STRICTURE OF FEMORAL HERNIA. 429 



ing it externally is the femoral vein (6) without the intervention of the 

 sheath. In front is Poupart's ligament, with the deep arch ; and behind 

 is the pubes, covered by the pectineus and the fascia lata. Along the 

 front of the space, but at some little distance from it, lies the spermatic 

 cord in the male, and the round ligament in the female. 



Two of the boundaries, anterior and inner, are firm and sharp-edged, 

 though their condition varies with the position of the limb; for if the thigh 

 is raised and approximated to its fellow, those bounding parts will be 

 relaxed. 



Position of vessels around the ring (fig. 141). On the outer side is the 

 femoral vein (b) ; and above this are the epigastric vessels (c). In front 

 is a small branch (pubic) from the epigastric artery to the back of the 

 pubes ; and the vessels of the spermatic cord may be said to be placed 

 along the anterior aspect of the ring. The ring is bounded in the male by 

 vessels in front and on the outer side. 



But in some bodies the obturator artery takes origin from the epigastric, 

 and lies along the ring as it passes to the pelvis. It may have two posi- 

 tions 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 Gim- 

 bernat's ligament ; in this last condition the ring will be encircled except 

 at the posterior part. 



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

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

 large 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 peri- 

 toneum, and the subperitoneal fat (septum crurale) ; and it will displace, 

 or cause to be absorbed, 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 fas- 

 cia ; and, lastly, it is invested by the teguments of the thigh. The dissec- 

 tion of the thigh may be referred to for fuller detail. 



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

 the base of Gimbernat's ligament, or lower down at the margin of the 

 saphenous opening in the thigh. And the constriction may be caused 

 either by a fibrous band outside the upper narrow end of the tumor, or by 

 the thickening of the peritoneum inside that part, as in inguinal hernia. 



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

 fibrous band arching over it, an incision is to be made down to the neck 

 of the sac at the inner and upper part. 



And to relieve the deep stricture within the neck of the sac, the peri- 

 toneal bag is to be opened and a director introduced, and the 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 upwards and inwards to 

 loosen the constricting band in the neck of the tumor, there will not be 

 any vessel injured unless the cut should be made so long 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 view, 

 there is not usually any vessel in the way of the knife. But in some few 

 instances (once in about eighty operations, Lawrence), the obturator artery 



