766 SURGICAL ANATOMY OF FEMORAL HERNIA. 



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 

 be directed upwards. 



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 diffi- 

 cult 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 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 pro- 

 gress by the transversalis fascia and conjoined tendon. It differs also in its posi- 

 tion, being placed over the pubes, and not in the course of the inguinal canal. 

 The epigastric artery runs along 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. 



SUEGICAL ANATOMY OF FEMOEAL HEENIA. 



Dissection (fig. 383). The dissection of the parts comprised in the anatomy of femoral hernia 

 should be performed, 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 outwards, 

 when the superficial fascia will be exposed. 



The superficial fascia at the upper part of the thigh consists of two layers, 

 between which are found the cutaneous vessels and nerves, and numerous lym- 

 phatic glands. 



The superficial layer is a thick and dense cellulo-fibrous membrane, in the meshes 

 of which is found a considerable amount of adipose tissue, which varies in quantity 

 in different subjects ; this layer may be traced upwards over Poupart's ligament 

 to be continuous with the superficial fascia of the abdomen ; whilst below, and on 

 the inner and outer sides of the limb, it is continuous with the superficial fascia 

 covering the rest of the thigh. 



This 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 this vessel and its branches ; it should then be reflected outwards, 

 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 superficial fascia. These are 

 the internal saphenous vein, and the superficial epigastric, superficial circumflexa ilii, and super- 

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

 inguinal glands. 



The internal saphenous vein i's a vessel of considerable size, which ascends obliquely 

 upwards along the inner side of the thigh, below Poupart's ligament. It passes 

 through the saphenous opening in the fascia lata to terminate in the femoral vein. 

 This vessel is accompanied by numerous lymphatics, which return the lymph 

 from the dorsum of the foot and inner side of the leg and thigh ; they terminate 

 in the inguinal glands, whicn surround the saphenous opening. Converging 

 towards the same point are the superficial epigastric vessels, which run across 

 Pou part's ligament, obliquely upwards and inwards, to the lower part of the 



