FEMORAL HERNIA. 1191 



This form of hernia has the same coverings as the oblique variety, excepting 

 that the conjoined tendon is substituted for the Cremaster, and the infundibuli- 

 form fascia is replaced by a portion derived from the general layer of the fascia 

 transversalis. 



The scat of stricture in both varieties of direct hernia is most frequently at the 

 neck of the sac or at the external ring. In that form of hernia which perforates 

 the conjoined tendon it not unfrequently occurs at the edges of the fissure through 

 which the gut passes. In dividing the stricture the incision should in all cases bo 

 directed upward. 1 



If the hernial protrusion passes into the inguinal canal, but does not escape 

 from the external abdominal ring, it forms what is called incomplete direct hernia. 

 This form of hernia is usually of small size, and in corpulent persons very difficult 

 of detection. 



Direct inguinal hernia is of much less frequent occurrence than the oblique, 

 their comparative frequency being, according to Cloquet, as one to five. It occurs 

 far more frequently in men than in women, on account of the larger size of the 

 external ring in the former sex. It differs from the oblique in its smaller size and 

 globular form, dependent most probably on the resistance offered to its progress by 

 the transversalis fascia and conjoined tendon. It differs also in its position, being 

 placed over the os pubis and not in the course of the inguinal canal. The deep 

 epigastric artery runs on the outer or iliac side of the neck of the sac, and the 

 spermatic cord along its external and posterior side, not directly behind it, as in 

 oblique inguinal hernia. 



FEMORAL HERNIA. 



The dissection of the parts comprised in the anatomy of femoral hernia should be per- 

 formed, if possible, upon a female subject free from fat. The subject should lie upon its back : 

 a block is first placed under the pelvis, the thigh everted, and the knee slightly bent and 

 retained in this position. An incision should then be made from the anterior superior spinous 

 process of the ilium along Poupart's ligament to the symphysis pubis ; a second incision should 

 be carried transversely across the thigh about six inches beneath the preceding ; and these are 

 to be connected together by a vertical one carried along the inner side of the thigh. These 

 several incisions should divide merely the integument ; this is to be reflected outward, when the 

 superficial fascia will be exposed. 



The superficial fascia forms a continuous layer over the whole of the thigh, 

 consisting of areolar tissue, containing in its meshes much fat, and capable of 

 being separated into two or more layers, between which are found the superficial 

 vessels and nerves. It varies in thickness in different parts of the limb. In the 

 groin it is thick, and the two layers are separated from one another by the super- 

 ficial inguinal lymphatic glands, the internal saphenous vein, and several smaller 

 vessels. One of these layers, the superficial, is continuous with the superficial 

 fascia of the abdomen. 



The superficial layer should be detached by dividing it across in the same direction as the 

 external incisions : its removal will be facilitated by commencing at the lower and inner angle of 

 the space, detaching it at first from the front of the internal saphenous vein, and dissecting it 

 off from the anterior surface of that vessel and its tributaries ; it should then be reflected out- 

 ward in the same manner as the integument. The cutaneous vessels and nerves and superficial 

 inguinal glands are then exposed, lying upon the deep layer of the superficial fascia. These are 

 the internal saphenous vein and the superficial epigastric, superficial circumflex iliac, and super- 

 ficial external pudic vessels, as well as numerous lymphatics, ascending with the saphenous vein 

 to the inguinal glands. 



The internal or long saphenous vein ascends along the inner side of the thigh, 

 and. passing through the saphenous opening in the fascia lata, terminates in the 

 femoral vein about an inch and a half below Poupart's ligament. This vein 



1 In all cases of inguinal hernia, whether oblique or direct, it is proper to divide the stricture 

 directly upward : the reason of this is obvious, for by cutting in this direction the incision is made 

 parallel to the deep epigastric artery either external to it in the oblique variety, or internal to it in 

 the direct form of hernia and thus all chance of wounding the vessel is avoided. If the incision 

 was made outward, the artery might be divided if the hernia was direct ; and if made inward, it would 

 stand an equal chance of injury if the case was one of oblique inguinal hernia. 



