HERNIA. 



753 



inferior or external is rounder and more firm, 

 and attached to the external part of the crest or 

 tuberosity of the pubis. A triangular aperture 

 is thus formed of about an inch or an inch and 

 a quarter in length, the base of which, nearly 

 half an inch across, is situated at the pubis, from 

 which it tapers gradually off in a direction 

 upwards and outwards. For a neat demonstra- 

 tion of this aperture we must also be largely 

 indebted to the knife of the anatomist, its 

 edges being obscured by a fascia* which comes 

 off from them, and passing down on the cord 

 is generally of sufficient density to admit of 

 being traced as far as the tunica vaginalis testis. 

 This ring is never well developed in the female, 

 it then being smaller, rather of an oval figure, 

 and from its deficiency of size appearing to be 

 nearer the pubis than in the male: even in 

 subjects of the latter sex the size of this open- 

 ing exhibits considerable variety. When a 

 hernia has descended through it, the shape and 

 direction of the external ring are altered : the 

 inferior pillar is still more flattened and runs 

 in a more horizontal direction ; the superior is 

 banded in an arched form rather tightly above 

 it ; the shape of the entire ring is rendered more 

 oval and its direction more horizontal ; but still 

 its relative position with respect to the bone is 

 so far preserved that no hernia can pass, with- 

 out its internal edge resting on this bone. 



In dissecting a hernia of this description 

 from without, after removing the skin and 

 cellular tissue more or less loaded with fat, the 

 fascia superficialis is exposed. This is a tegu- 

 ment investing most parts of the body, though 

 far more dense in some situations than in 

 others, and is situated beneath the subcuta- 

 neous fat, with which it is sometimes so much 

 identified as to render its demonstration diffi- 

 cult. At the groin it is usually well developed, 

 and is described as consisting of two distinct 

 laminae, but may (by such as are curious in 

 these dissections) by care be separated into 

 many more.f The superficial layer is very 

 lax, passes over and has no connexion with 

 Poupart's ligament, arid is very generally re- 

 moved along with the skin and fat by the in- 

 experienced dissector. Its removal exposes 

 some of the glands of the groin. The deep 

 layer is more membranous, and possesses more 

 of the determined character of a fascia. It 

 adheres intimately to the muscular fibres of the 

 external oblique, passes thence inwards over 

 the tendon, to which it cannot be said to be 

 attached, as the connecting cellular tissue is 

 extremely loose, and meets its fellow of the 

 opposite side at the linea alba, to which both 

 are attached. It has an insertion into the 

 pubis, and its adhesion to Poupart's ligament 

 is in many respects extremely intimate. Pass- 



* This also has been called an intercolumnar 

 fascia, and a spout-like fascia, &c. It is to be re- 

 gretted that such a confusion of nomenclature ob- 

 tains in the description of these parts, a confusion 

 always embarrassing to the student, and rendering 

 the subject uselessly perplexing and difficult. 



t Velpeau describes three distinct layers. Aua- 

 tomie des Regions, torn. ii. p, 70. 



VOI., IJ. 



ing down in front of the thigh, it covers* several 

 of the lymphatic glands, or in many instances 

 leaves small apertures or deficiencies in which 

 glands are lodged : it then reaches the opening 

 in the fascia lata for the transmission of the 

 saphena vein, to the edge of which it adheres 

 more or less closely, and afterwards descends 

 upon the thigh, having this vein interposed 

 between it and the fascia lata. At the external 

 abdominal ring the fascia superficialis sends 

 down a sheath-like process, investing the cord 

 and descending down over the tunica vaginalis 

 and the testicle : it must, therefore, under any 

 circumstances give a covering to the hernial 

 sac. On the removal of this, the fascia that 

 comes from the edges of the pillars of the ring 

 is observed, and this is generally much thicker 

 and firmer than in the normal condition of the 

 parts. When so thickened, it also admits of 

 subdivision into several laminae. Immediately 

 underneath is the cremaster muscle, its fibres 

 spread out and separated so as to resemble a 

 fascsa, though in some instances the contrary may 

 be observed, and they are seen gathered into 

 bundles and greatly thickened. Still deeper 

 are three other layers of fascia, perhaps derived 

 from that which comes from the edges of the 

 internal ring, and finally the hernial sac is 

 exposed. 



In herniae of moderate size, the spermatic 

 artery, veins, and the vas deferens are usually 

 found in one cord and enclosed in one common 

 sheath lying behind the sac : some exceptions, 

 however, to this rule are observed, one of which, 

 wherein the bloodvessels are situated on its 

 anterior and external surface, and the vas defe- 

 rens posteriorly and internally, has been already 

 noticed and explained. But there is another 

 deviation that seems to be occasioned by the 

 growth of the hernia, and the compression exer- 

 cised by it on the cellular substance connecting 

 the constituent parts of the cord together. It 

 can therefore only be met with in large and old 

 ruptures. Thus, as the tumour increases, it 

 causes this cellular tissue to be stretched just 

 as if the vas deferens and the artery were pulled 

 asunder in different directions, whilst the sac 

 insinuates itself between them, until finally the 

 vessels come to lie on one side of the hernia, or 

 it may be to occupy its anterior surface. The 

 greatest divarication of these vessels exists, as 

 might a priori be expected, towards the lower 

 part of the tumour; it is less towards the 

 middle, and scarcely if at all above, and in the 

 vicinity of the neck of the sac. A knowledge 

 of this fact may teach us to beware how we 

 prolong an incision very far down in operating 

 on large and old herniae. 



Perhaps the next point of practical import- 

 ance to consider is, whether, with all this ana- 

 tomical and pathological information, it might 

 nevertheless be possible to mistake this disease 

 and confound it with any other affection. The 



* The inguinal glands arc generally described as 

 lying between the layers of the superficial fascia. 

 On dissection, this has not appeared to me to be 

 the case, 



3 P 



