THE FRONT OF THE THIGH 405 



pelvis and the increased size of the femoral ring, and partly 

 because the peritoneal fossa, which lies opposite the ring, is 

 more pronounced in the female. In young girls and female 

 infants inguinal hernia (p. 264) is the commoner variety, but 

 after puberty femoral hernia is the commoner of the two. 



Owing to the narrowness of the canal and the unyielding 

 character of its walls, the occurrence of irreducible femoral 

 epiplocele is not uncommon, and femoral hernias frequently 

 become strangulated. In operating on a strangulated femoral 

 hernia, some difficulty may be experienced in recognising the 

 sac when it is reached on account of the cedema and congestion. 

 All the layers must be divided until the escape of the discoloured 

 fluid from within the sac indicates the proximity of the bowel. 

 Before the condition of the gut at the constricted neck can be 

 examined and the hernia reduced the femoral ring must be en- 

 larged. Owing to the nature of the boundaries of the ring 

 (p. 403) this can only be carried out on the medial side. A 

 director is passed along the medial side of the neck of the sac 

 and a guarded knife is introduced. Two. or three small incisions 

 are made in the free edge of the lacunar ligament (of Gimbernat), 

 until the opening is sufficiently enlarged to permit of the bowel 

 being withdrawn for examination. In a very small percentage 

 of cases this proceeding is at once followed by severe haemorrhage, 

 due to injury of an abnormal obturator artery. Normally the 

 obturator artery (p. 411) arises from the hypogastric, but in 

 about 20 per cent of cases it arises from the inferior (deep) 

 epigastric (Fig. 121). In its subsequent course towards the 

 obturator foramen it may pass either to the medial or lateral 

 side of the femoral ring. When the artery passes medial to 

 the ring it is apt to be injured when the lacunar ligament is 

 incised in relieving the strangulation of a femoral hernia. If 

 the bleeding points cannot be caught it will be necessary to cut 

 down on and ligature the inferior epigastric artery (p. 253). 



Cold abscesses originating in connection with the vertebral 

 column or the hip- joint may give rise to a swelling in the proximal 

 part of the thigh. As they possess an impulse on coughing, 

 and disappear or decrease in size in the recumbent position, 

 they may be mistaken for femoral hernise. The point at which 

 they emerge from behind the inguinal ligament may clear up 

 the diagnosis, for the neck of a femoral hernia is always placed 

 distal to the medial extremity of the ligament, whereas a cold 

 abscess appears to the lateral side of the femoral vessels (p. 522). 



