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70 Commentary on plate 27.

Herniae may happen at other localities, such as at the thyroid aperture, which transmits the thyroid vessels; and at the greater sacro­sciatic notch, through which the gluteal vessels pass; and all regions of the abdominal walls may give exit to intestinal protrusion in consequence of malforma­tions, disease, or injury. But as the more frequent varieties of herniae are those which traverse the localities, A, D, E, and as these, fortunately, are the most manageable under the care of the surgical anatomist, we proceed to examine the structures concerned in their occurrence.

A direct opening from within outwards does not exist in the walls of the abdomen; and anatomy de­monstrates to us the fact, that where the spermatic cord, D F, and the femoral vessels, pass from the abdo­men to the external parts, they carry with them a covering of the several layers of structures, both muscular and membranous, which they encounter in their passage. The inguinal and crural forms of herniae which follow the passages made by the sper­matic cord, and the crural vessels, must necessarily carry with them the like investments, and these are what constitute the coverings of the herniae them­selves.

The groin in its undissected state is marked by certain elevations and depressions which indicate the general relations of the subcutaneous parts. The abdomen is separated from the thigh by an undulat­ing grooved line, extending from C*, the point of the iliac bone, to B, the symphysis pubis This line or fold of the groin coincides exactly with the situation of that fibrous band of the external oblique muscle named Poupart's ligament. From below the middle of this abdomino-femoral groove, C B, another curved line, D, b, springs, and courses obliquely, inwards and downwards, between the upper part of the thigh and the pubis, to terminate in the scrotum. The exter­nal border of this line indicates the course of the spermatic cord, D F, which can be readily felt beneath the skin. In all subjects, however gross or emaciated they may happen to be, these two lines are readily distinguishable, and as they bear relations to the several kinds of rupture taking place in these parts, the surgeon should consider them with keen regard. A comparison of the two sides of the figure, PLATE 27, will show that the spermatic cord, D F, and Poupart's ligament, C B, determine the shape of the inguino­-femoral region. When the integument with the subcutaneous adipose tissue is removed from the inguino-femoral region, we expose that common in­vesting membrane called the superficial fascia. This fascia, a a a, stretches over the lower part of the abdomen and the upper part of the thigh. It becomes intimately attached to Poupart's ligament along the ilio-pubic line, C B; it invests the spermatic cord, as shown at b, and descends into the scrotum, so as to encase this part. Where this superficial fascia over­lies the saphenous opening, E, of the fascia lata, it assumes a "cribriform" character, owing to its being pierced by numerous lymphatic vessels and some veins. As this superficial fascia invests all parts of the inguino-femoral region, as it forms an envelope for the spermatic cord, D F, and sheathes over the saphenous opening, E, it must follow of course that wherever the hernial protrusion takes place in this region, whether at D, or F, or E, or adjacent parts, this membrane forms the external subcutaneous covering of the bowel.

There is another circumstance respecting the form and attachments of the superficial fascia, which, in a pathological point of view, is worthy of notice--viz., that owing to the fact of its enveloping the scrotum, penis, spermatic cord, and abdominal parietes, whilst it becomes firmly attached to Poupart's ligament along the abdomino-femoral fold, B C, it isolates these parts, in some degree, from the thigh; and when urine happens to be from any cause extravasated through this abdominal-scrotal bag of the superficial fascia, the thighs do not in general participate in the inflammation superinduced upon such accident.

The spermatic cord, D, emerges from the abdomen and becomes definable through the fibres of the sheathing tendon of the external oblique muscle, H, at a point midway between the extremities of the ilio-pubic line or fold. In some cases, this place, whereat the cord first manifests itself in the groin, lies nearer the pubic symphysis; but however much it may vary in this particular, we may safely regard the femoro-pubic fold, D, b, as containing the cord, and also that the place where this fold meets the ilio­pubic line, C B, at the point D, marks the exit of the cord from the abdomen.

COMMENTARY ON PLATE 27 71

The spermatic cord does not actually pierce the sheathing tendon of the external oblique muscle at the point D, and there does not, in fact, exist naturally such an opening as the "external abdominal ring," for the cord carries with it a production of the tendon of the external oblique muscle, and this has been named by surgical anatomists the "intercolumnar fascia,"[Footnote] the "spermatic fascia." The fibres of this spermatic fascia are seen at D F, crossing the cord obliquely, and encasing it. This covering of the cord lies beneath the spermatic envelope formed by, a b, the superficial fascia; and when a hernial protrusion descends through the cord, both these investing mem­branes form the two outermost envelopes for the in­testine in its new and abnormal situation.

[Footnote: On referring to the works of Sir Astley Cooper, Hessel­bach, Scarpa, and, others, I find attempts made to establish a distinction between what is called the "intercolumnar fascia" and the "spermatic fascia," and just as if these were struc­tures separable from each other or from the aponeurotic sheath of the external oblique muscle. I find, in like manner, in these and other works, a tediously-laboured account of the super­ficial fascia, as being divisible into two layers of membrane, and that this has given rise to considerable difference of opinion as to whether or not we should regard the deeper layer as being a production of the fascia lata, ascending from the thigh to the abdomen, or rather of the membrane of the abdomen descending to the thigh, &c. These and such like considera­tions I omit to discuss here; for, with all proper deference to the high authority of the authors cited, I dare to maintain, that, in a practical point of view, they arc absolutely of no moment, and in a purely scientific view, they are, so far as regards the substance of the truth which they would reveal, wholly beneath the notice of the rational mind. The prac­titioner who would arm his judgment with the knowledge of a broad fact or principle, should not allow his serious attention to be diverted by a pursuit after any such useless and trifling details, for not only are they unallied to the stern requirements of surgical skill, but they serve to degrade it from the rank and roll of the sciences. Whilst operating for the reduction of inguinal hernia by the "taxis" or the bistoury, who is there that feels anxiety concerning the origin or the distinctiveness of the "spermatic fascia?" Or, knowing it to be present, who concerns himself about the better propriety of naming it "tunica vaginalis communis," "tunique fibreuse du cordon spermatique," "fascia cremasterica," or "tunica aponeuro­tica?"]

The close relations which the cord, D F, bears to the saphenous opening, E, of the fascia lata, should be closely considered, forasmuch as when an oblique in­guinal hernia descends from D to F, it approaches the situation of the saphenous opening, E, which is the seat of the femoral or crural hernia, and both varie­ties of hernia may hence be confounded. But with a moderate degree of judgment, based upon the habit of referring the anatomy to the surface, such error may always be avoided. This important subject shall be more fully treated of further on.

The superficial bloodvessels of the inguino-femoral region are, e e, the saphenous vein, which, ascending from the inner side of the leg and thigh, pierces the saphenous opening, E, to unite with the femoral vein. The saphenous vein, previously to entering the sa­phenous opening, receives the epigastric vein, i, the external circumflex ilii vein, h, and another venous branch, d, coming from the fore part of the thigh. In the living body the course of the distended sa­phenous vein may be traced beneath the skin, and easily avoided in surgical operations upon the parts contained in this region. Small branches of the femoral artery pierce the fascia lata, and accompany these superficial veins. Both these orders of vessels are generally divided in the operation required for the reduction of either the inguinal or the femoral strangulated hernia; but they are, for the most part, unimportant in size. Some branches of nerves, such as, k, the external cutaneous, which is given off from the lumbar nerves, and, f, the middle cutaneous, which is derived from the crural nerve, pierce the fascia lata, and appear upon the external side and middle of the thigh.