392 APPLIED ANATOMY. 



Point of Strangulation. As a femoral hernia descends it may be strangulated 

 on the sharp edge of Gimbernat's ligament or at the upper portion of the falciform 

 process (Fig. 404). 



Division of Stricture. If Gimbernat's ligament is the constricting band the 

 incision is to be made in an upward and inward direction. If the upper portion of 

 the falciform process is the constricting part the incision should be made directly 

 upward into Poupart's ligament. 



In order to avoid wounding an anomalous obturator artery which may wind 

 around the neck of the sac, the stricture is best cut from without inward. 



Radical Cure of Femoral Hernia. The intestine and omentum having 

 been replaced, the neck of the sac is ligated as high up as possible and cut away or, 

 preferably, the two ends of the ligature are brought up through the aponeurosis of 

 the external oblique and tied on its surface just above Poupart's ligament. To close 

 the femoral canal two or three sutures are inserted as follows: If the hernia is on the 

 right side, the needle is passed downward through the inner end of Poupart's liga- 

 ment, close to the spine of the pubis, into the pectineal or pubic portion of the 

 fascia lata, and brought out alongside of the femoral vein. It is then inserted again 

 through the edge of the falciform process and the suture tied, thus pulling the falci- 



Iliac portion of fascia lata \V^jfc^^-- Poupart's ligament 



Falciform process 



T> u- -4.- ft i i . xT Fascia over the pectineus muscle 



Pubic portion of fascia lata I 



PIG. 406. Operation for the radical cure of femoral hernia. 



form process and the lower edge of Poupart's ligament down on the fascia covering 

 the pectineal muscle. Two or three sutures are all that are required. Another way 

 of inserting the sutures is longitudinally, instead of transversely. The first would be 

 close in to Gimbernat's ligament, the second a little farther out, and the third as 

 close to the femoral vein as possible (Fig. 406) . 



THE LUMBAR REGION. 



This region is at times affected with abscesses or hernial protrusions and 

 through it incisions are made to reach the kidney (Fig. 407). 



Muscles. The quadratus lumborum muscle arises from the transverse 

 processes of the lower four lumbar vertebrae, the iliolumbar ligament, and 5 cm. (2 in.) 

 of the iliac crest. It inserts into the posterior half of the last rib and transverse 

 processes of the upper four lumbar vertebrae. The erector spinae is the muscular 

 mass which fills the groove to the outer side of the spinous processes. It arises 

 from the spines of the lumbar vertebras, the back of the sacrum, the sacrosciatic and 

 sacroiliac ligaments, and about the posterior fourth of the crest of the ilium. It 

 inserts into the posterior portion of the vertebrae and ribs above. The latissimU 1 " 

 dorsi arises from the spinous processes of the lower six thoracic vertebrae and tr . 

 vertebral aponeurosis, which is attached to the spinous processes of the lumbi./ 

 vertebrae, the posterior surface of the sacrum, and the posterior third of the crest of 



