lower, as opposed to upper, motor neurone lesions. It may also be applied to other tissues, such as subcutaneous tissue (as in hemifacial atrophy). Atrophy may sometimes be remote from the affected part of the neuraxis, hence a falselocalizing sign, for example, wasting of intrinsic hand muscles with foramen magnum lesions. Cross Reference Dementia Attention Attention is a distributed cognitive function, important for the operation of many other cognitive domains; the terms concentration, vigilance, and per sistence may be used synonymously with attention. Distinction may be made between different types of attention, as follows: Sustained; Selective; Divided/executive function. It is generally accepted that attention is effortful, selective, and closely linked to intention. Impairment of attentional mechanisms may lead to distractability (with a resulting complaint of poor memory, perhaps better termed aprosexia), disori entation in time and place, perceptual problems, and behavioural problems. The neuroanatomical substrates of attention encompass the ascending retic ular activating system of the brainstem, the thalamus, and the prefrontal (mul timodal association) cerebral cortex (especially on the right). In the presence of severe attentional disorder (as in delirium) it is dif ficult to make any meaningful assessment of other cognitive domains. Cross References Aprosexia; Delirium; Dementia; Disinhibition; Dysexecutive syndrome; Frontal lobe syndromes; Pseudodementia Auditory Agnosia Auditory agnosia refers to an inability to appreciate the meaning of sounds despite normal perception of pure tones as assessed by audiological examination. This agnosia may be for either verbal material (pure word deafness) or non verbal material, either sounds (bells, whistles, animal noises) or music (amusia, of receptive or sensory type). This may be equivalent to noise induced visual phosphenes or soundinduced photisms. Augmentation also refers to the paradoxical worsening of the symptoms of restless legs syndrome with dopaminergic treatment, manifesting with earlier onset of symptoms in the evening or afternoon, shorter periods of rest to provoke symptoms, greater intensity of symptoms when they occur, spread of symptoms to other body parts such as the arms, and decreased duration of benefit from medication. Auras are exclusively subjective, and may be entirely sensory, such as the fortifica tion spectra (teichopsia) of migraine, or more complex, labelled psychosensory or experiential, as in certain seizures. Although initially classified (by Gilles de la Tourette) with tic syndromes, there are clear clinical and pathophysiological differences. Cross Reference Tic Automatic Writing Behaviour Automatic writing behaviour is a form of increased writing activity. It has been suggested that it should refer specifically to a permanently present or elicitable, compulsive, iterative and not necessarily complete, written reproduction of visu ally or orally perceived messages (cf. This is characterized as a particular, sometimes isolated, form of utilization behaviour in which the inhibitory functions of the frontal lobes are suppressed. Increased writing activity in neurological conditions: a review and clinical study. Cross References Hypergraphia; Utilization behaviour Automatism Automatisms are complex motor movements occurring in complex motor seizures, which resemble natural movements but occur in an inappropriate set ting. These may occur during a state of impaired consciousness during or shortly after an epileptic seizure. Automatisms occur in about onethird of patients with complex partial seizures, most commonly those of temporal or frontal lobe origin. Although 52 Autoscopy A there are qualitative differences between the automatisms seen in seizures arising from these sites, they are not of sufficient specificity to be of reliable diagnostic value; bizarre automatisms are more likely to be frontal. Automatisms may take various forms: Orofacial movements: for example, lip smacking, chewing and swallowing movements, saliva tion (especially temporal lobe origin). Cross References Absence; Aura; Pelvic thrusting; Poriomania; Seizure Autophony the perception of the reverberation of ones own voice, which occurs with external or middle, but not inner, ear disease. Unlike heautoscopy, there is a coincidence of egocentric and bodycentred perspectives. Autoscopy may be associated with parietooccipital spaceoccupying lesions, epilepsy, and migraine.

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In this case gastritis diet 2 weeks purchase aciphex from india, the ring of the fibrous tube gastritis or gallstones aciphex 20mg overnight delivery, 2 gastritis symptoms vs ulcer symptoms buy aciphex online now, 2 gastritis kod pasa purchase aciphex uk, will be much widened; but the artery and spermatic vessels will remain in their normal position gastritis diet 911 order 10mg aciphex otc, being in no wise affected by the gravitating hernia chronic atrophic gastritis definition purchase aciphex 20 mg with mastercard. If the conjoined tendon, 6, be so weak as not to resist the gravitating force of the hernia, the tendon will become bent upon itself. If the umbilical cord, 10, be side by side with the epigastric artery at the time that the hernia enters the mouth of the fibrous tube, then, of course, the cord will be found external. If the cord lie towards the pubes, apart from the vessel, the hernia may enter the fibrous tube between the cord, 10, and artery, 9. Cloquet states that the umbilical cord is always found on the inner side of the external hernia. But this is not the case with respect to the fibrous membrane which forms the fascia propria. If the hernia enter the inguinal wall immediately on the inner side of the epigastric artery. That part of the conjoined tendon which stands external to the hernia keeps the tube, 2, 2, in its proper place, and separates it from the fold of the fascia which invests the hernial sac. This is the only form in which an internal hernia can be said to be absolutely distinct from the inguinal canal and spermatic vessels. This hernia, when passing the external ring, 4, has the spermatic cord on its outer side. The change of place exhibited by this form of hernia does not imply a change either in its original investments or in its position with respect to the epigastric artery and spermatic vessels. The change is merely caused by the weight and gravitation of the hernial mass, which bends the epigastric artery, 9*, from its first position on the inner margin of the internal ring, 1, till it assumes the place 9. In consequence of this, the internal ring of the fascia transversalis, 2, 2, is considerably widened, as it is also in. It is the inner margin of the fibrous ring which has suffered the pressure; and thus the hernia now projects directly from behind forwards, through, 4, the external ring. The change of place performed by the gravitating hernia may disturb the order and relative position of the spermatic vessels; but these, as well as the hernia, still occupy the inguinal canal, and are invested by the spermatic fascia, 3, 3. Lawrence, Sir Astley Cooper, Scarpa, Hesselbach, and Langenbeck, state, however, that the internal hernia does not disturb the artery from its usual position threefourths of an inch from the external ring. This obliquity is caused by a change of place, performed rather by the internal than the external ring. When, in company with these facts, we recollect how much the parts are liable to be disturbed in ruptures, it must be evident that their relative position cannot be exactly ascertained by measurement, from any given point whatever. The inguinal canal and external abdominal ring are parts concerned in the passage of inguinal herniae, whether oblique or direct, external or internal; whilst the femoral canal and saphenous opening are the parts through which the femoral hernia passes. Both these orders of parts, and of the herniae connected with them respectively, are, however, in reality situated so closely to each other in the inguinofemoral region, that, in order to understand either, we should, examine both at the same time comparatively. The simple line, therefore, described by this ligament explains the narrow interval which separates both varieties of the complaint. So small is the line of separation described between these herniae by the ligament, that this (so to express the idea) stands in the character of an arch, which, at the same time, supports an aqueduct (the inguinal canal) and spans a road (the femoral sheath. Immediately above and below its pubic extremity appear the external ring and the saphenous opening. The shape of the ligament is acutely triangular, corresponding to the form of the space which it occupies. Its apex is internal, and close to the pubic spine; its base is external, sharp and concave, and in apposition with the sheath of the femoral vessels. It measures an inch, more or less, in width, and it is broader in the male than in the femalea fact which is said to account for the greater frequency of femoral hernia in the latter sex than in the former, (Monro. The falciform process also blends with the ligament; and thus it is that the femoral hernia, when constricted by either of these three structures, may well be supposed to suffer pressure from the three together. This structure consists of tendinous fibres, lying deeper than, but parallel with, those of the superficial arch. The deep arch spans the femoral sheath more closely than the superficial arch, and occupies the interval left between the latter and the sheath of the vessels. On its outer side are situated the anterior crural nerve, and the femoral parts of the psoas and iliacus muscles. Of the three compartments into which the sheath is divided by two septa in its interior, the external one, E. The inner compartment, G, is the femoral canal, and through it the femoral hernia descends from the abdomen to the upper and forepart of the thigh. The sheath of the femoral vessels, like that of the spermatic cord, is infundibuliform. The femoral sheath being broader above than below, whilst the vessels are of a uniform diameter, presents, as it were, a surplus space to receive a hernia into its upper end. There is, however, corresponding to each ring, a depression in the peritonaeal covering; and here it is that the bowel first forces the membrane and forms of this part its sac. On removing the peritonaeum from the inguinal wall on the inner side of the iliac vessels, K L, we find the horizontal branch of the os pubis, and the parts connected with it above and below, to be still covered by what is called the subserous tissue. The femoral ring is not as yet discernible on the inner side of the iliac vein, K; for the subserous tissue being stretched across this aperture masks it. The portion of the tissue which closes the ring is named the crural septum, (Cloquet. The ring is the point of union between the fibrous membrane of the canal and the general fibrous membrane which lines the abdominal walls external to the peritonaeum. This account of the continuity between the canal and abdominal fibrous membrane equally applies to the connexion existing between the general sheath of the vessels and the abdominal membrane. The difference exists in the fact, that the two outer compartments of the sheath are occupied by the vessels, whilst the inner one is vacant. From the femoral ring the canal extends down the thigh for an inch and ahalf or two inches in a tapering form, supported by the pectineus muscle, and covered by the iliac part of the fascia lata. It lies side by side with the saphenous opening, but does not communicate with this place. On a level with the lower cornu of the saphenous opening, the walls of the canal become closely applied to the femoral vessels, and here it may be said to terminate. This vessel occasionally gives off the obturator artery, which, when thus derived, will be found to pass towards the obturator foramen, in close connexion with the ring; that is, either descending by its outer border, G*, between this point and the iliac vein, K; or arching the ring, G, so as to pass down close to its inner or pubic border. In some instances, the vessel crosses the ring; a vein generally accompanies the artery. As the course to be taken by the bowel, when a femoral hernia is being formed, is through the crural ring and canal, the structures which have just now been enumerated as bounding this passage, will, of course, hold the like relation to the hernia. The manner in which a femoral hernia is formed, and the way in which it becomes invested in its descent, may be briefly stated thus: the bowel first dilates the peritonaeum opposite the femoral ring, H. The crural septum has, at the same time, entered the canal as a second investment of the bowel. In general, it dilates the side of the canal, and this becomes the fascia propria, B G. Sometimes the hernia rests upon this ligament, and simulates, to all outward appearance, an oblique inguinal hernia. In this course, the femoral hernia will have its three partsneck, body, and fundusforming nearly right angles with each other: its neck [Footnote 3] descends the crural canal, its body is directed to the pubis through the saphenous opening, and its fundus is turned upwards to the femoral arch. With what difficulty and perplexity does this impenetrable fog of surgical nomenclature beset the progress of the learner! The neck of the sac may, indeed, be supposed always to suffer more or less constriction at the crural ring. The part which occupies the canal is also very much compressed; and again, where the hernia turns over the falciform process, this structure likewise must cause considerable compression on the bowel in the sac. There are no muscular fibres crossing the course of this hernia; neither are the parts which constrict it likely to change their original position, however long it may exist. In the inguinal hernia, the weight of the mass may in process of time widen the canal by gravitating; but the crural hernia, resting on the pubic bone, cannot be supposed to dilate the crural ring, however greatly the protrusion may increase in size and weight. Cooper (Crural Hernia) is of opinion that the stricture is generally in the neck of the sheath. The inguinal hernia, 3, arising above, 5, the crural arch, descends the canal, 3, 3, under cover of the aponeurosis of the external oblique muscle, obliquely downwards and inwards till it gains the external abdominal ring formed in the aponeurosis, and thence descends to the scrotum. The femoral hernia, commencing on a level with, 5, the femoral arch, descends the femoral canal, under cover of the fascia lata, and appears on the upper and forepart of the thigh at the saphenous opening, 6, 7, formed in the fascia lata; and thence, instead of descending to the scrotum, like the inguinal hernia, turns, on the contrary, up over the falciform process, 6, till its fundus rests near, 5, the very place beneath which it originated. Such are the peculiarities in the courses of these two hernial; and they are readily accounted for by the anatomical relations of the parts concerned. The infundibuliform fascia, 3, 3, of the spermatic vessels is like the infundibuliform sheath, 9, 9, of the femoral vessels. The ring of the femoral canal, 12, is situated immediately below, but to the inner side of the internal inguinal ring, 3. The epigastric artery, 1, marks the width of the interval which separates the two rings. When the bowel is about to protrude at either of the rings, it first dilates the peritonaeum, which covers these openings. As the space which the femoral arch spans external to the vessels is fully occupied by the psoas and iliacus muscles, and, moreover, as the abdominal fibrous membrane and its prolongation, the femoral sheath, closely embrace the vessels on their outer anterior and posterior sides, whilst on their inner side the membrane and sheath are removed at a considerable interval from the vessels, it is through this interval (the canal) that the hernia may more readily pass. The peritonaeum, 2, and crural septum, 13, form at this place the only barrier against the protrusion of the bowel into the canal. Neither will the hernia force a way at a point external to the femoral vessels in preference to that of the crural canal, which is already prepared to admit it. The septum crurale itself, having been dilated before the sac, of course invests it also. An incipient femoral hernia of the size of 2, 12, cannot, in the undissected state of the parts, be detected by manual operation; for, being bound down by the dense fibrous structures which gird the canal, it forms no apparent tumour in the groin. Cloquet has seen the hernia descend the sheath once in front of the vessels, and once behind them. The external form has never been met with by Hey, Cooper, or Scarpa; whilst no less than six instances of it have come under the notice of Mr. Still, the neck of the sac, 2, remains constricted at the ring, whilst the part which occupies the canal is also very much narrowed. The fundus of the sac, 9*, 12, alone expands, as being free of the canal; and covering this part of the hernia may be seen the fascia propria, 9*. This fascia is a production of the inner wall of the canal; and if we trace its sides, we shall find its lower part to be continuous with the femoral sheath, whilst its upper part is still continuous with the fascia transversalis. When the hernia ruptures the saphenous side of the canal, the fascia propria is, of course, absent. The direct hernia, 13, traverses the inguinal wall from behind, at a situation corresponding with the external ring; and from this latter point it descends the scrotum. An oblique external inguinal hernia enters the internal ring, 3, which exists further apart from the general median line, and, in order to gain the external ring, has to take an oblique course from without inwards through the inguinal canal. A femoral hernia enters the crural ring, 2, immediately below, but on the inner side of, the internal inguinal ring, and descends the femoral canal, 12, vertically to where it emerges through, 6, 7, the saphenous opening. The direct inguinal hernia, 13, owing to its form and position, can scarcely ever be mistaken for a femoral hernia. But in consequence of the close relationship between the internal inguinal ring, 3, and the femoral ring, 2, through which their respective herniae pass, some difficulty in distinguishing between these complaints may occur. An incipient femoral hernia, occupying the crural canal between the points, 2, 12, presents no apparent tumour in the undissected state of the parts; and a bubonocele, or incipient inguinal hernia, occupying the inguinal canal, 3, 3, where it is braced down by the external oblique aponeurosis, will thereby be also obscured in some degree. But, in most instances, the bubonocele distends the inguinal canal somewhat; and the impulse which on coughing is felt at a place above the femoral arch, will serve to indicate, by negative evidence, that it is not a femoral hernia. The inguinal hernia, 13, descends the scrotum, whilst the femoral hernia, 9*, turns over the falciform process, 6, and rests upon the fascia lata and femoral arch. Though in this position the fundus of a femoral hernia lies in the neighbourhood of the inguinal canal, 3, yet the swelling can scarcely be mistaken for an inguinal rupture, since, in addition to its being superficial to the aponeurosis which covers the inguinal canal, and also to the femoral arch, it may be withdrawn readily from this place, and its body, 12, traced to where it sinks into the saphenous opening, 6, 7, on the upper part of the thigh. An inguinal hernia manifests its proper character more and more plainly as it advances from its point of origin to its termination in the scrotum. A femoral hernia, on the contrary, masks its proper nature, as well at its point of origin as at its termination. If, on the other hand, the obturator artery descend external to the neck of the sac, the vessel will be comparatively remote from danger while the ligament is being divided. In addition to the fact that the cause of stricture is always on the pubic side, 8, of the neck of the sac, 12, thereby requiring the incision to correspond with this situation only, other circumstances, such as the constant presence of the femoral vein, 11, and the epigastric artery, 1, determine the avoidance of ever incising the canal on its outer or upper side. And if the obturator artery, [Footnote] by rare occurrence, happen to loop round the inner side of the neck of the sac, supposing this to be the seat of stricture, what amount of anatomical knowledge, at the call of the most dexterous operator, can render the vessel safe from dangerfi Quain (Anatomy of the Arteries) gives, as the result of his observations, the proportion to be as 1 in 31/2, and in this estimate he agrees to a great extent with the observations of Cloquet and Hesselbach. Numerical tables have also been drawn up to show the relative frequency in which the obturator descends on the outer and inner borders of the crural ring and neck of the sac. Cooper never met with an example where the vessel passed on the inner side of the sac, and from this alone it may be inferred that such a position of the vessel is very rare. It is generally admitted that the obturator artery, when derived from the epigastric, passes down much more frequently between the iliac vein and outer border of the ring. The researches of anatomists (Monro and others) in reference to this point have given rise to the question, "What determines the position of the obturator artery with respect to the femoral ringfi When this cannot be effected by the taxis, and the stricture still remains, the cutting operation is required. But it is to be presumed that the sac and contained intestine suffer constriction throughout the whole length of the canal. In some instances, it will be the fibres of the deep crescentic (femoral) arch; in others, again, the neck of the sac itself, and produced by a thickening and contraction of the subserous and peritonaeal membranes where they lie within the circumference of the crural ring. This incision divides the skin and subcutaneous adipose membrane, which latter varies considerably in quantity in several individuals. On cautiously turning aside the incised adipose membrane contained between the two layers of the superficial fascia, the fascia propria, 9. This envelope, besides varying in thickness in two or more cases, may be absent altogether.

Diseases

• CDG syndrome type 3
• Massa Casaer Ceulemans syndrome
• Michels Caskey syndrome
• Pelvic lipomatosis
• Deafness X-linked, DFN3
• Holt Oram syndrome
• Pulmonary atresia with ventricular septal defect
• Neuronal intranuclear hyaline inclusion disease