1036 SURGICAL ANATOMY OF HEENL2& 



outwards in the groin, no error in diagnosis is likely to arise. It is only in 

 distinguishing between a bubonocele and a femoral hernia of moderate size 

 that a difficulty occurs. The position of the femoral hernia is, in most 

 cases, characteristic. The tumour is upon the thigh, and a narrowed part, 

 or neck, may be felt sinking into the thigh near its middle. Besides, the 

 femoral arch is usually to be traced above this hernia, while that band is 

 lower than the mass of a tumour lodged in the inguinal canal. At the 

 fcame time the inguinal tumour covers the femoral arch, and cannot be 

 withdrawn from it like a femoral hernia, when it has turned over that cord. 

 Some assistance will be gained, in a doubtful case, from the greater facility 

 with which the tumour emerging at the saphenous opening admits of being 

 circumscribed, in comparison with the bubonocele, which is bound down by 

 a more resistent structure the aponeurosis of the external oblique muscle. 

 Other practical applications of the foregoing anatomical observations come 

 now to be considered. 



The taxis. During the efforts of the surgeon to replace the hernia, the 

 thigh is to be flexed upon the abdomen and inclined inwards, with a view 

 to relax the femoral arch ; the tumour is, if necessary, to be withdrawn 

 from over the arch, and the pressure on it is to be directed backwards into 

 the thigh. 



The operation. The replacement of the hernia by the means just adverted 

 to being found impracticable, an operation is undertaken with the view of 

 dividing the femoral canal (or some part of it), thereby widening the space 

 through which the protruding viscus is to be restored to the abdomen, or 

 with the view of relieving strangulation when the restoration of the part is 

 not possible or not desirable. Inasmuch as the manner of conducting the 

 operation chiefly depends on the place at which the constricting structures 

 are to be cut into, it will be convenient in the first instance to determine 

 this point ; and with this object we shall inquire into the practicability and 

 safety of making incisions into the femoral canal at different points of its 

 circumference. As the hernia rests upon the pelvis, the posterior part of 

 the canal may at once be excluded from consideration ; so likewise may its 

 outer side on account of the position of the femoral vein, and also the outer 

 part of its anterior boundary, because of the presence of the epigastric 

 artery in this direction. There remains only the inner boundary with the 

 contiguous part of the anterior one, and through any point of this portion 

 of the ring or canal an incision of the required extent (always a very short 

 one) can be made without danger in nearly all cases. The sources of danger 

 are only occasional ; for the urinary bladder, when largely distended, and 

 the obturator artery when it turns over the femoral ring a very unusual 

 course are the only parts at the inner side of the hernia liable to be 

 injured ; while the last-named vessel, when it follows the course just referred 

 to, and in the male the spermatic cord, are the structures in peril when the 

 anterior boundary of the canal is cut into towards the inner side of the 

 hernia (see p. 624 and fig. 291). 



Returning now to the steps of the operation : After it has been ascer- 

 tained that the urinary bladder is not distended, the skin is to be divided 

 by a single vertical incision made on the inner part of the tumour, and 

 extending over the crural arch. When the subcutaneous fat (the thickness 

 of which is very various in different persons) is cut through, a small blood- 

 vessel or two are divided, and some lymphatic glands may be met with. 

 The haemorrhage from the blood-vessels seldom requires any means to 

 restrain it ; but the glands, if enlarged, retard the operation in some 



