IK MORAL HERNIA. 295 



pubic branch of that vessel, and lies along the ring as it passes to 

 the pelvis. It may have two positions with respect to the crural 

 ring : either it is placed close to the iliac vein, so as to leave the inner 

 side of that space free from vessels ; or it arches over the aperture, 

 descending on the inner side at the base of Gimbernat's ligament ; 

 in this last condition the ring will be encircled by vessels except 

 behind. 



Course of femoral hernia. The intestine leaves the abdomen by Femoral 

 the opening of the crural ring ; and it descends internal to the vein e 

 in the crural sheath, as far as the saphenous opening in the thigh, 

 where it projects to the surface. 



Coverings. In its progress the intestine will push before it the Coverings, 

 peritoneum and subperitoneal fat (septum crurale) ; and it will number, 

 displace the gland which fills the crural ring. Having reached the 

 level of the saphenous opening, the intestine carries before it the 

 inner side of the crural sheath, and a layer called the cribriform 

 fascia ; and, lastly, it is invested by the superficial fascia and skin of 

 the thigh. The dissection of the thigh may be referred to for fuller 

 details (pp. 143146). 



Seat of stricture. The stricture of a femoral hernia is placed stricture 

 opposite the base of Gimbernat's ligament, or lower down at the ng^^orat 

 margin of the saphenous opening in the thigh. And the constric- saphenous 

 tion may be caused either by a fibrous band outside the upper F 

 narrow end of the tumour, or by the thickening of the peritoneum 

 inside the neck, as in inguinal hernia. 



Division of the stricture. To free the intestine from the constricting incision to 

 fibrous band arching over it, an incision is to be made down to the ^ernll 6X 

 neck of the sac at the inner and upper part. 



And to relieve the deep stricture within the neck of the sac, and internal 

 the peritoneal bag is to be opened and a director introduced, and the s 

 knife is to be carried horizontally inwards, or upwards and inwards, 

 through the thickened sac and a few fibres of the edge of Gimbernat's 

 ligament. 



Danger to vessels. When the incision is made up wards and inwards Risk of 

 to loosen the constricting band in the neck of the tumour, there vessels 1 ?!? 

 will not be any vessel injured unless the cut should be made so long regular 

 as to reach the spermatic cord in the male, or the small pubic branch 

 of the epigastric artery. 



And when the incision is made directly inwards with the same and irr fg"- 



,, 1-1 ,. i i -e- -r. lar condition 



view, there is not usually any vessel in the way ot the knite. But of them, 

 in some few instances (once in about eighty operations, Lawrence) 

 the obturator artery takes its unusual course in front, and on the 

 inner side of the neck of the hernia, and will be before the knife in 

 the division of the stricture. As this condition of the vessel cannot 

 be recognised beforehand, the surgeon will best avoid the danger of 

 wounding the artery by a cautious and sparing use of the knife. 



