314 Femoral Hernia 



downwards, and backwards round the falciform process, and then 

 upwards through the crural ring. 



The seat of the strangulation of a femoral hernia is at the rigid 

 margin of the crural ring, that is, outside the sac. Therefore, the 

 operator may expect to effect reduction, after easing this constriction, 

 with the hernia-knife, without opening the sac. He divides all the 

 coverings down to the sac by a vertical incision, and then slips the probe- 

 pointed bistouri through the crural ring, in front of the neck of the sac, 

 easing the constriction by a slight incision upwards and inwards, but 

 not too much upwards, lest he sever Poupart's ligament, and wound 

 the spermatic cord which lies along it, or the epigastric artery which is 

 above it. The fibres divided are those at the junction of Poupart's 

 and Gimbernat's ligaments. 



Allusion is made elsewhere (p. 371) to those rare instances in which 

 the operator wounds an irregular obturator artery. 



Perinea! and vaginal berniae are closely associated anatomi- 

 cally ; they pass down in front of the rectum. The former descends 

 in its peritoneal sac along the rami of the ischium and pubes to the 

 perineum through the levator ani, deriving a covering from the recto- 

 vesical fascia ; the latter simply bulges into the vagina. 



Obturator hernia escapes through the upper part of the thyroid 

 foramen, where it would compress the obturator nerve, causing peri- 

 pheral neuralgia. (There is a good example of this hernia in the 

 museum of St. Mary's Hospital, No. C. d. 19). To ease the strangula- 

 tion of an obturator hernia, an incision would be made from the inner 

 third of Poupart's ligament vertically down the thigh for three or 

 four inches, dividing skin, superficial fascia, fascia lata the common 

 femoral and the long saphenous veins being carefully avoided. Then 

 the pectineus would be exposed, and the interval between it and the 

 adductor longus would be carefully traversed. The short adductor 

 having been drawn downwards and inwards, the small protrusion 

 would be recognised. If it were necessary to enlarge the shallow 

 obturator canal, the obturator membrane might be incised by the 

 hernia-knife. 



Hernia through the great sacro-sciatic foramen, like the varieties 

 just mentioned, is very rare. 



THE CAVITY OF THE ABDOMEN 



The peritoneum lines the abdominal cavity and is stretched 

 around (Ti-f/K, rcti/ftp) most of the viscera, its reflections constituting 

 ' false ligaments.' The attachment to the abdominal walls is not very 

 intimate except in the neighbourhood of the umbilicus ; in the opera- 

 tion of ligation of an iliac artery the peritoneal pouch can be easily 

 stripped up from the iliac fossa ; whilst an abscess bursting through 

 the back of the liver, between the layers of the coronary ligament, 





