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ON THE 
 
 SURGICAL ANATOMY 
 
 OF 
 
 ill (SUBdDXH* 
 
 AS CONNECTED WITH 
 
 HERNIA OF THE ABDOXfflEXff, 
 
 BY 
 
 ALEXANDER F. VACHE, 
 OF NEW-YORK. 
 
 " Da mihi numine tuo vinceie, Apoho ." 
 
 PRINTED BY WILLIAM GRATTAN, 
 
 JVb. 8, Thames-street, 
 
 1825. 
 

 fit 
 
 ,V/J 
 
AN 
 
 INAUGURAL DISSERTATION, 
 
 ON THE 
 
 SURGICAL ANATOMY 
 
 OF 
 SUBMITTED TO THE PUBLIC EXAMINATION OF THE 
 
 PROFESSORS AND TRUSTEES 
 
 OF THE 
 
 COLLEGE OF PHYSICIANS AND surgeons 
 
 f OF THE 
 
 UNIVERSITY OF NEW- YORK, 
 
 WRIGHT POST, M. D. PRESIDENT, 
 
 ON THE 4tb OF APRIL, 1825, 
 FOR THE 
 
 DEGREE OF DOCTOR OF MEDICINE. 
 
TO 
 
 VALENTINE MOTT, M. D. 
 
 PROFESSOR OF SURGERY 
 
 IN THE 
 
 UNIVERSITY OF THE STATE OF NEW-YORK, 
 
 kc. Sec. kc. 
 
 WHOSE SPLENDID DISSECTIONS OF THE ANATOMY OP THE GROIN, 
 
 AND 
 
 WHOSE DEMONSTRATIONS AND ILLUSTRATIONS 
 
 OF THE 
 
 HERNIA OF THE ABDOMEN, 
 
 DISTINGUISH HIM ALIKE AS THE PRACTICAL SURGEON 
 AND SCIENTIFIC LECTURER, 
 
 THIS DISSERTATION 
 
 IS MOST RESPECTFULLY PRESENTED, 
 BY HIS PUPIL, 
 
 THE AUTHOR. 
 
vmavMau 
 
 The study of Surgical Anatomy, or the 
 acquirement of the connexion and relative 
 situation of one part with another in relation 
 to surgical operations, is one of the most im- 
 portant requisites which operative surgery de- 
 mands for its accomplishment. It is with this 
 knowledge that the surgeon fearlessly performs 
 the boldest of operations ; it is this, in dark 
 deep-seated places which distinguishes one 
 part from another, and guides the knife cor- 
 rectly, and with perfect safety to the patient. 
 It is this knowledge alone, which can give con- 
 fidence to the operator, and save him from hesi- 
 tation, confusion, and error. In short, it is 
 to the assiduity and perseverance with which 
 surgico-anatomical and pathological investiga- 
 tions have been pursued by the votaries of these 
 particular sciences, that the splendid progress 
 of surgery in modern days can alone be attri- 
 buted. 
 
Vlll 
 
 The union of anatomy with pathology, or the 
 knowledge of the natural state of our organs, 
 with the various diseases to which they are sub- 
 jected, can alone form the basis for correct 
 reasoning on disease, and point out the most 
 rational method of cure with which modern 
 surgery may be enriched. 
 
 As such, I have selected the Surgical- Ana- 
 tomy of the Groin, as connected with Hernia, 
 for the subject of my dissertation ; not however, 
 with the wish of becoming an author, but solely 
 with the view of conforming with one of the 
 requisites for the obtaining of a degree. Should 
 I succeed in elucidating the most trivial parti- 
 cular relative to this highly important piece of 
 surgical anatomy, which I am aware has already 
 undergone the closest investigations, I shall be 
 satisfied. Should I fail, no disappointment will 
 follow. 
 
ESSAY ON 
 HSUNXA ABDOMINIS, 
 
 Hernia is the protrusion of any viscus from 
 its natural cavity. Hernia, as a class, may 
 very properly be divided into three orders, viz. 
 
 Hernia Cerebri, 
 
 Hernia Thoracis, 
 
 Hernia Abdominis. 
 To the last we confine ourselves exclusively. 
 
 Hernia of the abdomen is the protrusion of 
 any of the abdominal viscera from their natural 
 cavity, forming an external tumour. It consists 
 of four distinct genera, viz. 
 
 Hernia Inguinalis, 
 
 Hernia Femoralis, 
 
 Hernia Urnbilicalis, 
 
 Hernia Ventralis. 
 
 Inguinal hernia always protrudes above Pou- 
 part's ligament, and is of two species, viz. 
 Direct and Indirect. Direct, when it comes 
 
 1 
 
10 
 
 directly from the abdomen through the externa! 
 ring. Indirect, when it comes indirectly from 
 the abdomen through the internal ring, follow- 
 ing the course of the spermatic cord, and most 
 frequently protruding at the external ring. Fe- 
 moral hernia protrudes below, and from under 
 Poupart's ligament, and has no distinct species, 
 but several varieties. Umbilical hernia, pro- 
 trudes at the umbilicus. Ventral hernia, pro- 
 trudes at any point not peculiar to the others. 
 Besides these, there are hernise protruding from 
 the pelvic foramina, though of rare occurrence, 
 which take their names from their location. 
 There are also some internal herniee, which are 
 not, perhaps, strictly entitled to the appellation 
 
 BXSS2CTXON OF ?KS PAXLTS COCTCTECTZm 
 WITH XNCTOXXI AL HXSRSrXA. 
 
 The subject selected for this purpose should 
 be emaciated, as this facilitates the dissection, 
 and permits the parts to be shown distinctly. 
 A male is preferable for inguinal hernia, and a 
 female for femoral ; the former, however, will 
 answer for both purposes. 
 
II 
 
 The subject should be placed on a common 
 dissecting table, with a block passed under the 
 body immediately above the pelvis, sufficiently 
 high to put the abdominal parietes on the 
 stretch. The hair is now to be shaved from 
 the pubes, and then an incision is to be made 
 from the upper part of the umbilicus in a straight 
 line to the symphysis pubis. This is to be 
 intersected by another, commencing at the um- 
 bilicus, and continued at right angles with the 
 former, sufficiently far on the back to allow the 
 anterior and lateral parts of the abdomen to be 
 shown. 
 
 The dissection is to be carefully commenced 
 on either side, at the angle formed by the inci- 
 sions, being particular to remove the integu- 
 ments alone ; and it is to be continued until 
 the whole flap is turned off, when will be ex- 
 posed to view the Fascia Superficialis. 
 
 The fascia superficialis is a firm, dense, 
 inelastic membrane, pervading the whole body, 
 lying immediately under the adipose substance 
 of the common integuments, and thus forming 
 one of the coverings to all the herniae of the 
 
12 
 
 abdomen ; consequently it should be particu- 
 larly noticed. 
 
 An incision is now to be made, in the same 
 manner as the former, and this fascia is to be 
 raised cleanly from the parts beneath, observ- 
 ing particular care at Poupart's ligament, with 
 which it is intimately connected, and from which 
 it cannot be easily separated. We now have 
 exposed to view the external oblique muscle, 
 and Poupart's ligament terminating its lower 
 external boundary. 
 
 Previous to describing this muscle, it will be 
 more strictly anatomical to observe the abdo- 
 minal lines, which, however, are only in part 
 brought within the limits of this dissection. 
 
 The line a alba is a white line, reaching from 
 the ensiform cartilage to the symphysis pubis, 
 and is formed by the tendinous insertion of the 
 three abdominal muscles into their fellows of 
 the opposite side. About midway of this line 
 is to be observed the umbilicus, a cicatrix formed 
 by the separation of the umbilical cord. 
 
13 
 
 The linea semilunaris is seen on the outer 
 edge of the recti muscles, of a semilunar shape, 
 and is formed by the fleshy fibres of the abdo- 
 minal muscles becoming at this point tendinous 
 in their structure. 
 
 The LiNEiE transversa are three, sometimes 
 four tendinous intersections of the recti mus- 
 cles, running across at right angles to their lon- 
 gitudinal fleshy fibres. 
 
 We now proceed to the consideration of the 
 external oblique muscle, and successively to the 
 remaining muscles of the abdomen ; annexing, 
 however, their origin, which cannot be seen in 
 this view of the parts, and attaching to each the 
 points connected with inguinal hernia, as they 
 appear on separate dissection. 
 
 Obliquus externus vel descendens abdo- 
 minis, arises from the outside of the eight lower 
 ribs, a little posterior to the junction with their 
 cartilages, by as many fleshy digitations with 
 the serratus major anticus ; being connected, 
 also, with the pectoralis major, intercostales, 
 and latissimus dorsi muscles. 
 
14 
 
 Its fibres run obliquely downwards and for- 
 wards, becoming tendinous at the linea semilu- 
 naris. Inserted fleshy, into the outer labium of 
 the crista of the ilium ; tendinous, into the whole 
 length of Poupart's ligament, by what is called 
 the outer column, which terminates at the tube- 
 rosity of the pubis, in contradistinction to 
 the tendinous fibres which separate, and are 
 inserted into those of the muscle of the op- 
 posite side, at the symphysis pubis, called the 
 inner column. It is next inserted into the 
 whole length of the linea alba and the ensiform 
 cartilage. 
 
 By the separation of the fibres of this muscle, 
 above Poupart's ligament, an opening is left for 
 the passage of the spermatic cord of the male, 
 and the round ligament of the female, permit- 
 ting their exit from the oblique canal. It has 
 received the name of external abdominal ring, 
 although of a triangular shape, bounded on each 
 side by the two tendinous columns, with its 
 apex above and its base below, formed by that 
 part of the pubis between the tuberosity and 
 symphysis. This opening can most generally 
 be traced as far up as the fleshy fibres of the 
 
15 
 
 muscle, and can be distinctly observed by a 
 dark shade from the absence of the tendon, 
 beneath where it is crossed at its upper part 
 by numerous transverse tendinous fibres bound- 
 ing and giving strength to it above. That the 
 parietes should not, however, be weakened by 
 this deficiency of tendinous matter, there are 
 numerous layers of fibres sent off from the sur- 
 rounding parts, crossing each other in all direc- 
 tions, and are intimately connected with the 
 tendon of the muscle. Besides these, this 
 part is also strengthened by a triangular ten- 
 dinous portion furnished by the tendon of the 
 opposite side, extending from the symphysis 
 to the tuberosity of the pubis. This can be 
 seen, on raising the tendon of one side, 
 showing the fibres from the opposite muscle 
 beneath. 
 
 It has been advanced, that this additional 
 tendon of the muscle from the opposite side r 
 besides strengthening the insertion of the inter- 
 nal oblique and transversalis into the pubis, 
 also, when the abdominal muscles and linea 
 alba are stretched, closes up a greater portion 
 of the external ring ; accounting, in this man- 
 
16 
 
 ner, for the rare occurrence of direct inguinal 
 hernia.* 
 
 This aperture in the male is about an inch 
 in length ; in the female, about half an inch : 
 the round ligament being smaller, and less lia- 
 ble to suffer from the contraction of the muscle. 
 
 The use of the external oblique muscle is to 
 assist to sustain the abdominal viscera, to bend 
 the body to one side, and when both act, to ap- 
 proximate the chest to the pelvis : but when 
 the pelvis is fixed, it draws down the ribs, be- 
 coming a muscle of expiration. It also assists 
 the voiding of fceces and urine, by pressure on 
 the abdominal and pelvic viscera. 
 
 The dissection can now be continued on the 
 same side ; but it is much better to dissect the 
 opposite precisely as the former, that the one 
 may remain unmolested, while the other must 
 necessarily be disturbed for an inspection of 
 the parts beneath. This leaves on one side 
 the external parts in situ, while the other de- 
 
 * Professor Colles', of Dublin, Treatise on Surgical Anatomy. 
 
17 
 
 monstrates its connexion and relative situation 
 with those within, and also adds much to the 
 beauty and neatness of the view. 
 
 After this is accomplished, an incision is to 
 be made on either side, of a semicircular form, 
 extending from a little above the external ring, 
 so that it may be preserved, and ending it a 
 little within the termination of the tendinous 
 fibre into those of a fleshy structure. The ten- 
 dinous flap is to be raised from the muscle be- 
 low, which will expose to view the lower margin 
 of the internal oblique muscle. 
 
 Obliqdus internus vel ascendens abdomi- 
 nis, arises fleshy from the outer third of Pou- 
 part's ligament, and from the whole length of 
 the spine of the ilium, between the outer and 
 inner labia ; tendinous from the back part of 
 the os sacrum, and from the transverse proces- 
 ses of the three last lumbar vertebra?. The 
 fibres ascend obliquely upwards and forwards 
 to be inserted into the lower edges of the car- 
 tilages of the five false ribs, by as many fleshy 
 slips. Becoming tendinous at the linea semi- 
 lunaris, it divides into two lamina?, forming a 
 
 2 
 
18 
 
 sheath for the rectus muscle, at the inner edge 
 of which the laminae again unite and terminate 
 into the whole length of the linea alba, inser- 
 ted, also, into the symphysis pubis, and into the 
 ensiform cartilage. Its use is similar to that 
 of the former, acting in a reverse direction. 
 
 The next muscle coming within this dissec- 
 tion, and which must be particularly noticed, is 
 the Cremaster, This muscle always forms a 
 covering to an indirect hernia, and when suffi- 
 ciently strong to be seen, distinguishes it from 
 a direct. 
 
 The cremaster arises from Poupart's liga- 
 ment, just before the internal oblique commen- 
 ces its attachment, and has, by many, been 
 described as additional fibres furnished by that 
 muscle. The cremaster descends upon the 
 spermatic cord from the inguinal canal, and is 
 inserted into the tunica vaginalis of the testicle, 
 upon which it spreads, and is insensibly lost. 
 Its use is, to suspend and draw up the testicle, 
 and to compress it in the act of coition, facili- 
 tating the passage of semen along the vas 
 deferens. This muscle is stronger and more 
 
19 
 
 visible from the presence t)f hernia of some 
 duration. 
 
 The fibres of the internal oblique can now 
 be detached from their origin, leaving the ere- 
 master in its situation, as far as the external 
 incision, and turned up so as to expose the 
 transversalis beneath, and to allow of its fur- 
 ther dissection when necessary. 
 
 Transversalis abdominis arises tendinous. 
 but soon becomes fleshy, from the inner surfaces 
 of the six or seven lower ribs, and is connected 
 to the diaphragm and intercostal muscles ; also, 
 from the transverse processes of the last dorsal 
 and four superior lumbar vertebrae, from the 
 inner labium of the crista of the ilium, and from 
 Poupart's ligament, one third its length from 
 its origin. The iibres run across the abdomen, 
 become tendinous at the linea semilunaris, and, 
 passing behind the rectus, are inserted into 
 the symphysis pubis, into the linea alba, and 
 into the ensiform cartilage. Its use is, to 
 support and compress the abdominal viscera, 
 and is, perhaps, the proper constrictor of the 
 abdomen. 
 
20 
 
 Previous to proceeding to the dissection of 
 the transversalis muscle, as immediately con- 
 nected with the subject, it may be well to ob- 
 serve the situation of the two remaining pairs 
 of muscles of the abdomen, the recti, and pyra- 
 midales. They require no dissection, as they 
 can be sufficiently observed through the sheath 
 which contains them. 
 
 Rectus abdominis arises tendinous from the 
 ligament of the cartilage which joins the ossa 
 pubium to each other. It soon becomes fleshy, 
 and its fibres ascend broad and flat, parallel to 
 the linea alba, to be inserted into the cartilages 
 of the three inferior true ribs, and into the ensi- 
 form cartilage. Its fibres also frequently inter- 
 mix with the pectoralis major muscle. Its use 
 is to compress the fore part of the abdomen, to 
 draw down the ribs in expiration, to bend the 
 body forwards, and to raise the pelvis. 
 
 This muscle is generally divided by three 
 transverse tendinous intersections, into nearly 
 three equal portions, between its upper extre- 
 mity and the umbilicus, and there is frequently 
 a half intersection between it and the pubes. 
 
21 
 
 These seldom penetrate the thickness of the 
 muscle, but adhere firmly to the anterior part 
 of the sheath, and very slightly to the poste- 
 rior layer. By the tendinous intersections, it 
 is enabled to contract at any of the interme- 
 diate spaces, and by its connexion with the 
 other muscles it is kept in its place. 
 
 Pyramidalis is enclosed within the same 
 sheath, and arises in common with the rectus. 
 It is inserted by an acute termination, about 
 midway between the pubes and umbilicus. Its 
 use is to assist the lower part of the rectus. 
 This muscle is not always found. 
 
 The transversal is muscle can now be detach- 
 ed from its connexions below, and dissected 
 neatly from the fascia beneath, sufficiently far 
 up to expose to view the internal abdominal 
 ring, which will complete all the dissection ne- 
 cessary for the abdominal muscles, and enough 
 of the fascia transversalis for surgical purposes. 
 
 The fascia transversalis is a membranous 
 expansion of various density ; arising from Pou- 
 part's ligament, and immediately investing and 
 
22 
 
 accompanying the peritoneum throughout its 
 extent, it would seem to give additional strength 
 to that delicate membrane, and defend it from 
 friction during muscular action. In this fascia 
 we find the internal abdominal ring.* 
 
 The internal abdominal ring is the aper- 
 ture through which the spermatic cord of the 
 male and the round ligament of the female 
 make their first exit from the abdominal cavity. 
 It is situated about midway between the supe- 
 rior spinous process of the ilium and symphysis 
 of the pubes. To see this opening distinctly, 
 it is necessary to remove the Cylindrical pro- 
 cess, a process sent from its edges less dense 
 than the fascia itself, and embracing and ac- 
 companying the cord to the external ring. 
 
 On raising the cord and opening the cylin- 
 drical process, we can then observe the inter- 
 nal ring to be rather oval than round, with its 
 longest diameter placed perpendicularly to 
 Poupart's ligament having well defined bor- 
 
 * We shall, for surgical purposes, consider these fasciae as procpsses 
 of Poupart's ligament,, although not anatomically correct. 
 
23 
 
 ders formed by two fibrous columns of tlie 
 fascia itself. 
 
 These columns do not run into each other, 
 but decussate ; the outer one crossing the inner 
 in a direction towards the pubes, and termi- 
 nating in the superior edge of Poupart's liga- 
 ment. The inner, having a direction backwards 
 and outwards towards the spine of the ilium, 
 is lost in the posterior edge of the same liga- 
 ment near to the mouth of the crural sheath. 
 
 These margins are frequently of a strong 
 tendinous structure, and quite sufficient to effect 
 a powerful strangulation at the neck of a her 
 nial tumour. 
 
 The remaining parts to be noticed, are the 
 spermatic cord and epigastric vessels, which 
 ought to be particularly observed from the inti- 
 mate connexion they have with the operations 
 performed at the groin. 
 
 The spermatic cord is made up of the artery, 
 vein, absorbents, and excretory duct of the tes- 
 ticle. It also receives branches from the in- 
 
24 
 
 ternal iliac and epigastric arteries; and nerves, 
 from the second lumbar and renal and aortic 
 plexuses. 
 
 The spermatic artery arises from the late- 
 ral parts of the aorta, a little above the inferior 
 mesenteric, and taking a course along the psoas 
 muscles, crosses the ureter and reaches at 
 length the internal abdominal ring ; here it 
 enters into the composition of the cord, accom- 
 panies it to the scrotum, disperses upon the 
 epididymis of the testicle, and performs the 
 secreting of the semen. 
 
 The spermatic vein passes from the testicle 
 along the cord into the abdomen, and, opposite 
 to the lower end of the kidney, ends in a single 
 trunk, which proceeds onward ; that on the right 
 side, terminating into the vena cava ; that on 
 the left, at right angles into the left cmulgent 
 vein. These veins have many valves. 
 
 The vas deferens is a cylindrical, cartilagi- 
 nous tube for conveying the semen from the 
 testicle to the urethra. It commences at the 
 posterior and inferior part of the epididymis. 
 
25 
 
 and takes a course along the back part of the 
 cord until it reaches the internal ring, when it 
 separates from it and passes downwards and 
 backwards along the psoas muscle, and is 
 attached to the side of the bladder. It then 
 crosses the ureter and proceeds from behind 
 forwards, between the vesiculse seminales, until 
 it reaches the prostate gland, where it unites 
 with the duct of the vesiculse seminales, forming 
 a tube about an inch in length common to both. 
 This perforates the prostate gland, and opens 
 into the urethra by the side of the veru monta- 
 num. The covering of the spermatic cord is 
 the tunica vaginalis, with the cremaster muscle 
 spread on its surface. 
 
 The tunica vaginalis is a process of the 
 peritoneum, accompanying the descent of the 
 testicle of the foetus into the scrotum. Pre- 
 vious to the eighth month, the testicle is within 
 the abdomen, lying below the kidney upon the 
 psoas muscle, covered anteriorly and laterally 
 by the peritoneum ; about this time it descends, 
 receiving direction, as is supposed, from a liga- 
 mentous substance named Gubernaculum. In 
 consequence of more peritoneum being brought 
 
 3 
 
26 
 
 down into the scrotum than was in close adhe- 
 sion with the testicle, we have a loose or re- 
 flected portion not adhering to it, constituting 
 the cavity of the tunica vaginalis. This pro- 
 cess of peritoneum may be divided into two 
 portions ; the tunica vaginalis of the cord, which 
 has its cavity obliterated soon after birth by ad- 
 hesion f and the tunica vaginalis of the testicle 
 which remains disconnected, excepting at its 
 posterior part, and secretes a lubricating fluid. 
 
 The cremaster muscle, if it has not been re- 
 moved, can now be distinctly seen, taking, from 
 its origin, a course towards the external ring, 
 along the inferior edge of the cord, and is lost 
 on the tunica vaginalis testis. 
 
 The epigastric artery is about the size of 
 a crow quill, and arises from the external iliac 
 as it is about passing under the crural arch. It 
 runs upwards and inwards, from one to two 
 inches, between the fascia transversalis and 
 •peritoneum ; it then perforates the fascia ob- 
 liquely and runs anterior to it. A little above 
 
 * When this does not occur, a passage is afforded for intestine, con- 
 stituting the hernia congenita. 
 
27 
 
 this, it penetrates the posterior sheath of the 
 rectus ; and near the umbilicus, it enters the 
 substance of that muscle previous to its meet- 
 ing with the internal mammary artery. 
 
 It thus takes a course between the two rings, 
 on the inner edge of the internal ring, and on 
 the outer edge of the external ring. In the 
 inguinal canal it gives off a branch to the 
 spermatic cord ; and within the sheath of the 
 rectus it supplies lateral branches to that 
 muscle. 
 
 This artery has been found, and not unfre- 
 quently, to arise from the external pudic, also 
 from the arteria profunda femoris. Occasion- 
 ally it arises high up from the external iliac, it 
 then takes a course downwards, then forwards 
 and upwards, to pass in its usual direction. 
 Doctor Monro mentions a specimen, in which 
 it arose from the obturator, and ran upwards and 
 inwards to the rectus muscle. There are also 
 some other uncommon origins mentioned, but 
 they so seldom occur, if at all, as to be hardly 
 worth acknowledging. 
 
m 
 
 The only remaining artery to be known and 
 described, as connected with hernia, is the 
 obturator. This can be examined at any future 
 time, and much better from an injected prepa- 
 ration ; we will however proceed, while on the 
 arteries, to a description of it, and conclude the 
 particular anatomy of this part of our subject, 
 by an examination and description of the peri- 
 toneum. 
 
 The obturator artery is generally a branch 
 of the internal iliac, and taking a course a little 
 below, and nearly parallel to the brim of the 
 pelvis, passes out together with the obturator 
 nerve, at the small hole in the upper part of the 
 obturator ligament, and is distributed princi- 
 pally to the upper part of the triceps muscle* 
 
 With this origin and course, this artery does 
 not come within the operations for inguinal or 
 femoral hernia, and would be of little surgical 
 importance. It however has various origins, 
 and thus becomes of some consideration. 
 
 It not unfrequently arises by one common 
 trunk with the epigastric from the external 
 
29 
 
 iliac, and occasionally from the same artery by 
 a separate trunk ; with this origin it passes by 
 Gimbernat's ligament, and is connected to it 
 by cellular substance. It has also been seen 
 to come from the femoral artery, within the 
 crural sheath. Mr. Anderson mentions a case, 
 in which it arose from the ordinary place, and 
 took its usual course ; but that a branch was 
 also given off from the inside of the external 
 iliac under the crural arch, that took a curved 
 direction over the linea ileo pectinea, and joined 
 the former a little behind the hole in the obtu- 
 rator ligament, forming a common trunk to be 
 distributed in its usual manner.* 
 
 The various origins of these arteries, unfor- 
 tunately, cannot be ascertained at the time of 
 operating, and thus produce no variation in the 
 mode of performing it ; but will account for 
 any unusual hemorrhage which may take place. 
 Some of them, however, are not endangered, 
 and those which are must take their chance. 
 
 The peritoneum is an expansion of dense 
 cellular membrane, enveloping the abdominal 
 
 * See System of Surgical- Anatomy, p. 74. 
 
30 
 
 viscera, and is also partly reflected upon some 
 of the contents of the pelvis. It is a white, 
 thin, shining membrane of the serous class ; its 
 inner surface smooth, secreting a serous fluid 
 for its lubrication, and forming no adhesions ; 
 its outer surface covered by the fascia transver- 
 salis, investing the inside of the abdominal 
 muscles, the posterior part of the abdomen, and 
 the surface of the several viscera. 
 
 The peritoneum superiorly and inferiorly 
 lies anterior to the abdominal viscera, and is 
 loosely attached about an inch or two above 
 Poupart's ligament previous to its descending 
 to line the posterior part of the abdomen. 
 Thus, when a hernia occurs, it yields readily 
 to the pressure of the protrusion, and accom- 
 panies it out of the abdomen, forming the her- 
 nial sac. 
 
 The hernial sac is a common covering to 
 all the abdominal hernia, with the exception of 
 congenital, which also, it will be remembered, 
 is a process of the peritoneum, descending with 
 the foetal testicle, taking the name of tunica 
 vaginalis. 
 
31 
 
 Having completed the dissection and parti- 
 cular anatomy of the individual parts, as they 
 appear in regular succession under the knife ? 
 we shall now take a general review of them, 
 connecting the relative situation of one with 
 the other, their connexion with inguinal hernia, 
 and the operation for its relief when strangu- 
 lated. 
 
 OF TH1 ©ESKTEIL&ii ANATOMY OF 
 
 xNCNrinrA* herexia. 
 
 We commence by restoring the parts to their 
 natural situation, and we then find, by begin- 
 ning externally, that the order will be as follows. 
 
 First, the common integuments. Secondly, 
 the fascia superficialis, which are both com- 
 mon coverings, and always form the two ex- 
 ternal coats of a hernial tumour. Thirdly, 
 the external oblique muscle, inserted into the 
 whole length of Poupart's ligament, contain- 
 ing the external abdominal ring for the pas- 
 sage of the male or female cord, and through 
 which a direct inguinal hernia always protrudes : 
 
32 
 
 it would thus have for its coverings, besides the 
 hernial sac, the integuments and fascia super- 
 ficialis. Fourthly, the internal oblique mus- 
 cle ; and fifthly, the transversalis. The two 
 last form the superior boundary of the oblique 
 canal, and by the former extending a little 
 lower down than the latter, a valvular structure 
 is given them, rendering additional strength to 
 the parts. 
 
 The oblique or inguinal canal can now be 
 seen to be the space between the external and 
 internal abdominal rings. It is bounded ante- 
 riorly by the tendon of the external oblique 
 muscle ; posteriorly by the fascia transversalis ; 
 superiorly by the lower edges of the internal 
 oblique and transversalis muscles ; and infe- 
 riorly by Poupart's ligament. In this canal, 
 we find the spermatic cord, or the round liga- 
 ment, covered by the cylindrical process from 
 the internal ring, and the cremaster muscle 
 lying at its lower edge. By this construction, 
 the oblique canal will be observed superiorly 
 to be of a valvular structure, adding strength 
 to the parietes when pressed upon by the vis- 
 cera, and, by the openings for the passage of 
 
35 
 
 the cord being removed a distance from each 
 other, a greater security is given against her- 
 nial protrusions, than if they were in apposi- 
 tion, allowing a direct passage to the cord from 
 the abdomen. 
 
 We next observe the fascia transversalis to 
 be in close contact with the peritoneum, and 
 containing the internal abdominal ring midway 
 between the spine of the ilium and symphysis 
 of the pubis, and through which an indirect 
 hernia always protrudes, carrying the cremas- 
 ter muscle before it, and in this additional 
 covering alone differs from a direct. Through 
 this opening the cord enters from the abdomen 
 into the oblique canal. 
 
 The relative situation of the epigastric artery 
 and vein to the rings, can now be particularly 
 observed, the vessels running on the inside 
 of the internal and on the outside of the external 
 ring ; consequently the division of the stricture at 
 the former would be safely performed directly 
 outwards, and at the latter directly inwards ; but 
 to be perfectly safe, for fear of mistaking the spe- 
 cies, it can be divided directly upwards in both. 
 
 4 
 
34 
 
 We now observe the situation of the sper- 
 matic cord, which can be seen occupying the 
 inferior edge of the internal ring, and probably 
 kept in its place by the weight of the testicle. 
 It then takes an oblique direction through the 
 inguinal canal, and passes out at the external 
 ring accompanied by the cremaster, and de- 
 scends into the scrotum to the testicle. 
 
 The situation of the spermatic cord, as re- 
 gards direct and indirect herniee, is generally be- 
 hind the neck of the sac ; there are, however, oc- 
 casional varieties in which it gets before it, and 
 sometimes it seems to be divided ; the vas de- 
 ferens getting in front of the sac, or on either 
 side. This may also occur to the blood vessels. 
 
 All that remains to be noticed, is the perito- 
 neum, as forming the hernial sac. 
 
 OPERATION TOR INGUIETAX. HERNIA. 
 
 The operation for direct inguinal hernia con- 
 sists of a middle incision through the integu- 
 ments, extending the whole length of the tu- 
 
35 
 
 mour, which are to be dissected off, when the 
 fascia superficialis beneath will be exposed to 
 view. The fascia superficialis is next divided 
 and turned off, when the hernial sac, to which 
 we have now come, presents itself. Here the 
 knife is to be placed flatwise, and this coat is 
 to be cut into, delicately and cautiously ; which 
 is generally manifested by the escape of a quan- 
 tity of fluid, although this does not always occur. 
 
 A director is now to be introduced, and the 
 sac freely dilated, by placing a bistoury in its 
 groove and cutting outwards. The finger is 
 then introduced to the seat of stricture, and the 
 nail, if possible, insinuated within it. A probe 
 pointed bistoury is now introduced flatwise on 
 the face of the finger, and then turned up, di- 
 viding the stricture, to be perfectly safe, directly 
 upwards. 
 
 After this, the contents of the sac should be 
 cautiously examined, and particularly the stric- 
 tured part, to ascertain if there are any ulcera- 
 tions at the seat of strangulation, and whether 
 it be returnable or not. If returnable, and 
 should it be intestine, the gut is to be emptied 
 
M 
 
 as much as possible of its contents, and the last 
 portion protruded passed into the abdomen first, 
 and so successively, until it shall be returned. 
 If not returnable, it must then be left in the 
 sac, and subjected to one of three alternatives. 
 First, by leaving it entirely to nature, and allow- 
 ing the intestine to slough, when an artificial 
 anus will be the consequence. Secondly, by 
 removing the intermediate diseased portion, 
 and bringing the edges together, connecting 
 them by an uninterrupted suture making an 
 attempt at union. Thirdly, by introducing one 
 extremity of the divided gut within the cavity 
 of the other, sewing it in the same manner, to 
 accomplish the same purpose as the former. 
 
 Should these attempts fail, there is still ano- 
 ther means by which union may be effected, 
 independent of the duration of an artificial 
 anus. This project owes its origin to the inge- 
 nuity of Mr. Dupuytren. It consists in bring- 
 ing each extremity of the divided gut in lateral 
 contact, and the blades of a bluntly serrated 
 forceps, with bulbous extremities, are introdu- 
 ced separately into the open mouth of each in- 
 testine. The forceps is then locked, making 
 
37 
 
 of course the most pressure at their extremi- 
 ties, thus promoting the absorption of intestine 
 at that point, and establishing a communication 
 between the two. The forceps is now removed, 
 and when the fceces pass readily through the 
 new made aperture, the extremity of each in- 
 testine is to be united, which, when accomplish- 
 ed, is returned to the abdomen. 
 
 Union, I think, ought always to be attempt- 
 ed, for if it succeeds, a very great object is at- 
 tained ; if it fails, the patient is precisely in 
 the same situation as though it had been left 
 to nature. 
 
 The operation for indirect inguinal hernia 
 does not differ from the former, when the pro- 
 trusion reaches the external ring, with the ex- 
 ception of its having one more covering, the 
 cremaster muscle. This protrusion, however, 
 does not always reach the external ring, but 
 occasionally remains within the inguinal canal ; 
 consequently it is beneath the tendon of the 
 external oblique muscle, which is then divided, 
 and exposes the fibres of the internal oblique, 
 more or less, according to the muscularity of 
 
38 
 
 the subject, covering the hernial sac, which is 
 seen after turning them up. 
 
 The seat of stricture, in indirect hernia, may 
 be at the external ring, within the inguinal 
 canal, or at the internal ring ; that must be 
 ascertained at the time of operating ; and the 
 same rules govern this precisely as do the 
 direct. 
 
 DISSECTION Or THE FARTS CONNECTED 
 WITH FEMORAL HERNIA. 
 
 In the dissection of the parts connected with 
 femoral hernia, we shall follow the same order 
 as observed in inguinal ; that is, each part sepa- 
 rately, as it appears on dissection ; and then 
 collectively, after the dissection is completed. 
 
 For this purpose an incision is to be made, 
 commencing at the pubes, a little within the 
 external ring, continuing it on the scrotum, and 
 terminating it about six inches down the inner 
 side of the thigh. The dissection is to be com- 
 menced at the upper part, and the integuments 
 
39 
 
 alone are to 1>e removed. Next, the fascia 
 superficialis is to be dissected off, removing 
 with it the superficial glands of the groin, which 
 are enveloped in it. We now have exposed to 
 view the fascia lata of the thigh, and ascending 
 on its inner anterior surface the major saphena 
 vein. 
 
 Previous to proceeding with the dissection 
 and description of these parts, Poupart's liga- 
 ment, or, more properly, the inguinal ligament, 
 and its connexions, first claim our notice. 
 
 The inguinal ligament arises from the ante- 
 rior superior spinous process of the ilium, and 
 is inserted in the tuberosity of the pubes, into 
 the symphysis pubis, and into the linea ileo 
 pectinea. This last insertion has received the 
 name of Gimbernat's ligament, and was sup- 
 posed to be the seat of stricture in femoral 
 hernia. The inguinal ligament is a firm fibrous 
 substance, and has by many been considered 
 as formed by the interior termination of the 
 tendon of the oblique muscle ; by others it has 
 "been considered as two distinct ligaments ; the 
 superior one of arounded appearance, extending 
 
40 
 
 from the ilium to the pubes, retaining its origi- 
 nal name ; and the inferior one inserted by Gim- 
 bernat's ligament into the linea ileo pectinea> 
 taking the name of crural arch, from its arched 
 appearance, and under which the great vessels 
 pass out from the abdomen. This division, how- 
 ever, would seem to be more the effect of the 
 knife, dividing and removing the cellular sub- 
 stance between its fibres, than from airy real 
 existence. 
 
 We shall consider it anatomically as one 
 ligament, retaining however, for perspicuity., 
 the name of crural arch, as more immediately 
 expressive of the aperture through which femo- 
 ral or crural .hernia protrudes. The inguinal 
 ligament has three processes, viz. the fascia 
 transversalis, running directly upwards between 
 the peritoneum and transversalis muscle ; the 
 fascia lata, running downwards and investing 
 the muscles of the thigh ; and the fascia iliaca 
 lining the iliacus interims muscle. 
 
 We can now proceed to the removal of the 
 fat and cellular substance immediately about 
 the crural arch, feeing careful not to take away 
 
41 
 
 the anterior portion of the sheath of the femo- 
 ral vessels. All the dissection necessary being 
 now completed, we will consider the processes 
 of the inguinal ligament. 
 
 The fascia transversalis has already been 
 noticed when on inguinal hernia, and nothing 
 more remains to be described, with the excep- 
 tion of a process sent down the leg, forming the 
 anterior part of the sheath of the vessels, which 
 shall be more particularly spoken of when on 
 the femoral sheath. 
 
 The fascia lata is a thick shining mem- 
 brane of a fibrous structure, enveloping the 
 muscles of the thigh. It arises from the spine 
 of the ilium, from the inguinal ligamerit, and 
 from the arch of the pubes, and is divided at the 
 upper and fore part of the thigh into two por- 
 tions, viz. the pectineal or pubic, and the iliac 
 portions of the fascia lata. 
 
 The pubic portion arises from the arch of the 
 
 pubes, and invests the gracilis and pectinalis 
 
 muscles. AH that part of it, superior to the point 
 
 at which the saphena enters the femoral vein, 
 
 5 
 
42 
 
 passes inward under the sheath of the vessels, 
 and is lost among muscular fibre. Inferiorly 
 it passes under the saphena on the face of the 
 sheath and becomes continuous with the iliac 
 portion. 
 
 The iliac portion arises from the spine of 
 the ilium, runs inwards covering the sheath of 
 the vessels, and terminates in an abrupt edge 
 at the inguinal ligament. It is the termination 
 of this edge interiorly which has received the 
 name, from its crescentic or falciform appear- 
 ance, of crescentic edge oy falciform process of 
 the fascia lata, It is about two inches in length, 
 its upper horn passes down by the inner side of 
 the femoral sheath, and is connected to Gim- 
 bernat's ligament ; its lower horn passes under 
 the saphena vein, immediately below where it 
 terminates into the femoral, to meet its fellow 
 portion of the opposite side. 
 
 It can now be readily conceived in looking 
 at the parts, how a femoral hernia must neces- 
 sarily protrude from under the iliac portion and 
 rest upon the pubic. 
 
43 
 
 The fascia iliaca can be examined next, if 
 desired, or it can be left for a more advanced 
 stage of the dissection. We however, to finish 
 the fasciae, will describe it. 
 
 The fascia iliaca arises from the inner 
 labium of the crista of the ilium, and from all 
 the posterior edge of the inguinal ligament, 
 with the exception of that part forming the 
 crural arch. By this origin from the iliac 
 portion of the inguinal ligament, or that space 
 from the out3r edge of the sheath to the spine 
 of the ilium, a hernia is prevented in that 
 direction ; and by the origin, from the inner 
 edge of the crural sheath to the symphy- 
 sis pubis, a space is left between the two for 
 the passage of the femoral vessels to descend 
 to the thigh. This last portion of the fascia 
 iliaca is continuous with the fascia transversalis, 
 and passes down into the cavity of the pelvis 
 to be attached to the bladder. 
 
 The fascia iliaca has its posterior surface 
 in contact with the iliacus internus and psoas 
 magnus muscles, and the upper part of the ante- 
 rior crural nerve. Its anterior surface is con- 
 
nected with the iliac vessels, and loosely with 
 the peritoneum. 
 
 The only particular importance attached to 
 this fascia, as connected with hernia, is a pro- 
 cess sent down under the femoral vessels, form- 
 ing, as it were, a floor for them to rest on, and 
 which joining laterally with the process from 
 the fascia transversalis, makes up the femoral 
 sheath. 
 
 The fascia lata can now be detached from 
 its connexion with the inguinal ligament, and 
 carefully turned off, that the femoral sheath 
 which comes next to be examined, may be 
 exposed. 
 
 The femoral or crural sheath is a mem- 
 branous canal enclosing the femoral vessels. 
 It is formed anteriorly by the process of the 
 fascia transversalis, and posteriorly by that of 
 the fascia iliaca ; the one forming the roof, 
 and the other the floor, connected at the sides. 
 
 The femoral sheath, by its superior portion 
 arising from the circumference of the arch of the 
 
45 
 
 inguinal ligament, and becoming narrower, and 
 in closer contact with the vessels, as it proceeds 
 down the thigh, is of a funnel like form. 
 
 On cutting into this sheath, we can distinctly 
 see that it is a regularly circumscribed cavity, 
 convex at its superior surface ; we can also see 
 that point at the upper and forepart about an 
 inch and a half from its commencement, w r here 
 the saphena perforates the sheath to join the 
 femoral vein, 
 
 The point to be most particularly noticed, 
 and which is of essential importance to be ac- 
 quainted with and understood, is that part called 
 the cribriform portion of the femoral sheath. 
 It is situated on its anterior and inner surface 
 a little below the crural arch, and is the place 
 at which the subcutaneous absorbents of the 
 thigh perforate it, to enter a gland lying within 
 this canal. 
 
 These holes are about twelve in number, 
 and the portion of the femoral sheath thus per- 
 forated, is that part which yields to the pres- 
 sure of a hernial protrusion, and forms, with 
 
46 
 
 the assistance of the reticular membrane, the 
 fascia propria of a femoral hernia. 
 
 All that now remains to be observed within 
 this canal, is the relative situation of the artery 
 with the vein, and the seat of the crural ring. 
 The femoral artery is seen occupying the outer 
 boundary of the sheath, and the vein lying on 
 the inside of the artery nearly in the centre, and 
 divided from it by a septum of a membranous 
 structure. 
 
 The crural ring is that part of the sheath 
 seen from the abdomen, and is the space be- 
 tween the vein and Gimbernat's ligament. This 
 is occupied by the glands through which the 
 absorbent vessels pass into the pelvis, and is 
 the aperture through which femoral hernia pro- 
 trudes, and the seat of stricture when it is 
 strangulated. 
 
 The dissection and the description of the 
 individual parts of femoral hernia being now 
 finished, we will proceed to the revision of 
 them, as they are respectively situated and con- 
 nected with each other. 
 
47 
 
 OF THE GENERAL ANATOMY CONHTSCB* 
 ED WITH FEMORAL HERNIA, 
 
 As in inguinal hernia, we restore the parts 
 to their natural situation, and we then find the 
 following arrangement : 
 
 First, the common integuments. Secondly, 
 the fascia superficialis. Thirdly, the inguinal 
 ligament having one origin from the spine of 
 the ilium, and three insertions, viz. into the 
 tuberosity of the pubis, into the symphysis 
 pubis, and into the linea ileo pectinea, forming 
 Gimbernat's or the femoral ligament. It also 
 has three processes, the fascia transversalis, 
 running upwards ; the fascia iliaca, investing 
 the iliacus internus muscle ; and the fascia lata, 
 covering the muscles of the thigh : this last 
 consists of two portions, the pubic and iliac ; 
 the pubic covering the gracilis and pectinalis 
 muscle, the iliac covering the outer and ante- 
 rior part of the thigh, and terminating at the 
 inguinal ligament in a falciform manner, mak- 
 ing the falciform process or crescentic edge of 
 
48 
 
 the fascia lata. The saphena major vein is seen 
 ascending on its surface, and terminating in the 
 fe moral at the inferior termination of the cres- 
 centic edge. 
 
 Next, we have the femoral sheath of a funnel 
 like form, lying under the iliac portion of the 
 fascia lata, and made up anteriorly of a process 
 or continuation of the fascia transversalis down- 
 wards, and posteriorly of a process of the fascia 
 iliaca continued in the same direction. In the 
 anterior part of the sheath, we find the cribri- 
 form plate, marking the entrance of the absorb- 
 ent vessels to a gland within it. We are also 
 to remember that from the weakness of this 
 part, from its numerous perforations, it becomes 
 together with the reticular membrane, the 
 covering immediately preceding the hernial 
 sac, constituting the fascia propria. 
 
 On opening the crural sheath, we observe the 
 relative situation of the vessels, that the artery 
 is on the outside, and the vein on the inside, 
 divided by a septum from each other, and that 
 the crural ring, occupied by glands, is the space 
 between the vein and Gimbernat's ligament. 
 
49 
 
 through which femoral hernia protrudes, and 
 by which it is strangulated. 
 
 A femoral hernia must thus have for its co* 
 verings the integuments, the fascia superficialis, 
 the fascia propria, and the hernial sac. 
 
 OF THE OPERATION FOB. FS2MCOR.A& 
 HBRZfXA, 
 
 This consists in making a transverse inci- 
 sion through the integuments along the base of 
 the tumour, its whole length. This is met by 
 another, two or three inches in length, as may 
 be required, terminating at the middle of the 
 former : the two making the form of the letter 
 T inverted. 
 
 The flaps of integuments are to be dissected 
 off, and the fascia superficialis then removed by 
 similar incisions. We now have reached the 
 fascia propria, which in a similar manner is to 
 be carefully dissected from the hernial sac. 
 
 6 
 
50 
 
 The knife is now placed flatwise, and a small 
 hole cut through this last covering, the accom- 
 plishment of which, the escape of a fluid will 
 most probably evince. Should this not occur, 
 the anatomy of the parts can be the only cau- 
 tious guide. 
 
 The same rules and caution are now to be 
 observed in the division of the hernial sac, and 
 dilatation of the stricture, as mentioned in in- 
 guinal hernia ; that of introducing a director, 
 and placing the bistoury within its groove, and 
 cutting freely outwards ; next, introducing the 
 finger to the seat of stricture, keeping the pro- 
 trusion behind it, and introducing the probe 
 pointed bistoury flatwise upon its face, and then 
 turning it upwards. 
 
 The stricture in this protrusion is at the 
 crural ring, and is to be divided upwards and 
 inwards ; thus the epigastric artery and the fe- 
 moral vein are avoided, which might otherwise 
 be opened and be of serious consequence. 
 
 This protrusion, if returnable, is to be return- 
 ed in the same manner as in inguinal hernia, 
 
51 
 
 and if not, must then take its chance for union 
 by adhesion, or an artificial anus must be the 
 consequence. 
 
 Or THIS AWATOBSIT COTTOTESCTSD WITH 
 UZHZBXLIC AL AITO VSNT&AL KEH3NTI.J5. 
 
 The dissection of the parts connected with 
 these two forms of hernia, was included in the 
 same performance with inguinal, and needs no 
 particular description. They protrude directly 
 from the abdomen, the former at the umbilicus, 
 the latter at any point not peculiar to the others, 
 and consequently have three coverings ; the 
 common integuments, the fascia superficialis, 
 and the peritoneal hernial sac. 
 
 The operation for their relief when strangu- 
 lated, must be governed by the size of the tu- 
 mour. Generally a simple incision through the 
 integuments in the long axis of the tumour, and 
 continued successively through the remaining 
 coats is su fficient. Sometimes, when large, a 
 T incision is necessary, and when still larger, 
 a crucial is required. 
 
52 
 
 The division of the stricture must be govern- 
 ed by the location of the tumour, having a par- 
 ticular reference to the course of the epigas- 
 tric artery. 
 
 Pelvic herniae are so rare as to require no 
 distinct head or description. 
 
 I have now arrived at the end proposed in my pre- 
 face ; but it would be doing an injustice to my feelings 
 to conclude this essay, without acknowledging the obli- 
 gations due to my distinguished preceptor, Doctor 
 Mott, not only for the opportunities afforded me of 
 seeing his masterly dissections, and hearing his scien- 
 tific elucidations of the subject of Hernia, but also, of 
 witnessing his operations performed for it, in all its 
 various forms. 
 
 To his bright example I owe my taste and desire for 
 surgical knowledge ; and whilst I reflect on his manly 
 exertions to elevate his profession to the highest point 
 of excellence and public usefulness, I can never want 
 an incentive necessary for its complete acquirement. 
 
 To him I return my thanks, and shall always remem* 
 ber with pleasure, the many kind attentions 1 have 
 received from him both privately and publicly. 
 
 THE END. 
 
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