1774 



HUMAN ANATOMY. 



Fig. 1407. 



Femoral artery 

 Femoral vein 



Hernia! sac pro- 

 truding through 

 saphenous open- 

 ing 



hood is relatively undeveloped ; its outer edge and the vein may then almost touch. 

 It is strengthened by the conjoined tendon and CoUes's ligament, while some fibres 

 of the iliac portion of the fascia lata and of the deep femoral arch {vide infra^ 

 also contribute to the formation of the inner boundary. On the outer side is the 

 femoral vein. Behind lies the horizontal ramus of the pubes covered by the origin 

 of the pectineus muscle and its fascia. In front are Poupart's ligament and the 

 strong band of fibres running along its deep surface from the anterior superior iliac 

 spine to the pubic spine, and known as the deep femoral arch. At the pohit at which 

 the sheath of the vessels closely embraces them — the lowest limit of the femoral canal 

 — the saphenous opening in the fascia lata ( described on page 635) has somewhat 

 the same relation to a femoral hernia that the external abdominal ring has to an in- 

 guinal hernia. After emerging from these openings neither hernia is further arrested 

 in its progress by any strong aponeurotic barrier, and they are both therefore more 



likely to increase in size ; but in femoral hernia 

 the change in direction of the axis of the fundus 

 as compared with that of the neck is much 

 more marked. 



In its etiology femoral hernia conforms 

 to the general laws already enumerated (page 

 1759). As the knuckle of gut involved presses 

 the peritoneum before it into the femoral ring 

 and down through the femoral canal, it car- 

 ries before it (i) the extraperitoneal tissue ; 

 (2) the septum crurale, when that constitutes 

 a distinct layer ; (3) ^h^ femoral sheath, some- 

 times described as transversalis fascia because 

 the anterior layer of the sheath is derived from 

 that structure; (4) the crih^if arm fascia ; 

 (5) the superficial fascia ; (6) the skin. 



As the transverse axis of the femoral ring 

 — parallel with that of Gimbernat's ligament 

 — is, in the erect posture,, nearly horizontal, a 

 fenloral hernia first descends almost perpen- 

 dicularly. After it reaches the point of close 

 adhesion of the sheath to the femoral vessels it takes the direction of least resistance 

 and protrudes through the saphenous opening. Its neck is, of course, the portion of 

 the sac between the femoral ring and the bottom of the femoral canal. The body is 

 apt to be small and globular or hemispherical in shape. 



The following anatomical relations will be found of great importance in distin- 

 guishing between femoral and inguinal hernia, (aj The upper edge of a femoral 

 hernia does not, as a rule, pass above the inguinal furrow (page 670), although it 

 may reach it, — i.e., the hernia will be below a line drawn from the anterior superior 

 spine of the ilium to the spine of the pubes. This may usually be determined by 

 inspection. Exceptionally, on account of the stronger attachment of the cribriform 

 fascia to the lower edge of the saphenous opening, the hernia finds its direction of 

 least resistance after emergence from that opening to be upward, when this sign will 

 be fallacious. (3) The neck of a femoral hernia is external to the pubic spine, that 

 of a complete inguinal hernia internal to it. The already described methods for 

 locating that process (page 349) may fail in very fat persons, especialh- in females. 

 In that case the lower crease that in such persons crosses the abdomen (page 531), 

 and which in the mid-line rests upon the symphysis pubis, will be a reliable guide to 

 the latter point ; the bone may thence be traced outward to the pubic spine. 



In the reduction of a femoral hernia — apt to be difficult on account of the nar- 

 rowness of the channel of exit — the position of the patient should be that already 

 described as appropriate when the hernia is inguinal. The thigh should be in a posi- 

 tion of inward rotation, flexion, and adduction, to relax the fascia lata and relieve ten- 

 sion about the saphenous opening. After the hernia — the axis of the body of which 

 is nearly at right angles with the axis of the neck — is drawn downward so that the 

 axes correspond, it is gradually pushed backward and then upward. 



Superficial dissection of left femoral hernia pro 

 truding through saphenous opening. 



