FEMORAL HERXIA. OPERATIOX. 1037 



degree. The fascia propria of the hernia, which succeeds to the sub- 

 cutaneous fat, is distinguished by its membranous appearance and the 

 absence of fat. It is very thin, and caution is required in cutting through 

 it, as the peritoneal sac is immediately beneath : the two membranes are 

 indeed in contact, except in certain cases to be presently noticed. A flat 

 director is now to be insinuated between the hernial sac and the inner side 

 of the fermoral canal, space for the instrument being gained by pressing its 

 smooth surface against the neck of the hernia. On the groove of the director 

 so introduced, or under the guidance of the fore finger of the left hand if the 

 use of the director should be dispensed with, the probe-pointed bistoury is 

 passed through the canal, and the dense fibrous structure of which it 

 consists is divided, the edge of the knife being turned upwards and in- 

 wards, or directly upwards. By the former plan of relieving the stricture, 

 the parts divided are the following, viz. , the falciform process of the fascia 

 lata and the structures fixed to the pectineal line of the pubes, namely, 

 Gimbernat's ligament, and, it may be, the tendon of the two deep abdominal 

 muscles, with the fascia transversalis, and the inner end of the deep femoral 

 arch ; while if the incision be directed upwards, the falciform process of the 

 fascia lata and the two femoral arches are divided. The opening being 

 sufficiently dilated, the protruded part is restored to the abdomen as with the 

 taxis. 



But it may be found necessary to lay open the hernia! sac in order to 

 examine its contents, or in order to relieve the impediment to the return of 

 the hernia if that should happen to reside in the neck of the sac itself. In 

 this case it will probably be required to add to the vertical incision already 

 made through the integuments and superficial fascia, another directed out- 

 wards over the tumour, and parallel with the femoral arch. Such additional 

 incision is readily made, by passing the scalpel beneath the integument and 

 fat, and cutting outwards after the skin has been pierced with the point of 

 the knife. The sac being now opened, the hernia knife is used at the inner 

 side of its neck, while the bowel is guarded with the left hand. During the 

 restoration of the protruded parts, some advantage will be gained if the 

 edges of the divided sac should be held down with a pair or two of forceps 

 in the hands of an assistant. 



In the foregoing observations, it has been stated that the fascia propria 

 is in contact with the sac of the hernia, except in certain cases. The 

 exception is afforded by the interposition of fat, and sometimes in consider- 

 able quantity. The adipose substance is deposited in the subserous mem- 

 brane ; it has the peculiarity of resembling the fat lodged in the omentuin, 

 and it is occasionally studded with small cysts, containing a serous fluid. 

 The hernia will be most readily found in such circumstances behind the 

 inner part of the adventitious substance ; which should be turned outwards 

 from the inner side, or cut through. 



III. THE PERINEUM AND ISCHIO-RECTAL REGION. 



A connected view of the structures which occupy the outlet of the pelvis 

 becomes necessary, in consequence of the important surgical operations occa- 

 sionally performed on the geuito-urinary organs and the rectum, which are 

 contained in that part. In the examination of these structures, which it is 

 proposed to make in this place, attention will be confined to the male body. 



The hip-bones as they bound the outlet of the pelvis are already 



