1817
ARTES
SCIENTIA
LIBRARY VERITAS OF THE
UNIVERSITY OF MICHIGAN
WITT
TCEBOR
CIRCUMSPICE
The
George E. Wantz
(UM Medicine 1946)
Collection
All Nor
3 plates.





ON
SOME POINTS
CONNECTED WITH
THE ANATOMY AND SURGERY
OF
INGUINAL AND FEMORAL HERNIE:
BEING
THE SUBSTANCE OF THE LECTURES DELIVERED IN THE THEATRE
OF THE ROYAL COLLEGE OF SURGEONS IN FEBRUARY 1831.
BY
G. J. GUTHRIE, F.R.S.
SURGEON TO THE WESTMINSTER HOSPITAL, AND TO THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL, &c. &c.;
DEPUTY INSPECTOR-GENERAL OF ARMY HOSPITALS DURING THE LATE WAR IN
PORTUGAL, SPAIN, FRANCE, AND THE NETHERLANDS.
LONDON:
BURGESS AND HILL, GREAT WINDMILL STREET.
1833.

Taubman/Rare
Book Room
RD
621
G87
20
102.
COTA
PRINTED BY RICHARD TAYLOR,
RED LION COURT, FLEET STREET.

33
THE following observations were written nearly two years ago, and
the press has been standing for many months, with the hope that they
might form part of the first volume of the Transactions of the Royal
College of Surgeons in London. This hope being disappointed, they
are unavoidably published, and will probably be the first of a series
on various subjects, which may at some future day compose a volume
of Contributions in Surgery.
2 Berkeley Street, August 22, 1833.

SURGICAL WORKS BY MR. GUTHRIE.
ON GUN-SHOT WOUNDS, ON INFLAMMATION, ERYSIPELAS, MORTIFICATION,
INJURIES OF NERVES, AND OF THE EXTREMITIES requiring the greater Operations of
Amputation at the Hip Joint, Shoulder Joint, &c. &c. Third Edition, 8vo. Plates. Boards, 18s.
vers Jedi sgor odd miw edinom ynam rol galbuste mood and easy sit
LECTURES ON THE OPERATIVE SURGERY OF THE EYE; being an Historical and
Critical Inquiry into the Methods recommended for the Cure of Cataract, &c. &c. Third Edition.
The SECOND VOLUME on the DISEASES OF THE EYE, being the Lectures of 1832, is preparing
for the Press.
ARTERIES,
ON THE DISEASES AND INJURIES OF ARTERIES, AND THE OPERATIONS RE-
DISEASES AND INJURIES OF
S. AND T
OPER
QUIRED FOR THEIR CURE; being the Substance of the Lectures delivered in the Theatre of the
Lectures delivered in t
Royal College of Surgeons in the Spring of 1829. 8vo. Boards, 14s.
The LECTURES ON THE ANATOMY AND DISEASES OF THE BLADDER AND
URETHRA, delivered in the Theatre of the Royal College of Surgeons in the Spring of 1830, will be
published in the course of the ensuing Winter.

of neitslogacza to san
61 boysilad
guitudinis si nobalized to luoiib silit
ONordh
edi no deixe of
110
POINTS
SOME
batov
siis seor
alsobivibn
evaid ele
CONNECTED WITH
sw noilossino inoxi
239
gai sus ni 10) if
stimp me I osidue out of
THE ANATOMY AND SURGERY
sdown adt
modi
OF
01 insy to sellem
10
INGUINAL AND FEMORAL HERNIE.s
nd bus bis radi vd Jooldus ein stegikovni of drob odw
gu beburol
penins al fonso lenioggi
I HAD the honour of delivering the Lectures in the Theatre of the Royal
College of Surgeons, in February 1831, on the Anatomy and Surgery of Inguinal
and Femoral Herniæ; and I took the liberty on that occasion to demonstrate
the anatomy of some of the parts concerned in these derangements in a manner
which had not been commonly adopted, but which I trust will be found more
satisfactory than the method which is usually followed. A difference of opinion
in regard to the structure of a part of the body is not of much real importance,
unless it involves some practical point; and it is under this impression I venture
to hope that the dissections made on that occasion, and the elucidations and
explanations which resulted from them, have enabled me to remove a discrepancy
that existed between the anatomy and surgery of these parts, which I had always
pointed out in my private lectures, but was unable previously to explain.byd
According to the prevailing opinion of modern surgeons, the parts through
which an inguinal hernia passes or proceeds, have little or nothing to do with the
causes of strangulation; which are supposed to depend upon certain circum-
stances connected with the state of the protruded parts themselves, rather than
upon any positive contraction or diminution of the size of the aperture through
which they pass. If it had been generally demonstrated or believed that the inner
or superior opening of the inguinal canal was a muscular opening or split, through
or between the fibres of which the protrusion took place, there would have been
B

2
little difficulty or hesitation in attributing the cause of strangulation to a sudden
or irregular contraction of these fibres: but as such fibres were not believed to
exist, or were supposed only to exist on the upper part, the impossibility of any
circular contraction was necessarily inferred; and other causes of strangulation
were sought for in the ingenuity of those individuals whose attention was devoted
to the subject. I am quite aware, that these individuals have been and are among
the number of the most celebrated anatomists and surgeons in Europe; that any
effort to add to their labours may be considered an act of supererogation; and
that any attempt to differ in opinion from them will be thought, perhaps, a
matter of vanity. Facts have, however, forced themselves upon me so strongly,
that I could not help acknowledging their influence; and it will be for those
who doubt, to investigate this subject by their aid, and, by a similar patient
inquiry, to confirm or confute the opinions I have founded upon them; viz. that
the inner or superior opening of the inguinal canal is a muscular opening, or
rather split, capable of a great degree of contraction, which is usually the cause
of strangulation in cases of recent herniæ, and is by no means an infrequent
one even in older ones. Before I was enabled to demonstrate the muscular
structure of these parts, I had had the opportunity of examining the bodies of
two persons who had died from strangulated hernia, in both of whom the
stricture on the intestine had been so great, that a common silver probe could
not be easily passed in the canal of the gut. The last case was that of a person
who had been operated upon, and died shortly afterwards; the intestine had
been returned into the cavity of the abdomen, and was found lying behind the
inner ring, with a narrow but deep indentation around it, marking the place at
which the stricture had existed, and through which a probe could only be passed
by dilating the contraction. I showed the preparation at my Lecture, and declared,
what I believe to be true, that this could only have taken place from some direct
muscular pressure from without, and not from any congestion or dilatation from
within or below the stricture. I also acknowledged that I could not show, by
dissection, in what manner this contraction had taken place, or by what parts it
was effected. I have always, however, continued to impress upon the minds of
the gentlemen attending my Lectures for the last ten years, that the principal
cause of strangulation in recent hernia was a contraction of the superior or
internal opening of the inguinal canal, the cause and nature of which I could
MU

3
not satisfactorily explain; that it was, therefore, a point in anatomy deserving
investigation, for a discrepancy of this kind could not exist in nature; and that
there must be something defective in our knowledge of the subject. iied visib
That it may not be considered I am combating a shadow, I shall first show
what are the opinions of some of the ablest anatomists who have written on
these points, and then proceed to develope my own.odt baided tedt bas
Mr. Samuel Cooper, whose Surgical Dictionary may be justly consulted as a
summary of the opinions of the principal surgeons of Europe, has given, in the
last edition of this Work (of 1830), page 653, the following account of the anatomy
of the parts concerned in inguinal hernia, compiled with especial reference to the
Works of Sir Astley Cooper, Messrs. Lawrence, Scarpa, Hesselbach, Cloquet, and
Langenbeck. como leour ads fou el si od of eggs i en sleg 367
30-03
"The tendinous fibres of the aponeurosis of the external oblique muscle, as
they run downwards and forwards towards the pubes, separate from each other,
so as to leave a triangular opening, called the abdominal ring, which is usually
more capacious in the male than the female subject. The upper and inner pillar
(as it is termed,) of this aperture is inserted into the symphysis of the pubes, and
is the weakest of the two; the lower and outer one, which is the strongest, is
chiefly a continuation of Poupart's ligament (Hesselbach, Über den Ursprung, &c.
der Leisten-und-Schenkelbrüche, p. 4.), and is fixed into the angle and crista of
the same bone. Some tendinous fibres cross the upper and outer angle of the
ring, so as to diminish the triangular appearance of the whole aperture: these
are said to be very strong in old hernia. The anterior and thicker layer of the
aponeurosis of the internal oblique muscle joins the tendon of the external oblique;
the posterior and thinner one joins that of the transversalis; but the lower por-
tion of this tendon, together with the corresponding part of the transversalis,
goes wholly in front of the rectus muscle. Thus, the inferior border of the obli-
quus internus and transversalis, which originates from the upper part of Pou-
part's ligament, lies behind the outer pillar of the abdominal ring. Sir Astley
Cooper first noticed, that a thin fascia proceeds from the inner edge of Poupart's
ligament, and spreads over the posterior surface of the transversalis. This fascia
forms the only partition between the peritoneum and the outer opening of the
abdominal ring; and were it not for its existence, inguinal hernia would pro-
bably be much more frequent. The partition in question, however, is said by
B 2

4
Scarpa to be formed by the aponeurosis of the internal oblique and transverse
muscles; while Hesselbach, who has named the small smooth point, situated
directly behind the outer opening of the abdominal ring, its crural surface,
distinctly states that it is formed by delicate fleshy and tendinous fibres of the
internal oblique muscle (Über den Ursprung, &c. der Leisten-und-Schenkelbrüche,
p. 4.); and that behind them is the weakest part of what he names the internal
inguinal ligament, in the rear of which is the peritoneum, with the intervention
of a very loose cellular substance (Op. cit., p. 26.). The internal inguinal liga-
ment of Hesselbach is, therefore, clearly the same thing as the above fascia, first
pointed out by Sir Astley Cooper. This point of the abdomen is one of the
three weak places on the inside of the inguinal region, where herniæ are liable
to occur; yet, weak as it appears to be, it is not the most common situation for
such tumours. A computation has been made, that in a hundred cases of inguinal
hernia, not ten occur at the point here specified (H. J. Brünninghausen, Unter-
richt über die Brüche, &c. Wurzb. 1811.). Mr. Lawrence observes, that if we
trace the fascia transversalis from the crural arch upwards, we shall find it
divided immediately into two portions, an internal and external, which leave
between them a considerable interval, just in the middle of the crural arch.
The former of these, which is the strongest and most decidedly fibrous, is con-
nected by its inner edge to the outer margin of the rectus, and to the inferior
margin of the tendon of the obliquus internus and transversus; and both are
gradually lost above, between the peritoneum and transversus (On Ruptures,
ed. 4. p. 179.).”—Mr. S. Cooper then proceeds to give the following explanation of
the parts as they appear on dissection (p. 658.). "The removal of the integuments
exposes the exterior investment of the hernial tumour, continuous with the mar-
gins of the ring, and formed of tendinous fibres from the aponeurosis, the cre-
master muscle, &c. This is connected by cellular substance with the proper
hernial sac, formed of the peritoneum. This production of the peritoneum
passes within the ring of the external oblique, and then goes upwards and out-
wards. Behind and above the ring, the inferior margin of the obliquus internus
and transversalis crosses the neck of the sac. When these muscles are reflected
towards the linea alba, the fascia, ascending from Poupart's ligament, and form-
ing the upper opening of the ring, is exposed, and the epigastric artery is disco-
vered emerging from the inner side of the neck of the hernial sac (Camperi

5
Icones, tab. x. 6. M.), which, at this precise point, becomes continuous with the
peritoneum lining the abdomen. The removal of the hernial sac will disclose
the course of the spermatic cord in its descent towards the testicle; and when
this is also elevated, the first part of the course of the epigastric artery, and
its origin from the iliac trunk, are exposed. (Lawrence On Ruptures, edit. 4.
p. 203.)"
The following is Cloquet's description of these parts :-
"The inferior fibres of the internal oblique muscle have a direction nearly
transverse. They are usually intimately intermingled with those of the trans-
versalis muscle, which is placed behind it. They are inserted externally into
Poupart's ligament, internally into the pubes, between its spine and angle. The
inferior edge of the internal oblique is then parallel with the crural arch (Pou-
part's ligament). In some persons it is separated, and very distinct from the
transversalis muscle; in others it is so intimately connected with it, that they
cannot be separated. A number of dissections, carefully made, appear to show,
that the inferior edge of the transversalis muscle, composed of very pale fine fibres,
passes in a transverse direction across the spermatic cord, at the spot where it
enters the inguinal canal; that is, on a level with the superior opening of the
canal. It is inserted internally in the inferior part of the linea alba, and slightly
to the pubes by uniting with the aponeurosis of the internal oblique, the inferior
edge of which muscle, arising, as I have said, from the crural arch (Poupart's
ligament), descends parallel to it, covering the spermatic cord in the inguinal
canal, and is attached internally to the pubes. The internal oblique crosses over
the spermatic cord just at the point where it passes out from the superior opening
of the inguinal canal. The fibres, which go to form the cremaster muscle,
change their direction and form; those which were straight and nearly hori-
zontal, become curved and vertical. They pass through and descend below the
ring, forming successively, in front of the spermatic cord, several nooses or
arches, with their concavities turned upwards, and which may be traced to the
bottom of the scrotum. These fibres are situated upon the anterior face of the
spermatic cord and tunica vaginalis.
"The inferior fibres of the transversalis muscle are very thin, run transversely,
and give rise to an aponeurosis, which passes inwards, and soon unites with the
internal oblique muscle, which lies exterior to it and goes to be inserted with it in

6
the linea alba, passing in front of the rectus muscle, and into the superior part
of the pubes, behind the internal pillar of the ring and the pyramidalis muscle.
The spermatic cord does nothing more than slide under the inferior border of
the transversalis muscle, on a level with the superior opening of the canal.
"The Fascia transversalis," he says, (page 27.) after describing it minutely,
" is an aponeurosis, the thickness of which varies: it springs from the posterior
edge of the crural arch (Poupart's ligament), from the aponeurosis of the iliac
muscle, from the external border of the rectus muscle, and is continued upwards
with the cellular tissue on the internal surface of the abdominal muscles: below
and towards the middle of the crural arch this aponeurosis gives rise to a mem-
branous canal, commencing by a wide opening directed backwards and outwards,
the internal edge of which is thicker than the outer. This canal descends around
the spermatic vessels, forming their proper sheath. The fascia transversalis sup-
ports the peritoneum, which is behind it, the epigastric artery passing between
them. Before, it corresponds to the transversalis muscle, with the aponeurosis
of which it is often so closely united that it can only be distinguished from it by
the different direction of its fibres.
bosib seveni's ni
"Finally," he says, (page 32.) "the passage of the spermatic cord through the
abdominal parietes does not take place through a simple ring, but through a
truly oblique canal. This is the Inguinal canal. The aponeurosis of the external
oblique muscle is reflected, as I have already said, backwards, and then upwards
to give origin to the fascia transversalis. By thus passing backwards and then
upwards it forms a straight but deep groove, the convexity of which is turned
downwards towards the crural canal, and rests partly on the psoas and iliacus
muscles, the concavity being of course turned upwards, and corresponding to
the inguinal canal. This groove (gouttière) extends from the pubes to the supe-
rior and anterior spine of the ilium, and gives attachment in nearly all its length
to the fibres of the internal oblique and transversalis muscles; and, moreover,
contains, in a part of its extent, the spermatic cord in man, and the round liga-
ment of the uterus in the female. Its anterior wall is thick, and formed by the
tendon of the external oblique muscle, having, posterior to it, the internal oblique;
at the inner and under part, near the pubes, is the inguinal ring (the lower opening
of the inguinal canal). The posterior wall of the canal is formed by the reflected
portion of the aponeurosis of the external oblique (viz. the fascia transversalis),

7
which ascends behind and in connexion with the internal oblique and transversalis
muscles. It is pierced by the superior opening of the inguinal canal, situated
more outwardly and higher up than the inferior opening, from which it is about
an inch and a half distant, being the length of the inguinal canal containing the
spermatic cord. Between the superior orifice of the canal and the anterior
superior spine of the ilium, the groove formed by the external oblique and
Poupart's ligament is filled up by the internal oblique and transversalis muscles.
Between the superior and inferior orifices, the groove constitutes the inguinal
canal, containing these muscles and the spermatic cord. Lastly, the groove
ends within the inguinal ring, at the pubes, by a small triangular space,
bounded before by the internal pillar of the ring, behind by the tendon of the
rectus and pyramidalis muscles, and often by a fasciculus of radiated tendinous
fibres, which ascend in diverging from the external pillar of the ring, pass behind
its internal pillar, and are affixed into the lowest part of the linea alba." pildo
noP. F. Blandin, the latest French writer on this subject, says, in his Traité
d'Anatomie Topographique, Paris 1826, page 330:-
"The inguinal canal, or inguinal passage, is flattened from the front back-
wards, is about an inch and a half in length, is directed obliquely forwards and
downwards; it occupies the abdominal wall in that triangular interval which I
have already mentioned, an interval bounded within by the rectus muscle,
below by the crural arch, above by the conjoined inferior edge of the internal
oblique and transversalis muscles; a point of the abdominal wall which would
be very weak, as these two last muscles do not descend to it, if a special apo-
neurosis, the fascia transversalis, was not fortunately superadded. The inguinal
canal offers a middle and two extremities or openings; the middle part has four
walls; of the two openings, one is superior, the other inferior. quines
S" 1st. The anterior wall of this passage is formed by the aponeurosis of the
great oblique muscle, covered by the fascia superficialis, the external vessels,
and by the skin.
pildo larut
"2nd. The posterior wall is formed by the fascia transversalis, lined poste-
riorly by the peritoneum, and having behind it the epigastric artery.
ba" 3rd. The inferior wall is formed by the hollow of reflection upwards from
Poupart's ligament of the fascia transversalis.
4th. The superior wall, less strongly marked, is traced by the lower edge

8
of the internal oblique and transversalis muscles. The interior of this passage
is lined by the hollowed-out prolongation of the fascia transversalis."
Velpeau is to the same effect, Traité d'Anatomie Chirurgicale, ou Anatomie des
Régions, Paris 1826, tome ii. page 78.
Sir Astley Cooper, in his book on the Structure and Diseases of the Testis,
(1830,) gives the following description of the anatomy of the inguinal canal, and
which is a revision of, and improvement upon that to be found in his first Work
on this subject.
"This canal is bounded at the lower part by the external abdominal ring,
formed by the tendon of the external oblique muscle; at its upper part, by the
internal ring, formed by the fascia transversalis. In dissecting it, after removing
the integuments, the superficial fascia of the tendon of the external oblique
muscle is laid bare. An incision is to be made through the tendon of the external
oblique, beginning above the abdominal ring, and extending near to the anterior
and superior spinous process of the ilium. The edges of the divided tendon
being then turned down, the inguinal canal is brought into view. At the lower
part of the canal, just above the abdominal ring, the spermatic cord appears in
the centre, the cremaster muscle between it and Poupart's ligament; above it
the tendinous insertion of the internal oblique muscle, which passes behind the
upper part of the abdominal ring to the sheath of the rectus muscle. At the
upper part of the canal, in this first view, the internal oblique is seen arising
from Poupart's ligament, and crossing over the cord and part of the cremaster
muscle in the form of an arch: some of its muscular fibres blend with those of
the cremaster.
"Upon raising the lower edge of the internal oblique from Poupart's ligament,
and turning it upwards, the transversalis abdominis appears. It arises from
Poupart's ligament, under the internal oblique, and also blends with some of the
fibres of the cremaster. It forms an arch over the spermatic cord, and is inserted,
with the tendon of the internal oblique muscle, into the tendinous covering of
the rectus. But the lower edge of the transversalis has a very peculiar insertion,
which I have hinted at in my work on Hernia. It begins to be fixed in Poupart's
ligament, almost immediately below the commencement of the internal ring, and
it continues to be inserted behind the spermatic cord into Poupart's ligament, as
far as the attachment of the rectus. Thus the inguinal canal is endowed with

9
muscular contraction, which, under the action of the abdominal muscles, serves
to close it, to lessen the propensity to hernia. Sometimes a portion of muscle
descends from the tendon of the transversalis in the course of the linea semilunaris,
to be inserted into the fascia transversalis, behind the cord, and into Poupart's
ligament. It is this circular insertion of the transversalis which is the cause of stric-
ture in inguinal hernia, in the course of the canal, and nearly at the upper ring.
"Behind this insertion of the transversalis, the internal portion of the fascia
transversalis appears, adhering strongly to the tendon of that muscle at the back
of the inguinal canal. Thus the inguinal canal is, at its anterior part, formed
by the tendon of the external oblique; in its posterior, by the tendon of the
transversalis, and by its folded muscular fibres; behind which is the fascia
transversalis, into which those fibres are also inserted. It contains the spermatic
cord and the internal oblique muscle. Its lower part is bounded by the external
abdominal ring, formed by the separation of the tendons of the external oblique
muscle; and at its upper extremity are placed the two portions of the fascia
transversalis, forming, with the tendon of the transversalis, the internal ring;
the anterior continued from the edge of Poupart's ligament to the outer side of
the spermatic cord; the posterior, or internal, descending behind Poupart's
ligament, to form the crural sheath, and ascending behind the spermatic cord
and tendon of the transversalis. Between the two layers passes the spermatic
cord. From the edge of the two portions of fascia, a layer of membrane extends
in a funnel shape, uniting itself with the spermatic cord: thus the cord becomes
united to each aperture through which it passes; at the external ring, by the
fascia superficialis; at the upper part of the canal, by membranous processes
from the fascia transversalis, which descend upon and envelope the spermatic
cord. The epigastric artery, arising from the external iliac at Poupart's liga-
ment, curves inwards and upwards, behind the inguinal canal, to the rectus
muscle, giving an artery to the cremaster in its course."3
The reader cannot fail to be surprised at the great difference which exists
between these different versions of the same thing, and that a plain matter of
fact, and not of imagination; and a student in anatomy and surgery, on trying
to reconcile them by an actual examination of the parts, will find considerable
difficulty in making his dissection correspond with any one of the descriptions
which have been quoted; and he will be led to conclude, either that the descrip-
C

10
tions are not sufficiently clear and distinct, if not in some respects faulty, or that
there is so great a variety in the formation of these parts, as to render any one
account of them inapplicable to the greater number. No student can look at
the four engravings No. 1. of Plate I., and No. 1. 2. 3. of Plate II., appended to
this paper, and believe that they are intended to represent the same parts in the
same stage of dissection, without drawing very much on his imagination; yet
they are really intended for that purpose. et ed to coinssi eit buidaff
I hardly dare venture to give the reason which in my mind has led to the
great apparent discrepancy of opinion which exists between so many able men
on so plain a matter of fact. It is possible that it may have arisen from the
great minuteness with which it has been attempted to describe parts that
scarcely deserve it, especially the fascia transversalis, and from the great variety
which exists in the formation of several of the principal parts.
bas bioo
Sir Astley Cooper first gave to the fascia the name of fascia transversalis,
and drew attention to it in so marked a manner as to attract that of other
anatomists. Jules Cloquet made it an object of particular study, and Blandin
and Velpeau consider it to have been more accurately investigated by him, on
which account I have transcribed his account of it, page 5. Cloquet says, that
he had not seen Sir Astley Cooper's Work, but had formed his ideas of it from
that of Mr. Lawrence; and it appears to me that he, Blandin, and Velpeau,
have fallen into a misapprehension on the subject, common to many of our own
countrymen, who have described that to be fascia transversalis alone, which is
in reality the tendon or aponeurosis of the transversalis muscle implanted upon
it; for without such misapprehension it is impossible to say that the spermatic
cord always lies on the fascia transversalis in any part of its course after it has
passed the superior opening of the inguinal canal, and has emerged from under
the fleshy fibres of the transversalis muscle; nevertheless this is said to be the
case. The statement made by Cloquet, Blandin, and Velpeau, that the fascia trans-
versalis arises from the inner edge of Poupart's ligament by a reflection upwards
of that part, whilst Sir Astley Cooper describes it as passing beneath to form
the sheath of the femoral vessels is another cause, I suspect, of the misunder-
standing which has taken place. Cloquet, who wrote from very laborious ob-
servation, says, in a note at page 26 of his Work, and in addition to the obser-
vations I have quoted, page 6," that very often the fascia transversalis is evi-

11
dently formed of two aponeurotic layers, which are united on a level with the
top of the crural arch. Of these the anterior comes from the arch itself (Pou-
part's ligament), the posterior being only a continuation of the fascia iliaca,
which quits the iliac muscle to ascend upon the anterior wall of the abdomen.
These two layers thus reunited proceed back to back between the transversalis
muscle and the peritoneum. It is easy to separate them on the outside of the
superior opening of the inguinal canal, but on the inside and around it they
are intimately united. When this formation is met with, the posterior layer
passes usually behind the rectus muscle in its way to the linea alba, whilst the
anterior one is continuous with the edge of the tendon of the rectus. The
epigastric artery is sometimes posterior, sometimes anterior, and sometimes even
between these two layers." This description, which Cloquet gives as of an
accidental occurrence, is, in my opinion, that which most frequently takes place;
and if the fascia transversalis be said to be composed of two layers, the anterior
being fibrous, the posterior cellular, much confusion will be avoided.
The division which is made of the fascia transversalis into two parts, where it
lines the wall of the abdomen, one being called external, the other internal,
or anterior and posterior by Sir Astley Cooper, (but which are not the anterior
and posterior layers of Cloquet,) the spermatic cord passing between them through
an opening, which is named the superior opening of the inguinal canal; is also
a fertile source of inconvenience to the student, who will seek in vain for any
such opening. If he is taught to consider the fascia transversalis as a sheet of
condensed cellular membrane divisible in some parts into two layers, passing
upwards from Poupart's ligament to fortify the peritoneum, he will readily un-
derstand it; and if he is shown that at a certain spot it becomes much thinner
and allows the spermatic cord to pass through, he cannot fall into any misap-
prehension. This part is not however an opening; it is merely the thin portion
of the fascia which, as the testis escaped from the abdomen, was carried forward
by that gland, and is now seen attaching itself to the spermatic cord. If this
cord be drawn down and an incision be made around it close to where it is
attached to the peritoneum, a sort of ring is formed, and if the finger be intro-
duced, the thin part can be stretched or torn, until the firm internal edge of the
denser anterior layer of fascia transversalis can be distinctly seen, having the
epigastric artery a little to its inner side. The outer side of the ring is not so
c 2

12
well marked, and the hole thus made by the finger is usually so large, and its
outer edge so weak, as to occasion little fear of any great constriction being
made by it on any portion of the contents of the abdomen which may be pro-
truded through it. It is therefore not the part which constitutes the stricture
at what is called the inner ring. Hand becouser hollavor ruft eve
sand T
When the peritoneum is carefully removed from the inside of the wall of the
abdomen, by tearing through the cellular membrane which attaches the one to
the other; the fibrous or anterior layer of fascia transversalis is not the part next
brought into view, but a distinct layer of cellular structure resembling fascia,
although oftentimes loaded with fat, which can be readily dissected off in a com-
plete sheet, carrying with it the epigastric vessels which adhere rather to it than
to the fibrous texture in front. This cellular layer I take to be the same thing
as the posterior layer of Cloquet; but whether it is or not, it passes behind the
rectus to meet its fellow from the opposite side, covers the iliac vessels below and
passes under Poupart's ligament, forming their cellular and adipose sheath and
the septum which passes between them. When this cellular layer is turned down,
(as in Plate III. fig. 1.) the fibrous fascia transversalis is brought into view. If
an attempt is made to turn the latter down from the transversalis muscle two
inches above Poupart's ligament, it is often found to adhere very firmly to it, and
to its aponeurosis. When muscular at this part, many of the fibres seem to be
implanted on it, although both muscle and aponeurosis are sometimes wanting, in
which case only can the spermatic cord lie upon the fascia transversalis. When
the tendons of the internal oblique and transversalis muscles are complete and
well marked, and they and the fascia transversalis are traced inwards to the
rectus muscle, the two tendons are seen to pass in front of it very distinctly;
the fibrous layer of the fascia transversalis on the contrary divides, the anterior
and thickest part is attached to the anterior edge of the rectus; the other, which
is very thin, passes behind the rectus to meet its fellow from the opposite side;
but at the lower part close to the pubes, a portion of the fascia transversalis
becomes very strong, and resembles, more than any thing else, a round white
tendon going to be inserted into the pubes near its symphysis, and behind the
rectus. The interspace formed by the recedence of the two insertions is very
distinct, the rectus filling it up. The fascia transversalis passing externally
from this sort of tendinous insertion, is attached to the inside of Gimbernat's

13
ligament, of which it forms the internal layer, and is then continuous with the
pelvic fascia. Passing from the upper edge of Gimbernat's ligament, or the
third insertion of the external oblique muscle, to the inner edge of Poupart's
ligament, or the second insertion of the same muscle, the fascia transversalis
seems to adhere so strongly as to appear to be a reflection upwards from it,
which is the view taken of it by the French anatomists: but if care be taken
in making the dissection, it can with some difficulty be separated from it, and
be shown to pass under the ligament to form the septum crurale, and the an-
terior part of the sheath of the femoral vessels. Exterior to the femoral artery
the fascia transversalis is firmly attached to Poupart's ligament, and is con-
tinuous with the iliac fascia. ) to ogbamin
The transversalis muscle lies immediately upon the fascia transversalis. Its
inferior edge is said to pass over the spermatic cord at the inner or superior
opening of the ring, in order to form, with the internal oblique, the sheath of
the rectus. This I believe to be in many instances an incorrect description.
In the demonstration of these parts in the Theatre of the Royal College of
Surgeons, I had the opportunity of showing (see Plate I.) the transversalis
muscle advancing fleshy or muscular, until it reached the spermatic cord; a
portion of it then took the usual course above and over it, whilst another por-
tion passed below it, the terminating muscular fibres of which were inserted
along the inner edge of Poupart's ligament up to the pubes. The muscularity of
this insertion was admitted by the various teachers of anatomy, and other com-
petent judges who were present. The lower part of the abdomen was thus shown
to be defended by a layer of muscular and tendinous fibres, lying upon the
fibrous layer of the fascia transversalis; and the spermatic cord passed, not,
as it is usually stated, under the inferior edge of the transversalis muscle, but
through a split in it originally formed for the purpose of giving passage to the
testis. This split or opening was rounded on its under part where the spermatic
cord rested upon it, and formed a small opening essentially muscular in every
direction, and much less in size than that which is described as the opening of
the fascia transversalis, which adheres to the internal surface of the muscle.
It is this part therefore, and not the fascia transversalis alone, which consti-
tutes the inner or superior opening of the inguinal canal for all surgical purposes.
The transversalis muscle does not, however, in the generality of instances, send

14
its inferior portion forwards and beneath the spermatic cord in so marked a
manner. This part of the muscle more frequently becomes tendinous and apo-
neurotic; but its fibres, although tendinous, are distinctly marked, running
transversely in continuity with the fleshy fibres of the muscle, and are insepa-
rably united to Poupart's ligament. In some instances the muscular fibres of
the transversalis do not take so oblique a direction from without inwards and
downwards, but crossing more horizontally, send down a narrow tendon, on
forming with the internal oblique the sheath of the rectus, which descends
almost perpendicularly for some distance, to be inserted into the tuberosity or
spine of the os pubis. The inferior or aponeurotic part of the transversalis may
be equally present, forming the inferior edge of the inner opening of the inguinal
canal; but this formation cannot take place if the spermatic cord passes imme-
diately over Poupart's ligament, in which case, this ligament forms the under
part of the inner opening of the inguinal canal, the lower edge of the transver-
salis muscle the upper, and the fascia transversalis the sides. The epigastric
artery runs within a few lines of distance from the internal edge of this part or
opening; and between this vessel, on the outside, the edge of the rectus on the
other, and Poupart's ligament below as the base, the triangular space of Hes-
selbach is formed, through which that sort of hernia takes place, which is called
internal by him, but direct by Sir Astley Cooper, to distinguish it from the more
common one which, passing through the inner or superior opening of the ring, is
called external by Hesselbach, and oblique inguinal hernia by Sir Astley Cooper.
When the transversalis muscle is inserted broadly into Poupart's ligament
by its superior fibres only, the anterior ones pass on to form the sheath of the
rectus, and to be inserted into the tuberosity of the os pubis; but a layer of
fibres internal to these (the folded fibres of Sir Astley Cooper,) are implanted
on the fibrous external layer of the fascia transversalis, and curve downwards to
be inserted into Poupart's ligament, or proceed, according to Breschet, to form
what he calls the pretended ligament of Gimbernat, and which he will not admit
to be a third insertion of the external oblique muscle. These fibres are depicted
by Cloquet (Plate I. fig. 3.) as belonging to the fascia transversalis, and by
Breschet (Plate III. fig. 1.), in his Considérations et Observations Anatomiques et
Pathologiques sur la Hernie Fémorale, Paris 1819, as essentially going to form
the internal layer of Gimbernat's ligament, of which the fascia lata of the thigh

15
supplies the outer. They are very distinctly shown in Plate III. fig. 1., and
certain other fibres running in a less curved and more vertical direction, be-
longing to the anterior or fibrous layer of the fascia transversalis, are equally
well marked. These fortify this part in an especial manner, and something like
the way in which the outer angle of the external ring is strengthened by fibres
crossing in a similar manner. to
1195 and heq aidi
It may appear that I am laying claim to the discovery of the muscularity of
the superior opening of the inguinal canal, after such a structure had been pre-
viously described by Sir Astley Cooper. I had not, however, seen his Work at
the time; and it was in consequence of my mentioning my ideas to him, that he
made the dissection with Mr. Owen and myself, engraved in Plate II. fig. 1, to
show us his view of the subject. The opinion, that this opening is in many
instances a muscular one, was I believe first advanced by myself, having always
maintained that point since the year 1816, although I had not been able to
give a demonstrative proof of it until the delivery of my lecture on the subject
in the Theatre of the College of Surgeons. There is, however, a difference
between us, as to the manner in which the muscularity is effected. Sir Astley
Cooper considers it to be accomplished by what he calls the folded fibres of
the transversalis, that is, the internal layer of the fibres of the muscle which
turn down inside the ring to be inserted into Poupart's ligament, according to
Breschet as tendon of the transversalis going on to form the internal layer of
Gimbernat's ligament, or according to Cloquet being inserted into his anterior
layer of the fascia transversalis, as a part of which he has depicted them.
According to my view of the matter, the ring, opening, or split, cannot be
rendered a complete muscular circle, by any muscular fibres, which merely
pass over and curve round to one side for insertion; one half, or at most two
thirds only of a circle can be effected by such disposition of fibres; but if an
inferior portion of transversalis muscle be admitted, and in the manner I have
demonstrated it, then the circle is completed, and its muscularity is established,
in all cases in which such a disposition of fibres exists. If I might venture to
try to reconcile these views, I would do it by saying, that the circular structure
can only take place when the opening or ring is formed by a split in the
muscle, or in it and its aponeurosis, and can only be shown advantageously as
a circle when the part has suffered a certain degree of distention, which brings

16
it to that form; but even in that case there are no perfectly circular fibres,
each apparently circular one being of necessity formed of two parts, one from
the upper, and one from the under edge of the transversalis. sd of gal
From the misapprehension which has taken place with reference to the infe-
rior portion of the transversalis muscle, the coverings which a hernia of direct
descent receives at this part has been a matter of doubt. Mr. S. Cooper gives
(page 660 of his Dictionary,) the opinions upon this point of Messrs. Hesselbach,
A. Cooper, Cloquet, Lawrence, and Stanley, leaving it, however, undecided
whether the covering or investment is or is not formed as, he says, Sir Astley
Cooper is reported to have described it in his lectures, viz. one half by the tendon
of the transversalis, and the other half by the fascia transversalis. According
to my version of the anatomy, it appears to me quite clear that there are two
investments, one formed of the two layers of the fascia transversalis, and another
external to that formed by the tendon or aponeurosis of the transversalis. The
statement said to be made by Sir Astley Cooper can only be correct when there
is no inferior portion of muscular fibre or of aponeurosis to the transversalis
muscle, and which is sometimes wanting, although rather as an exception to the
general rule, than as the general rule itself, or when the insertion of the supe-
rior fibres of the transversalis is effected by a narrow tendon. In the hernia of
direct descent, or the internal inguinal hernia of Hesselbach, the coverings, when
enumerated from within, are, the peritoneum, fascia transversalis, tendon of the
transversalis, and tendon of the internal oblique more or less conjoined, the
intercolumnar fascia, the superficial fascia and integuments. As this hernia
passes to the inside, and rather underneath the spermatic cord, it does not re-
ceive a covering from the cremaster. The external inguinal hernia, or of ob-
lique descent, lies upon or above and to the outside of the spermatic cord; the
internal inguinal hernia, or of direct descent, lies to the inside of, or below and
underneath the cord, constituting the principal features of diagnosis, especially
in old herniæ. In the latter species, or of direct descent, the internal oblique
muscle may not always be inserted low enough down towards the pubes, so as
to give a covering to the hernia, which then only protrudes, or carries before
it the transversalis. This fact will not however be discovered in operating;
for the pressure on the parts causes such a consolidation of them, that the two
tendinous expansions when they exist, become so closely united as to form but

17
one covering. When enumerated from without, the coverings are the integu-
ments, superficial fascia, intercolumnar fascia, the tendinous expansions of the
internal oblique and transversalis muscles when they exist, the fascia transver-
salis, and peritoneum.
The internal oblique muscle would in the male form a layer of muscular and
tendinous fibres external to the transversalis, and a complete support or covering
to this part of the abdomen, if it were not for the opening to admit of the de-
scent of the testis and the passage of the spermatic cord. The gubernaculum
testis, a part of original formation, is supposed to possess the power of drawing
down the testis through this opening, which I very much doubt. I believe that
the testis descends or ascends, as the case may be, at the proper period, for the
same reason that a child is usually born at nine months in preference to any
other period of utero-gestation, which is, as Avicenna says, by the will of God.
The office of the gubernaculum appears to be to keep a passage open which
might otherwise be closed, if it were not occupied in this manner, rather than
to operate on the testis by any contraction of its substance. As the testis
passes through the transversalis muscle it may bring down with it any fibres
which lie in its way; and when this occurs, the transversalis is found to be
united at this part to the internal oblique, and the fibres thus brought down
assist in forming the cremaster muscle, which is nothing more than a certain
portion of the lower edge of the internal oblique caught by the testis and carried
before it. The fibres caught on the centre of the testis are carried down with
it into the scrotum, by a gradual elongation, so that they form a sort of sling
around the testis, which supports and can raise it towards the abdominal ring,
whilst those fibres which are only entangled on its anterior and posterior sur-
faces, form arches, which descend before or behind according to the situation of
the points of entanglement. The cremaster muscle is then a portion of the
under edges of the transversalis and of the internal oblique muscles, arising
also from Poupart's ligament by its under edge, until it is carried away by the
descent of the testis; but the point of insertion of these fibres remains the same,
viz. into Poupart's ligament near the pubes, after forming the sling and the arches
above described, and which point of insertion was considered by Scarpa and
others until the time of Cloquet, to be another or second origin, which is evi-
dently an error. When the testis is detained in the abdomen, it is not for the
D

18
want of an opening in the transversalis or internal oblique muscles, but for some
reason which has not yet been sufficiently explained, as the person commonly
suffers from a hernial protrusion, the consequence of the part being less defended
than usual by the natural structures.
The anatomy of the inguinal canal from without inwards is as follows. The
tendon or aponeurosis of the external oblique muscle being turned down upon
the thigh, the spermatic cord is seen lying in the inguinal canal, embraced by
the cremaster muscle, which passes down upon it. The lower edge of the
internal oblique separating from the cremaster which is a part of it, passes on
to form its share of the sheath of the rectus. The cremaster being cut across
and turned upwards, the spermatic cord is seen passing from under the fleshy
edge or through the split of the transversalis muscle, and having beneath it
another fleshy or aponeurotic portion of the same muscle descending to be
inserted into Poupart's ligament. It is on this part that the cord lies, and it
forms of course the posterior wall of the inguinal canal, having behind it more
or less closely attached the fascia transversalis. If the internal layer of fibres of
the transversalis curve downwards to be inserted into Poupart's ligament after
passing over the cord, this part lies more decidedly upon them, and not on the
fascia transversalis. See Plate III. fig. 1. intai ant of ting eidy
When, according to this view of the anatomy, an oblique hernia, or one of
indirect descent, takes place, the peritoneum is protruded against and carries before
it the thin portion of the fascia transversalis, which is nearly opposite to the open-
ing in the transversalis muscle, through which the spermatic cord passes. The
bend or elbow, which the cord makes in ascending to pass over the superior edge
of the lower or aponeurotic part of this muscle, or the fascia attached to it, opposes
an insuperable obstacle to a protrusion at this part, and the hernia necessarily
passes above the cord and between it and the lower or fleshy edge of the superior
part of the transversalis. The peritoneum covered by the thin part of the
fascia transversalis having passed through the opening in the transversalis muscle,
meets with the cremaster, from which it receives a covering. If the hernia is
incomplete, by which is understood that it remains within the inguinal canal, it
has no other covering; but if it is complete, or passes through the external ring
as it is called, or the triangular opening of the external oblique muscle, it gains
two additional layers; one from the thin fascia which runs from one column or

19
pillar of the external ring to the other, thereby closing the part, and is called,
with great propriety, the intercolumnar fascia; the other from the superficial
fascia lying under the integuments. The different coverings of an oblique in-
guinal hernia enumerated from without inwards, are, therefore, the integuments,
superficial fascia, intercolumnar fascia, cremaster muscle, fascia (sometimes
called also canalis,) transversalis, and the peritoneum. When an oblique inguinal
hernia takes place, the opening, or what may be truly called the inner opening
of the ring, is by this protrusion gradually stretched or dilated: but if this be
too suddenly done, the irritation caused by it gives rise to spasmodic contrac-
tion, followed by inflammation in the muscular fibres passing over it; and the
hernia becomes incarcerated or strangulated. If the split or opening in the
transversalis is muscular above and below, the contraction upon the protruded
parts will be considerable; if the upper portion only is muscular and the lower
aponeurotic, the pressure will not be so great.
If the hernia is of long standing, two great changes take place in the situation
and even in the structure of the parts. The opening in the transversalis muscle
becomes dilated and rounded. This change takes place principally in the supe-
rior fibres of the muscle, which instead of running obliquely downwards and
inwards become more curved, the convexity being upwards and inwards, and
are of course brought so much nearer to the median line of the body, and to
the pubes, which gives to the insertion of the muscle itself a peculiar curvature;
which is rather the effect of derangement, than a natural appearance of the part.
If the under edge of the opening be muscular, it will of course yield in a similar
manner; and circular fibres will then be seen, which are not I believe observ-
able in the part in its normal state. The fibres of the transversalis which come
from above and below, and meet a little beyond the lower part of the opening,
which is itself rounded to allow the spermatic cord to lie uninjured upon it even
under pressure, represent rather the truncated apex of a triangle or split than
a ring. As this opening is more used and increases in size, it becomes rounder,
approaches nearer to the pubes, and the second change takes place, viz. the
edges lose their sharpness, become less defined, harder and more tendinous;
so that in very old herniæ the muscle loses all power over them, and the ring
or opening remains unaffected by its contraction.old
This view of the nature of the parts and the changes which they undergo,
D 2

20
appears to me to account in a satisfactory manner for all the circumstances
and differences which take place between recent and old hernia. It does more;
it enables us to account for the great difference which exists in the treatment
of these two conditions of hernia. It also reconciles and removes the discre-
pancy observable between the anatomy as hitherto described, and the surgery
as hitherto taught. It removes the difficulty which students had in compre-
hending why some surgeons recommend one mode of treatment, and some
another: why for instance bleeding has been recommended by Sharp, Pott,
B. Bell, Sabatier, Richter, Callisen, Scarpa, and Sir Astley Cooper,-names
which can never be surpassed in respectability; whilst Wilmer, Alanson, and
others, have published against the practice.
In order to understand these points, it is necessary to consider the changes
which have been stated to occur in the relative situation and structure of the parts,
and to make a very marked difference between hernia which are of recent origin
and those of very long standing. In a RECENT HERNIA, or one which has taken
place but a short time before it became incarcerated or strangulated, the parts
through which it passes are comparatively but little altered from their natural
state; and from the view which has been taken of their anatomy, the inner
opening of the ring is a muscular structure capable of exercising great compres-
sion on the protruded parts, and often in a complete circle; so that when these
fibres are spasmodically excited, the compression may be so great as to prevent
all circulation in the hernia, giving rise to a state of strangulation; or it may
be only to that extent which compresses and retains the protruded parts without
entirely preventing circulation, and which is a state of incarceration. In either
case inflammation will soon follow, (unless the pressure is removed,) in conse-
quence of the sharpness of the edges of the compressing parts, and the force with
which they contract on those that are protruded, whilst the secretion of fluids
and of air into them adds to the mischief. The first and greatest object to be
attained in a recent, hernia which has become strangulated, is to take off the
spasmodic and inflammatory contraction of the transversalis muscle forming the
inner ring, which is best done by producing syncope; and there are three great
and common means for effecting this object; viz. bleeding, the warm bath, and
the tobacco enema. When blood is drawn in a recent hernia which has become
strangulated, it should be done or continued, the patient sitting in an erect position,

21
until he faints. When the warm bath is used, it should be at a temperature not
less than 100°, or even as hot as the patient can bear it, and he should be kept
in it until he is in the act of fainting. If the tobacco enema be had recourse to,
nearly the same effect should be produced by administering repeated small doses,
or no good will result from its use. When the patient is in this state of syncope,
or just approaching to it, an attempt should be made to restore the protruded
parts by a well directed pressure, technically termed the taxis, provided they are
capable of bearing it. On this point there is a marked difference between recent
and old hernia when strangulated; there is also no less difference in regard to
the situation of the pain. In recent hernia which have become strangulated in
young and healthy persons, inflammation soon commences in the protruded
intestine and in the part which is above the stricture; and if relief is not ob-
tained, the intestine below mortifies, or ulceration takes place, or would take
place if time were given, immediately at or directly above the part pressed on
by the edge of the transversalis or stricture. The patient therefore in a recent
hernia dies of acute inflammation followed by mortification, rather than of con-
gestion followed by low inflammation and perhaps, although not always, by
mortification; which is the state of parts to be found usually in old hernia which
have become strangulated. The symptoms correspond with the appearances
found after death. In recent hernia when strangulated, there is pain in two
distinct places: at the umbilicus and extending from it to the pit of the stomach,
and in the herniary tumour; and both may be equally acute to the touch as
well as to the sense of the patient. In old herniæ the pain is felt at first, and
often for a long time, at the umbilicus alone; the swelling shows little sign of
derangement, and admits of considerable pressure being made upon it for several
hours and even days after the incarceration and supposed strangulation are
complete. It is a peculiarity in inflammation of the intestines, that the pain is
referred to the umbilicus, whatever part of the intestines may be inflamed; be it
the jejunum or the rectum, the fact is the same; and the acute pain there, and in
the tumour in recent herniæ, only marks the higher degree of inflammation. I
have twice seen patients in whom bougies have been forced through the upper
part of the rectum: I have seen an ulcer eat its way from the rectum into the
cavity of the abdomen, allowing the contents of the gut to escape: and in all these
the principal and essential pain was felt at the umbilicus and upwards to the pit

22
of the stomach; and the same thing takes place in wounds. I have already
stated the reason why the inflammation is more acute in recent herniæ, and it only
therefore remains to show why certain remedies are more proper in one case
than in another;-why bleeding, for instance, which is a sheet-anchor in recent
herniæ that have become strangulated, is comparatively useless in old ones. In
recent hernia, the part forming the stricture is positively contracted from spasm
and inflammation, and the pressure is direct. In old herniæ, the rounded
smooth ring through which the protruded parts pass, does not admit of being
diminished in size by any spasmodic action of the surrounding structures, or
only in a comparatively trifling degree, and the pressure is therefore not direct;
the ring is passive. The parts forced into it by any sudden exertion, suffer from
their own distention, from whatever cause it may arise; and from the evils
which must invariably follow from soft parts being made to press unduly
against others of a much firmer nature. In old hernia which have become
strangulated, the first evil is from congestion and distention: the first stage
is that of incarceration, followed ultimately by inflammation, first shown by
pain at the umbilicus, and after a greater or less lapse of time by pain in the
part, but which is never so acute as in the recent cases. It is, then, in recent
cases of herniæ only which have become strangulated, that bleeding is of so
much importance, aided by the warm bath, and followed by the use of the
tobacco enema in young and healthy persons, previously to the performance of
an operation. The application of cold to the tumour is in my mind always
secondary to that of the hot bath, and should only be had recourse to in recent
hernia which have become strangulated, when it cannot be procured. On the
same principle, however, cold when used must be efficient. In large towns, and
in winter, a mixture of salt and pounded ice can at all times be obtained, and
applied in a half-filled bladder, or the freezing mixture of Sir Astley Cooper,
composed of two ounces and a half of nitrate of potash, with the same quantity
of muriate of ammonia and ten ounces of water, which in cases of old hernia
will often be found very efficient. ed nt laoined Jasoor ai moment ent
Tartar emetic is often talked of as a remedy in strangulated hernia; but as its
effects cannot be controlled, and great nausea and vomiting are often produced,
it is obvious that the efforts made in vomiting may be more detrimental than the
debilitating nature of the remedy can be beneficial. Purgatives are always

23
injurious as such, being merely irritants; although calomel combined with
opium in a soft state may be administered with advantage, as allaying irritation
of the stomach and procuring ease. Injections of hot gruel, with salt and oils
of various kinds, are useful, inasmuch as they clear the rectum, and may also
reach the great intestines, if the tube of the syringe be long and introduced to
its full length, which it always should be in every case of constipation, so that
it may reach the sigmoid flexure of the colon: but an error must not be com-
mitted in such cases, by supposing that the discharges are from above the
stricture unless all the symptoms subside, even if the protruded part is not
returned. all stealbai vino doserole to Jilidatiei bus
The application of pressure or the taxis, is limited by the state of the part.
In recent hernia which have become strangulated, it must entirely depend on
the pain felt by the patient. If the tumour is so painful when touched that the
person cannot bear it, the operation ought not to be delayed; and more parti-
cularly if the swelling is hard and tense like a ball, or if any discoloration of the
skin has taken place. In these cases, delay is not admissible; and the operation
should be done without reference to the time the part has been supposed to have
been strangulated; it being immaterial whether it has taken twelve or only two
hours to arrive at this state. In a young and healthy person, an attempt may be
made at once to return the protruded part by a well directed and steadily sup-
ported pressure in the direction of the swelling in the inguinal canal, the parts
being relaxed by position. But if there be any pain in the tumour, and this is
increased by the pressure, it will be advisable to bleed to fainting in the erect
position, before further efforts be made at reduction. I have frequently reduced
an incarcerated hernia after bleeding which was irreducible before, and much
more frequently after the patient had been again brought to a state of syncope
from the effects of the hot bath. The best time to make the attempt at reduc-
tion, is a few minutes after the patient has been taken out of bed and laid be-
tween the blankets. If it fails after a steady well supported application for at
least fifteen minutes, the patient should be returned to the bath, and a second
attempt be made in the course of an hour, provided always that delay is war-
ranted by the non-painful state of the part, and the absence of severe general
symptoms. lo atomom src edt: noede even ai lud amayzowy yd beensto
If a patient is presented with a strangulated hernia, even one of recent for-

24
mation, in whom the general symptoms are very severe, and evidently from that
cause; the operation (that is, the obtaining of complete relief,) should not be de-
layed, although the tumour itself may be comparatively but little painful. These
general symptoms are the pain at the umbilicus, the irritability of stomach, the
anxiety of countenance, and the failing state of the pulse. These symptoms
of inflammation of the intestines accompany each other; and when they are well
marked, the danger is imminent, and the decision must be prompt. The two
most important symptoms, are the anxiety of countenance, and the failing of
the pulse; they mark the severity of the inflammation and its tendency to
gangrene, whilst the pain and irritability of stomach only indicate its existence.
They are, in fact, symptoms which must always be judged of by comparison;
some people suffering more apparently than others, with less real cause: but
the anxiety of countenance to which I allude, and which, when complete in a
more advanced stage, is called the facies hippocratica, cannot be mistaken;
neither can the pulse, the almost extinction of which more distinctly marks the
great degree of inflammation. The state of the pulse in inflammation of the
viscera of the abdomen is remarkable, from being small, hard, quick, and vibra-
ting like a cord in the generality of cases; but when the inflammation sets in
with great intensity, the pulse often alters its character, becoming smaller, and
sometimes so indistinct as scarcely to be felt, rendering the abstraction of blood
imperative; and the quantity to be drawn must be regulated by the pain, as
ascertained by pressure on the umbilicus. The presence of pain on pressure, and
the diminution or absence of pulse, are only signs of great inflammation. The
absence of both pain and of pulse, are signs that gangrene has taken place;
but then the anxiety of countenance will be so marked, the face so pale and so
bedewed with large drops of perspiration, that an error cannot be committed as
to what has occurred. In acute inflammation of the liver as well as of the
intestines, the pulse will often become indistinct, and the countenance very
anxious; the pain will be constant, and increased on pressure. As blood is
drawn, the pulse rises, the anxiety of countenance and pain diminish, and the
patient after the loss of from fourteen to twenty ounces feels more at ease. In
all these cases of abdominal inflammation the pain is constant; it is often in-
creased by paroxysms, but is never absent: there are moments of relief, but it
is never complete: it is always augmented by pressure, whilst in colic, there

25
is in all cases an occasional positive absence of pain, and pressure gives relief.
Let us suppose a young and healthy man to be brought to an hospital with
an inguinal hernia of recent formation, presumed to have been strangulated
only four or six hours. On examination, the swelling is found to be painful,
and very tense when touched. The nausea and sickness are frequent; the pain
at the umbilicus severe and increased on pressure; the pulse small and hard;
the countenance distressed. What should be done? The answer is positive.
1. The operation with the least possible delay. 2. The exhibition of from
four to six grains of calomel with a grain and a half of soft opium. 3. The
abstraction of blood. 4. Stimulating injections per anum: and lastly, Gentle
purgatives if the bowels do not act of themselves satisfactorily. If on the
other hand a young and healthy man is brought to an hospital, with a similar
hernia which has been strangulated from four to six hours, the part being
but little painful, the umbilicus only tender on pressure, but not acutely
sensible, the operation may be delayed until the effect of bleeding unto syncope
in combination with the hot bath have been ascertained; but no time must be
lost in the trial, and it is quite useless to make it if the herniary swelling will
not admit of considerable pressure without much suffering. It is a difficult
thing to decide when incarceration ends and strangulation begins, and it is
consequently almost impossible to compute the length of time a part has been
in that state; frequent observation has, however, taught us, that a hernia of
recent formation cannot remain in a state of incarceration ending in strangu-
lation for a longer period than ten hours, without placing the patient's life in
great jeopardy, and that the operation is always less dangerous than the con-
tinuation of repeated and ineffectual trials at reduction. An operation, on the
other hand, is not to be had recourse to until its necessity is evident; inasmuch
as a person may die from it and not from the disease: and I have often been
enabled to restore the protruded parts by a well directed treatment, almost at the
moment when the failure to do so would have been followed by the operation.
I should regret, however, very much to be misunderstood on this point; for
I am quite satisfied the general result of cases of recent herniæ has shown that
it is better to operate even half an hour before it is absolutely necessary to do
it, than to delay for ten minutes after the necessity for an operation has become
obvious. The French surgeons, who operate at an earlier period than we gene-
E

26
rally do in this country, are certainly not less successful than ourselves; and of
two extremes, theirs is assuredly the safest.
The practice of surgery with reference to recent hernia is infinitely more
clear and precise than it is with regard to old herniæ, and for the reasons I
have assigned, viz. The symptoms are so much more marked and decided in
their course and termination. It is not often that an error is committed in
cases of recently strangulated herniæ; it is not uncommon in cases of old herniæ
which have become incarcerated or strangulated.
In old hernia which have become strangulated, the state of parts as well as the
nature of the symptoms are essentially different. From the alteration which has
taken place in the form, situation and structure of the openings through which
the parts are protruded, they are not likely to suffer any diminution of size from
muscular contraction; the herniæ are therefore incarcerated or detained, and
the bowel is obstructed, rather than it is compressed and strangulated, and the
symptoms are consequently more of obstruction than of inflammation. One of
the purest cases of this kind I am acquainted with, I had the opportunity of
seeing with Mr. Chinnock of Brompton. It was an old gentleman, who had an
incarcerated inguinal hernia of three days' duration. The swelling was large and
very hard; but as the integuments were thin, and the part not painful, it admitted
of accurate examination. The hardness appeared to be dependent on a collec-
tion of solid fæcal matter, and after some trials a portion of it at the upper part
was broken, and pressed through the external ring. This was followed by a
second, and so on in succession until the whole was pushed into the abdomen,
with the intestine which had contained it. The symptoms immediately subsided,
and a dose of purgative medicine completed the cure. The openings in the
abdomen through which the parts protruded were in this case entirely passive.
In some instances it has been proved by operation and consequent exposure
of the parts, that the symptoms induced depended entirely on mere detention
without compression, which had given rise to obstruction; the intestine in the
sac showing little or no signs of inflammation, and the openings being sufficiently
large to admit the fore finger in addition without any previous enlargement.
The symptoms in these cases were caused by the obstruction, whether dependent
on a peculiar apposition of different parts of the intestine, competent to produce
such effect, or by adhesions between them and the sac, or from other causes.

27
In every case, however, the operation is required for the relief of the patient, if
it cannot be obtained by other means.dwide of no lessings also on
In all these old and well-marked cases of the passive state of the abdominal
opening, the symptoms on incarceration differ much from those that take place
in recent herniæ which have become strangulated. The patient is uncomfortable,
the rupture is not reducible, the bowels are confined, he suffers from eructa-
tions, followed by pains referred to the umbilicus and to the pit of the stomach,
which become permanent, and gradually although slowly increase in intensity.
The abdomen becomes sore, and the tenderness and pain are increased on pres-
sure, although the rupture itself is scarcely painful, and admits of very great
pressure being made upon it. These symptoms are soon accompanied by ge-
neral ones; the pulse quickens and is smaller, perhaps a little harder than usual,
the skin becomes hot and dry, the tongue foul, the stomach irritable, nausea is
succeeded by vomiting, the countenance assumes a yellowish unhealthy appear-
ance; and gradually deteriorating from this state, at the end of four, five or
more days, the patient dies, worn out by the continuance of the constitutional
irritation, but not suffering much pain in the herniary swelling. On examina-
tion after death, the intestines above the detained or strictured part appear to
have suffered from low inflammation, rarely proceeding to gangrene. It is this
kind of case which is described in books as being caused by inflammation coming
on independently of the incarcerated hernia, but which I believe to be an error;
and in all instances in which the symptoms do not yield to the usual means, the
operation should be had recourse to, and the protruded parts returned if they
will admit of its being done. The patient must die if it is not done; and if it
is done without advantage, he has still had the chance of recovery, which
good surgery entitles him to. I am, however, of opinion, that the operation
will succeed in a great majority of cases if it be done in time, that is, before
the constitution is so much affected as to be unable to recover itself after it has
been done.
In these cases the treatment should differ materially from that recommended
in the foregoing pages on recent herniæ. Bleeding to syncope will only weaken
the patient and do little good. The warm bath will not be very effective, and
tobacco enemata with elderly persons are sometimes dangerous. The three
principal remedies in recent hernia which have become strangulated are here of
E 2

28
little use, save as they act generally in reducing inflammation, because there is
no muscular contraction to subdue; whilst on the other hand cold steadily ap-
plied may be of great service, when combined with such mechanical pressure as
may be found advisable. In these cases stimulating injections are of great use,
and if they be applied, as Mr. O'Beirne of Dublin advises, by means of a tube
ten inches long, with a hole at the end of it, and introduced into the sigmoid
flexure of the colon, the happiest results will I think follow in a much greater
proportion than at present. It draws off the flatus as well as the watery contents
of the bowels, whilst the cold acting on the tumour condenses the air contained
in the incarcerated intestine, and tends to cause it to pass more readily into the
abdomen.
In those cases which are of a mixed character, being neither of recent nor of
old formation, the proper course to be pursued must depend on the judgment
of the surgeon, in adopting an intermediate course, and in a proper selection of
these different remedies.
aid mont
The use of purgatives after the operation, which has been equally lauded and
decried, without sufficient reason being given, admits of strict regulation on
sound principles. In recent hernia which have been operated upon, none but
the most gentle aperients should be given; the object being to persuade the
bowels to act, and not to force them by irritation. They have been, if they are
not actually in a state of inflammation, and an irritating purgative may induce
its return, and counteract the effect for which it has been given. If on the con-
trary it acts violently, the intestine, weakened by the congestion and inflamma-
tion which it has suffered, may not be able to sustain this superadded irrita-
tion. I have known an intestine returned to the cavity of the abdomen in a
doubtful state, (which is the proper course to pursue,) give way under severe
purging, and allow the fæces to escape by the wound; the patient recovered,
but I have little doubt that mischief has been often done in a similar way. In
old hernia when the incarceration has continued some days, and probably arose
from obstruction in the first instance, the happiest effects have often followed
the exhibition of active purgatives after the restoration of the protruded parts,
whether by the taxis or by operation, and it appears to me that it is in these
cases only they are to be recommended.
With regard to the manner of performing the operation itself, I have nothing

29
to add worthy of remark. The sac should be cautiously opened on its anterior
and lower part, where some fluid will usually be found, and then slit up as high as
the external ring. If the stricture should not be situated there, but at the inner
or superior opening being formed by the edge of the transversalis muscle, the
method of proceeding depends on whether it is a recent or an old hernia. If a
recent oblique one and the inguinal canal is little altered from its natural state,
the aponeurosis of the external oblique muscle forming its outer wall, should be
divided in an oblique direction outwards, so as to expose the swelling near its
neck. This may now be drawn down, whilst the more external parts are drawn
up so as to bring the stricture into view, when it and the neck of the sac should be
divided together directly upwards. It has been recommended not to divide the
anterior wall of the inguinal canal, but to introduce a cutting instrument on its
flat side in an oblique direction outwards, for the distance of an inch and a half,
and then to turn its edge, and cut in the dark directly upwards, which appears
to me almost impossible to do, to say nothing of its being very dangerous. I
therefore always advise that the aponeurosis of the external oblique be slit up to
that extent, which will enable the surgeon, by drawing down the sac, to see
whereabouts his knife is to cut and the direction it is to take. I am an advocate
for dividing the neck of the sac with the stricture, rather than for leaving an
inch of it uncut below the stricture. It was supposed that this would prevent
an inflammation of the peritoneum; but the experience of the Peninsular war
proved, that a cut of half an inch in length was as dangerous as one of an inch,
and that the admission of air into the cavity of the abdomen did no mischief.
In old herniæ, and in those of direct descent, the openings are nearly opposed
to each other, and this difficulty does not occur. The incision in all cases should
be made directly upwards, because it more certainly obviates danger from the
epigastric artery in case of an error as to the kind of hernia; but the division of
this artery is after all but an anatomical bugbear. I am ready to admit that if a
surgeon pokes a knife the length of an inch and a half in the inguinal canal,
and then cuts with the end of it, he knows not what nor where, and in this
manner divides a large artery, his patient's case may be hopeless; but if he has
proceeded in the manner I have mentioned, he will have very little difficulty in
placing a ligature on the artery as soon as he has cut it, and the danger to his
patient will be but little increased.

30
If the symptoms denoting the presence of inflammation continue after the
stricture has been completely removed, the means necessary to be employed for
their removal must be had recourse to as in other cases of inflammation; for
there is no axiom so much to be doubted in medicine, as that which leads to the
belief that the removal of the cause will certainly lead to the subsidence of the
effect.
In femoral hernia, the parts through which the protrusion takes place being
entirely tendinous or aponeurotic, no positive contraction can occur in them, and
the symptoms of incarceration and strangulation must depend on obstruction and
distention of the contents of the hernia; these will be regulated of course very
much by the extent to which the distention is carried, and the sharpness of the
edges against which they press. The distinction between a recent and an old
femoral hernia will not be quite so marked as between a recent and an old in-
guinal hernia; and it is usually believed that there is less prospect of returning
a strangulated femoral hernia by the taxis, or without an operation, than a stran-
gulated inguinal hernia.
The points of anatomy on which I wish to remark with reference to femoral
hernia are few; and on referring to Mr. S. Cooper's Dictionary for the existing
state of opinions on them, I find the accounts as given by Hesselbach, Lan-
genbeck, &c. so prolix, and so minute as to be almost unintelligible to a person
not already well acquainted with the subject. I shall therefore refrain from
quoting them, and only notice those which are more commonly received, or
remain a matter of doubt. Poupart's ligament from its origin at the superior
spinous process of the ilium to its insertion at the pubes is extended over a space
more or less filled up; and constitutes what is called the crural arch. From
the ilium to the outside of the femoral artery, it is admitted that there is no pos-
sibility of a protrusion taking place. From this part the arch begins to spring, and
terminates at the insertion of the ligament into the pubes. The outer portion of
the arch is occupied by the femoral artery and vein which pass underneath it
inclosed in a sheath formed by the two layers of fascia transversalis described at
page 13. A septum separates the artery from the vein, whilst another septum
confines the vein on its inside, and separates it from the absorbents generally, and
from anything there may be in that situation, constituting all that I consider to
be the true sheath of the vessels. There is however a space exceeding an inch,

31
extending from the septum on the inside of the vein to the pubes where Pou-
part's ligament is inserted by its lower pillar, and by what is called its third
insertion, or Gimbernat's ligament. This is occupied by a continuation of the
fascia forming a barrier nearly at a right angle with the septum or sheath on
the inside of the vein, and is perforated for the passage of the absorbents. This
is called by Cloquet septum crurale, being the barrier between the abdomen and
the thigh, and when weakened and forced to descend before a hernia, it is called
fascia propria by Sir Astley Cooper. This same part is also called the inner and
superior opening of the crural canal by the German and French anatomists;
the opening through the fascia lata of the thigh which gives passage to the
vena saphena to join the femoral vein, being called the inferior and exterior
opening of the same canal.any od
The French anatomists do not describe the anterior portion of the sheath of
the vessels as formed by the fibrous layer of fascia transversalis which passes
under Poupart's ligament, the crural arch, or arcade crurale for this purpose;
but consider this sheath to arise from the ligament or arch, at its lower edge,
and not in the manner I have noticed it; and although they describe very
accurately the barrier which exists between the inside of the femoral vein and
the pubes, they do not look upon it as a part of the sheath of the vessels.
The septum crurale, as Cloquet calls it, and which I think the best name for
this barrier, is not a straight partition, but a curved one, being concave upwards
or inwards towards the abdomen, and convex towards the thigh, so that by a
little management in dissection it may be made to assume a funnel-like shape on
the thigh, and to lead to the conclusion that anything passing into it from
within must follow the inclination which such a formation naturally gives, and
of course be projected against the vein, by the side of which it would pass out
at the lower opening of what the French anatomists call the crural canal; this
does not however occur when a femoral hernia takes place. The inside of the
septum crurale, or that part which is next the abdomen, is concave, and the
oval hollow formed by it is partly filled up by an absorbent gland, which is
separated from the peritoneum by the cellular layer of fascia transversalis
extended across from the edges of the hollow. It is into this concave septum,
oval from side to side, that the hernial sac first passes; and it is this fact has
made Sir Astley Cooper say, that a hernia is protruded into the sheath of the

32
femoral vessels; but this manner of expressing it leads to the same misappre-
hension, in my opinion, as the French mode of describing it as protruding into
the superior opening of the crural canal. They both imply or admit of its
being supposed that the hernial or peritoneal sac passes down by the side of and
in direct contact with the femoral vein, which is demonstrably an error in those
who so understand it.
In all the dissections of femoral herniæ I have had an opportunity of making,
the septum crurale of Cloquet, or the fascia propria of Sir Astley Cooper, formed
a distinct sac, separated from the septum on the inside of the femoral vein by a
mass of condensed cellular structure, sometimes more than half an inch in thick-
ness; the septum had been elongated into an outer sac for the hernia, and had
grown down by the side of the sheath of the vein. The hernial sac or perito-
neum is not then projected into the sheath of the femoral vessels, but into a
separate sac, which it forms for itself by the side of them. When the French
anatomists say that the hernial sac is protruded into the superior opening of the
crural canal, takes the course of that canal, and re-appears at its lower opening,
or where the vena saphena joins the femoral vein, it is only intelligible by under-
standing that the hernial sac lies in contact with the femoral vein, whereas it
passes by the side of it, separated from it by two portions of sheath, viz. one
formed by the septum on the inside of the vein, the other by the elongated part
of the septum crurale, or fascia propria, which forms the outer sac. This lies
on the pubic portion of the fascia lata of the thigh, and if it descends far enough,
is found outside the opening for the passage of the vena saphena, but does not
come through it from the inside.
The hernial sac having descended below Poupart's ligament, carries before it
the septum, or fascia propria, and now has above it Poupart's ligament, behind
it the pubic portion of the fascia lata; to the pubic or in-side, Gimbernat's liga-
ment, to the outside the sheath of the femoral vein. Breschet considers Gim-
bernat's ligament to be erroneously described as a third insertion of the external
oblique muscle, or as a part of Poupart's ligament; and supposes it to be formed
behind by the transversalis tendon, and before by the fascia lata. The manner
in which the transversalis sends down its fibres to form the posterior part, is
shown in Plate III. fig. 1.; but the part which the fascia lata has in forming
the anterior part, does not appear to me to be sufficiently appreciated. The

33
falciform process which lies over the femoral artery, and passes inwards to
attach itself to Poupart's ligament, and to form the anterior part of Gimbernat's
ligament, does more than this; it passes on, and is inserted also into the pubes,
on a plane lower than the insertion of the inferior pillar of Poupart's ligament,
so that, in fact, it forms an arch exterior to the septum crurale, which, when it
is forced to descend, is compelled to pass under it; and it is this, and not
Poupart's ligament, which causes the greatest compression on the hernia, and
is the seat of external stricture. This portion of the fascia lata forms an arch
in reality when a hernia is protruded underneath it; but in its natural state it
is not the case; the absorbent vessels pass underneath it and through the
septum near the sheath of the femoral vein; but as the falciform process of the
iliac fascia lata passes on to its insertion in the pubes, it rests on, and is attached
to, the pubic portion of the fascia lata. This attachment, although not a very
intimate one, is sufficient to confine the part, but sometimes it is so strong just
at the pubes, and forms so firm and complete a union, that drawing on one part
evidently influences the other, and renders the arch a circle, through which
the hernia is protruded. The anterior part, or the iliac portion of the fascia
lata attached to Poupart's ligament, being tendinous, and firmly stretched across
from point to point, can yield but little; the inside, or Gimbernat's ligament,
can hardly yield at all; indeed it appears to retain its sharpness unimpaired.
The sheath of the femoral vessels is scarcely displaced, and the under part, or
the pubic portion of the fascia lata covering the pectinalis muscle, seems to be
the only part which can easily make room for the hernia to be protruded. This
it does by the separation of the attachment between it and the falciform process
of the iliac fascia lata, and by the muscle beneath yielding to the pressure.
The structure thus described is of great importance, in giving rise to stricture
when any additional matter is forced into the hernial sac, and is much more
frequently the cause of strangulation than has, I think, been hitherto supposed.
When a femoral hernia has passed this point, it would descend on the inside
of the thigh towards the knee, like a psoas abscess, if it were not prevented by
the vessels passing from the femoral artery to the superficial fascia, which bound
it below; and from the turn which it takes upwards, from the natural and almost
constant bending of the thigh. The herniary swelling, small as it is on passing
under Poupart's ligament, expands after it has passed it, turns upwards and
F

34
widens, so that as it increases it passes above the sheath of the vessels, above
the fascia lata, and even sometimes above Poupart's ligament. In doing this the
swelling changes its shape as well as direction, and becomes an oval tumour,
having its axis directed from the ilium to the pubes, and in fat elderly people so
much resembles an inguinal hernia, as to have been mistaken for it. I suspect
that it has been hernia of this form and shape, which have been supposed to
come out immediately in front of the femoral vessels, in which situation a hernia
is certainly of rare occurrence.
og aid
When a hernia commences, the peritoneum pushes some loose cellular or
fatty membrane before it, until it reaches the more condensed cellular structure
or fascia, which covers the oval hollow or concavity of the septum crurale;
this it presses against the gland contained in the hollow, and usually causes
it to be removed by absorption. The continued pressure now acts on the
septum, it begins to yield, is elongated, and forms a sac, which, like the peri-
toneum itself, is thickened as it descends, and increases by a regular growth;
its outer surface being rough and adherent to the surrounding parts, the inner
being a smooth secreting surface, moistened apparently by a serous fluid, which
keeps it distinct from the peritoneal sac inclosed within it; a quantity of fat is
sometimes found between them, rendering the detection of the herniary sac more
difficult. This sac is usually very thin, and contains little or no fluid, in which
respect it is unlike the same investment in inguinal hernia, and renders the
operation on this part more difficult. From without inwards the coverings are
the skin, fat, superficial fascia, absorbent glands in various states of enlarge-
ment, the fascia propria, and on opening that a second sac, viz. the herniary or
peritoneal one, and within this the omentum, intestine, &c. as the case may be.
It was the want of knowledge of the fascia propria as a distinct or external
sac that made many surgeons suppose that they had met with something extraor-
dinary, when they found one sac within another. But the more accurate know-
ledge we at present possess on this subject must also be modified by the fact,
that it is possible for the peritoneal sac to adhere so intimately to the fascia pro-
pria as to be divided with it; and then if the surgeon does not accurately dis-
tinguish the next part to be intestine when it presents itself, he may open it,
believing that it must be sac, and place his patient in the greatest danger. I
understand that one of the most distinguished surgeons in France states, that

35
he once fell into this error. I have seen it once committed in England, the
intestine being opened for the peritoneal sac; and Mr. Vincent informs me,
whilst this sheet is passing through the press, that he has lately operated in
a case, in which no fascia propria existed. After the sac formed by the fascia
propria has been opened, the surgeon must proceed with the greatest attention;
and when a second sac, or something like it, is brought into view, he must
increase his caution. If he can raise this, or take a small pinch of it up with
his finger and thumb, so as to satisfy himself that there is something separate
from it within, he may be sure it is the peritoneal sac which presents itself, and
may proceed to open it accordingly. But if he cannot do this, and the appear-
ance of the part exposed leads to the belief that it may be intestine, he must
not open it, but trace it upwards to Poupart's ligament, and where the firm
compression appears to be made upon it, there proceed to divide the stricture
until he can satisfy himself whether the part adheres or not. If it be intestine,
it will not be adherent, and on the division of the stricture will be readily drawn
down or reduced. If it be sac, its adherence to Poupart's ligament will prove
its nature, when it should be opened and its contents exposed, if the division of
the ligament does not admit of the perfect reduction of its contents.yanoilinogo
The manner of dividing the stricture has been, and is still, a subject of dis-
cussion, some surgeons recommending that it should be done upwards and rather
outwards, others directing that it should be done horizontally by a division of
Gimbernat's ligament, according to the opinions they severally entertain of the
seat of stricture. It is admitted that the stricture may be situated externally or
internally, by the anterior border of Poupart's ligament, (according to my views
it is formed by the fascia lata,) or by the edge of Gimbernat's ligament; but I am
not aware of any proportion ever having been stated in which they occur. In the
absence of this information I am disposed to believe that it happens much more
frequently anteriorly than posteriorly, and which will of course regulate the
operative process. Practical surgeons know that a very slight touch of the knife
is often sufficient to give the requisite relief; and the distended part yields with
a sound resembling that which would be heard on dividing a piece of parchment
tightly stretched between two points. The stricture thus cut, readily yields to
a little pressure with the nail or point of the fore-finger, and the part becomes
sufficiently dilated to allow of the return of the contents of the herniary sac into
F 2

36
the abdomen. In by far the greater number of cases this mode of proceeding will
be found as effectual as it is safe; but if it should not be sufficient, and a further
division of deeper-seated parts is necessary, in what manner should it be done?
By continuing the incision upwards, or by making a new one in connexion with
it, but horizontally? There are objections to both. It is urged against the
operation upwards, that the spermatic cord may be divided by it; but as the
operation is usually performed on women, this objection has not so much weight,
for this part may be easily avoided, and if necessary even drawn out of the way,
but which I do not however think will be necessary. The division of the edge
of Gimbernat's ligament by a horizontal incision is dangerous for two reasons:
first the depth of the parts and the greater chance of cutting the intestine, which
if protruded in any quantity can only with great difficulty be kept out of the way
of the knife; and secondly the danger of wounding the obturatrix artery when it
happens to surround the neck of the sac. I know that if the end of the bistoury
be just carried beyond the edge of Gimbernat's ligament and no further, it may be
cut without injuring this vessel, which in these cases runs close to it; but I have
been made aware of more than one accident of this nature having occurred in
operations performed by some of the best anatomists and surgeons in London,
and the patients subsequently bled at intervals until they died from hemorrhage.
It does not appear, then, that the ablest and best informed men can avoid such
a misfortune, and I am therefore disposed to recommend that the operation
should never be done in this way until the one directly upwards has been tried
in vain; and if attention is paid to the division of that portion of the fascia lata
which is attached to Gimbernat's ligament and to the pubes as well as of the
fascia propria, I suspect sufficient room will be obtained without cutting hori-
zontally inwards. If this should be insufficient, of which I have great doubts,
the horizontal incision may then be made with more ease and advantage, but to
a far less extent. The obturatrix artery is something of an anatomical bugbear
in this operation also; it has very rarely been injured, although the case I have
adduced shows that it may be cut, but then it may be tied, and ought to be tied
in every case in which it has been divided. The operation is very simple. In
the male a transverse incision should be made in the line of Poupart's ligament,
the aponeurosis or tendon of the external oblique muscle is then to be divided
and the spermatic cord exposed; this is to be drawn upwards and kept in that

37
situation by a bent probe; Poupart's ligament is to be then cut through, until
the first incision for dividing the stricture is met by that just made. The blood
will now easily lead to the artery, which must be secured by ligature; and to
render this easy of execution, sufficient space and a blunt knife only can be
wanted, in addition to the forceps and ligature. In the female the operation is
more simple, as the round ligament requires little attention being paid to it.
It is surprising to see men who place a ligature on the external iliac or on the
common iliac, as a matter almost of course, hesitate at tying the obturatrix
artery, and even allow a patient to die in the mean time of hemorrhage.

Iar deuord) do not ed of ai dasmsgil ausquo
boold efTebam tani tadi yd dom at ou
odong
of bas; outryil yd bewoes ed
ed mio vino
ei nobatago
9d3
of bisq guied not
osili Ismots
edt gaivi is
egadromed to emis
doidwy
ed
bas egoovel edt
ippos tomagil baros
oundsgil s coaly odw
sib of troiing a wol
Tol noisioni
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qu borit nood goi
EXPLANATION OF THE PLATES.
IT 201
11
PLATE I.
The parts concerned in Inguinal Hernia on the left side.
1. 1. 1. Integument.
2. Fascia superficialis.
3. External oblique muscle.
3. a. Its aponeurosis turned down on the thigh.
3. b. Poupart's ligament. II ETA 19
3. c. The insertion of the external oblique into the os pubis. T
bos broo
4. a. The internal oblique muscle passing across the abdomen to assist in
forming the sheath of the rectus.
sherr
4. b. A portion or slip of this muscle separated from its attachment, and
hanging down outside the spermatic cord.
To nobnet edT
5. The superior fibres of the transversalis muscle passing above the cord
to their insertion into the pubis.
6. The inferior fibres of the transversalis muscle passing below the cord,
forming the lower edge of the internal or superior opening of the
inguinal canal, and inserted into Poupart's ligament up to the pubes.
The fibres marked 6 are all muscular; in some instances they
are tendinous and aponeurotic; in others they are either wanting
or so indistinct as scarcely to be distinguished from the fascia
transversalis.
7. The cremaster muscle given off from the internal oblique, and partly
from the transversalis muscles seen lying upon the cord at 7, and
passing under it from 7 to 8.
doidy bas
8. The portion of the cremaster usually considered as a second origin,
but which is in fact its insertion after its fibres have proceeded the
whole length of the spermatic cord and testis, forming in this way
a sling partly muscular, partly tendinous, whereby it may be drawn
up towards the abdomen.

40
9. The rectus muscle, its sheath having been turned up.
10. The pyramidalis muscle.
11. The spermatic cord.
10 MOITAMANIZI
12. The cremasteric artery, a branch of the epigastric.
The preparation from which this engraving is taken, was made by Mr. Owen,
and is deposited in the Museum of the Royal College of Surgeons, as well as
that which shows the continuation of the cremaster muscle on the spermatic
cord and testis.-The drawing was made by Mr. Clift.
dgids odt no awob
PLATE II.
supildo
FIG. 1. The right side of the same individual whose left side is shown in
ni Jeinen of
Plate I. The drawing from which the engraving was taken was
made by Mr. Clift. Sir Astley Cooper dissected the internal parts
to show how far they accorded with the view of them given in his
abistvo awob guigaad
Work, and which is fig. 3. bistvo n
bus nom
Inco A. Poupart's ligament.
od
ant to tardit
odT G
B. The tendon of the external oblique, turned towards the linea alba.
ailea
500 C. The spermatic cord.
edlo D. The cremaster muscle. logbo
vedt as
to asadit tohish
wol od gairidh
E. E. The internal oblique muscle; at the upper part its anterior surface is
shown, at the under part it is separated from the transversalis, a
little raised and turned upwards and inwards, so as to show the
under surface of the muscular fibres at Eibni oa 10
gaitas
sigest
F. The transversalis muscle partly exposed and raised in a similar manner;
ything bas
the under surface is shown by the line extending from F.; the
Bas de bio outer surface of the same muscle is shown by the line extending
from I., and which corresponds with No. 3. and 4. c. of Plate I.; and
nigizo broo lower down with No. 6., or the fibres passing under the cord.
sdt bob G. Fascia transversalis, outer division.
H. Peritoneum.
I. The inferior fibres of the transversalis.
asmobda
ebiswet qu

10
40
4a
36
30
W. Clift. del.
J. Basire. sc.
1


41
J. The femoral vein.
K. The femoral artery.
FIG. 2. Is taken from Plate VI. of P. F. Blandin, Traité d'Anatomie Topo-
graphique, and which is supposed by him to be in accordance with
the opinions entertained by those French anatomists who preceded
him to 1826.
A. The inferior and united edges of the internal oblique and transversalis
muscles, horizontally directed across the abdomen to the linea alba.
B. The crural arch, or Poupart's ligament.
C. Fibrous expansion detached from around the inguinal ring, i. e. the
ring exposed by the removal of the intercolumnar fascia.
D. The internal or superior pillar of the ring.
E. The external or inferior pillar of the ring.
F. Muscular nooses or arches formed by the cremaster musele on the
spermatic cord, and derived from the inferior border of the internal
oblique and transversalis muscles.
G. This is S. in the original, and is described as the aponeurotic fascia
transversalis, which forms the posterior wall of the inguinal canal
in a spot where, of the three muscles of the abdomen, only one is
found, viz. the external oblique. This is internal to the cord.
H. This is also S. in the original, and represents the same thing, but ex-
ternal or to the outside of the cord.
I. The spermatic cord.
1. The femoral vein situated on the inside of
2. The femoral artery.
3. An opening made in the external part of the crural canal (sheath of
the vessel), to show the anterior crural nerve situated immediately
on the outside of it, and lying on the cellular structure covering the
psoas muscle.
4. Saphena major vein.
5. A lymphatic gland and vessels.
6. Falciform or semilunar fibres situated at the junction of the vena
saphena with the femoral vein.
G

42
LIT
7. The anterior wall of the crural canal or sheath of the vessels, opened
and turned outwards and inwards to show the canal.
FIG. 3. Is a copy reversed of Figure 1. of Plate V. from Sir Astley Cooper's
book on the Structure and Diseases of the Testis, showing the in-
guinal canal and course of the spermatic cord. go d
A. A. Poupart's ligament.
B. Internal oblique muscle.
bris ronging
C. C. Transversalis muscle arising from Poupart's ligament, and passing
around the spermatic cord at the internal ring, so that the fibres of
this muscle appear behind as well as before the spermatic cord, and
thus the inguinal canal is rendered a muscular canal: this is a
most important provision in preventing hernia; and when hernia
exists, it is often the cause and seat of stricture. za d
D. The cremaster muscle arising from Poupart's ligament between the
internal oblique and transverse muscles, and receiving fibres from
the transversalis behind the cord.
E. The rectus muscle. al bas
erpildo
faso F. Its sheath from the internal oblique and transverse muscles.
G. Superficial fascia of the cord.
H. Spermatic cord.
I. I. The internal ring. By an oversight the line running from I. rather
appears to stop at the cremaster muscle at D., than to go on to the
inner ring.
K. The external ring.
N.B. The difference between F. and G. of fig. 2. when compared with F. and I.
of fig. 1. is remarkable; it is no less so when compared with C. C. of fig. 3. of
the same Plate, or with No. 5. and 6. of Plate I.
The French anatomists generally appear to consider that formation of the
transversalis muscle to be the more natural one, in which it runs across to the
linea alba, without being inserted into Poupart's ligament, when the spermatic
cord will be found lying on the fibrous layer of the fascia transversalis, as in
fig. 2. Plate II. at G.; and in order to show the loops or nooses formed of the

PL.II.
B
H
FIG. 2.
J
B
A
B
FIG. 1.
E
G
F
A
I
H
Ꮐ
D
7
I
K
K
J
B.
D
A
D
I
C
B
FIG. 3.
I
G
E
A
-I
E


43
cremaster by the testis in its descent into the scrotum, they sacrifice the insertion
of those fibres which do not take this appearance, as seen in Plate I. No. 8.
Anatomists only can judge which description is most correct, and which forma-
tion is most commonly met with.
PLATE III.
An internal view of the left half of the pelvis and parts concerned in Inguinal and
Femoral Hernia.
1. The symphysis pubis.
2. The ilium, sawn across.
3. The rectus muscle, the inner layer of the fibrous fascia transversalis being
removed.
4. The transversalis muscle.
5. Gimbernat's ligament.
6. The posterior or fibrous layer of fascia transversalis lying on or lining the
transversalis muscle, the transverse fibres of which are seen passing on
to the edge of the rectus.
7. Additional strengthening fibres to the fascia.
8. A particular tendinous insertion of it running behind the rectus to be
inserted into the pubis at its symphysis.
9. The falciform edge of the fascia at the inner opening of the inguinal
canal.
10. The lunated edge of the posterior part of the conjoined tendons forming
the sheath of the rectus.
11. The internal or cellular layer of fascia transversalis turned down and lying
upon the peritoneum which is seen underneath it.
12. The peritoneum.
13. The epigastric artery with its two veins turned down with the cellular
layer of fascia transversalis.
14. The round ligament passing into the inguinal canal.
15. A femoral hernia covered by the cellular layer of fascia transversalis pro-
truding through the crural canal or ring.
16. The fibrous layer of fascia transversalis, passing under Poupart's ligament,

44
and by the edge of Gimbernat's ligament, to form the septum crurale,
and in this case of hernia the fascia propria of the hernial sac.
17. The part of the internal or cellular layer of fascia transversalis, which
corresponds to the commencement of the inguinal canal; the inner
edge of this has a very strong falciform appearance when the part is
replaced in its proper situation.
18. Pelvic fascia.
This preparation was made by Mr. Owen, to illustrate the lectures delivered
in the Theatre of the College of Surgeons. It is also preserved in the Museum.
-The drawing was made by Mr. Clift.
qizil to
THE END.
ed of autoar of aided gain
PRINTED BY RICHARD TAYLOR,
RED LION COURT, FLEET STREET.
Love

2
12
W Clift, del.
11
13
18
3
In Basire, sc.

CX38