is to say, as they really exist during life, and according to the uses and offices which they are intended to serve. No part of the body affords a more striking instance of this vicious custom than that which Mr. Callender has undertaken to describe. The little portion of fibrous tissue which, intervening between the superficial fascia of the thigh on the outside of the body and the peritoneum in the interior, and bounded towards the middle line by the pubic bone, and on the other side by the femoral vein, has been divided by the ingenuity of anatomists into about a dozen separate tissues, and has given immortality to at least half a dozen separate authors; its detailed description occupies the best part of forty-five quarto pages in the elaborate work of Mr. Gay; while the number of different objects which the student was apparently expected to recognise, and the list of names which he was expected to remember and to be able on occasion to define, threatened to lengthen with each successive author. Meanwhile it was certainly disheartening to the zealous youthful anatomist, after that he had by some triumphant expenditure of minute toil succeeded in demonstrating to his own satisfaction and that of his teachers the crural septum and the deep crural arch, the saphenous opening, the cribriform fascia, Hey's ligament, Burns's ligament, the crural opening, and the crural canal (the last and most difficult triumph of the dissector's art), to be told that few of these objects have any real existence in nature, and that a man might have operated successfully upon a hundred cases of femoral hernia without having ever heard of any of them; in fact, that they are portions into which the tissues may be divided, rather than divisions which nature has pointed out; and that they are described in our schools rather from respect to the anatomists who first demonstrated them, and to the examiners who still exact a knowledge of them from the students, than from any conviction on the part of the lecturer of their existence in nature. Each of these celebrated names comes out from the investigation of Mr. Callender shorn of much of its importance. Thus he says of the septum crurale, "If the sub-peritoneal fascia be reflected from the inner side of the lower extremity of the external iliac vein, or if the fascia lata be removed from the inner side of the crural vessels (here surrounded by dense reticulated tissue), a small collection of fat, held together by connective tissue, is exposed to view." (p. 38.) And in a foot-note to this passage, he says, "Cloquet has described some fascia, perforated by openings for the lymphatics, as extending between the vein and the posterior edge of the external oblique tendon (septum crurale)." So it is plain that Mr. Callender has not been able to satisfy himself of the real existence of the structure described by Cloquet. As to the saphenous opening and the cribriform fascia which closes it, Mr. Callender, correctly as we think, regards the opening as in most cases an artificial formation, and the fascia by which it is covered as a part of the fascia lata, and he gives a drawing (Plate ii.) which represents to our minds most accurately the state of the parts, and which shows the fascia lata extending uninterruptedly over the femoral vein and the opening for the saphenous vein. Mr. Callender does not however deny that a "saphenous opening" is really

present in some cases; but this he regards as the result of "the wasting or absorption of portions of the fascia lata, probably from the pressure of enlarged glands." Touching the deep crural arch, and the ligaments (or ligament) of Hey and of Burns, Mr. Callender makes the following very just and very sensible observations:

"The whole upper free edge of the iliac fascia lata is commonly called 'the falciform process,' whilst its deeper fibres receive the name of Burns's ligament.' Hey's femoral ligament would appear to consist of distinct fibres connected with the inner fold of the iliac fascia, which extend immediately beneath the tendon of the external oblique to the sub-peritoneal fascia. The upper border (cornu superius annuli cruralis anterioris, Hesselbach) of this opening thus receives, by an unfortunate complication, the names of 'Falciform process, Femoral ligament,'Burns's or Hey's ligament.' . The various divisions of the iliac fascia lata depend in great measure upon the skill of the dissector, and are, in my opinion, artificial." (Note, p. 19.)

The crural opening and the crural canal are made, as Mr. Callender remarks, by the femoral hernia, and have no existence before that tumour protrudes. In fact, it has appeared to us that the simplest, the most natural, and, above all, the most surgical way of looking at a femoral hernia would be to describe it as a mass of protruded omentum or intestine covered by two sacs lying under the subcutaneous tissue— the inner hernial or serous sac formed by peritoneum, and having usually a distinct neck, the outer or tendinous sac formed by fascia lata, or, which is the same thing, by the sheath of the vessels, and having its neck at the crural opening. The constriction of a strangulated hernia takes place either at the neck of the tendinous sac or at the neck of the serous sac. In the former case an incision into the tendon of the external oblique (Gimbernat's ligament) or into the neighbouring attached portion of the iliac fascia lata (Hey's ligament, Burns's ligament, deep crural arch), will relieve it; and if the tendinous sac do not adhere too closely to the serous at this part, it may be possible to relieve the stricture without opening the serous sac. If, on the contrary, the constriction is at the neck of the serous sac, the latter must necessarily be opened, and in dividing it some of the fibres of the neck of the tendinous sac will also usually be divided, when, as is generally the case, these two necks correspond. We may remark, however, that the necks do not always correspond, and that the seat of stricture in the neck of the peritoneal sac may be at any part of its circumference. In operating a short time since on a case of inguinal hernia we found it impossible to return the intestine until a tense band at the back of the sac had been divided. If this simple view of the ground plan of a hernia were more generally taught to students, we venture to think that their comprehension both of the disease and of its operative treatment would be much facilitated. At present, all the ingenuity of anatomists seems to have been expended upon the task of chopping up the tendinous investment of the hernia into as many distinct parts as possible, and describing each by names which convey little meaning to the mind of the student, while the outer or subcutaneous investment of the tumour is passed over with hardly any notice, and the inner or peri

toneal one is little dwelt upon. This is surely an error. In the anatomy of hernia the subcutaneous tissue, including the glands, plays a most important part; a part which we are glad to see that Mr. Callender restores to its due prominence (see Plate iii. and the comments on it). In the pathology of hernia, surely the contents, and serous covering, of the tumour are the essential parts to which attention should be directed. While in the operation for hernia the main element of success and safety is that the operator should be able to recognise the serous sac, so as to avoid mistaking for it the tendinous sac (as is constantly done), or the serous coat of the intestine, as has happened to very experienced operators. The dissecting-room refinements which occupy so much space in our books are little thought of in our operating theatres, and ought surely to be less pressed upon the attention of students than is now the fashion. In making these remarks nothing is farther from our intention than to depreciate the labours of the celebrated surgeons and anatomists who have promulgated these complicated descriptions; nor, we are sure, can so eminent a pupil of the school of Pott and Lawrence, as Mr. Callender is, intend to speak lightly of the labours of his distinguished predecessors. The minute anatomical examination which the regions of hernia have received is no doubt the foundation of the more rational and successful treatment of the disease in modern times. We would only reduce such anatomical niceties to their just value, and deprecate such an exclusive attention to them as would (nay, we think we may say does, in the case of too many students) draw the mind away from the consideration of the pathology of the disease. It is in this respect chiefly that we think Mr. Callender's little work of value: and regarded in that light its value is by no means to be measured by its unpretending size and appearance. We trust it may be only the first of a series of contributions to surgical anatomy from the same hand; and that Mr. Callender will do good service to the students who are fortunate enough to learn from him, in drawing their attention rather to the great principles of surgical disease, and to the mechanism which favours their production or their cure, than to the enumeration of little scraps of obscure tissue, about the correct description, or even the separate existence of which no two anatomists seem able to agree.

ART. VIII.-Ulcus Corrosivum Duodeni. Eu kasuistick Sammenstilling. Af Dr. F. TRIER. (Særskilt Aftryk af 'Ugeskrift for Læger,' 2den Række XXXVIII. Nos. 20-24.)-Kjöbenhavn, 1863. 8vo, pp. 79. Corrosive Ulcer of the Duodenum. A Collation of Cases. By Dr. F. TRIER. (Reprinted from the Ugeskrift for Læger.')Copenhagen.

THE fact that the so-called corrosive (simple, round, spontaneous, perforating) ulcer occurs only in the superior transverse portion of the duodenum, and very rarely in the lower part of the esophagus, is an indication which may possibly lead us in the right direction towards discovering the true origin and mode of development of the disease;

and these are precisely the points which, notwithstanding all theories, are in the present day most obscure, not to mention that the different situations and relations to neighbouring organs of the duodenum and stomach produce corresponding differences in the features of the disease, according as it is developed in the one or the other part.

The author proceeds in his observations to show in what respects the superior transverse portion of the duodenum may be considered as a transition from stomach to intestine. As bearing upon the origin of the ulcers in question, the fact that the contents of this portion of the intestinal tract have still in general an acid reaction, inasmuch as the liver and pancreas have not yet poured in their alkaline secretions, is probably of still greater importance than the structure of its mucous membrane. Thus, instead of the earlier, more or less defective, explanations of the origin of the gastric ulcers (Cruveilhier considered them, as is well known, as proceeding from a follicular inflammation, Rokitansky as a further development of the so-called hæmorrhagic erosions), Virchow has lately propounded a view which has met with very general acceptance. This writer,* in fact, lays great stress upon the corrosive nature of the acid contents of the stomach, but he sees in the defined form of the ulcer a strong indication that its first origin must be purely local, while the corrosive action of the acid is the most important element in its further progress. Virchow assumes that the first and purely local affection proceeds from interruptions or from essential disturbances in the circulation of the part, and supposes from what he has seen, that these irregularities may most frequently be referred to morbid conditions in the vessels of the stomach, and to a hæmorrhagic necrosis proceeding therefrom. It is chiefly the arteries of the stomach, to whose morbid states or obstructions he attaches great importance in this respect, while he does not deny that irregularities in the portal circulation, and dilatations of the vessels of the stomach thence proceeding, or acute and chronic catarrhs, especially when they are accompanied by violent vomiting and violent spasmodic contractions of the stomach, may give rise to lesions of nutrition in limited points, rendering the tissue accessible to the action of the gastric juice. This view finds support in various observations-among others, in those of Rokitansky,† according to whom, as the first commencement of the ulcer, "we find the mucous membrane in a circumscribed, round, elliptical part, changed to a pulpy and dusky, or to a solid yellow (diphtheritic) crust, after the removal of which, the submucous connective tissue lies exposed within the limits of a sharply cut off margin of the mucous membrane, or of a fringe of that which is changed to a yellow crust." In the next place it is not unimportant to observe that the favourite seat of the ulcers is the region adjoining

Virchow's Archiv. 1853, Band v. pp. 362 et seq.

Lehrbuch der Pathol. Anat., iii. p. 170, 1861.

Rokitansky refers to this class also the ulcers of the stomach first described by Curling (Medico-Chirurgical Transactions, vol. xxv.), and met with still more frequently in the duodenum, which occur after extensive burns, when suppuration has set in, and which are preceded by a formation of crust in the mucous membrane alone,

the curvatures of the stomach, precisely where the larger arteries send in their branches directly under the mucous membrane. With this agrees also the usual symmetrical occurrence of ulcers lying directly opposite to one another on the anterior and posterior surface of the stomach (more rarely of the duodenum), which arrangement is best explained by the fact that the vessels, after entering the curvatures, send symmetrically situated branches to both walls. When, therefore, the disturbance of the circulation is conveyed through such a vascular trunk, it will, for example in embolism, often happen that its results show themselves on symmetrically situated parts of the two mucous surfaces turned towards one another. Finally, with reference to the importance which Virchow attaches to the acid nature of the contents of the stomach in explaining the further progress of the ulcers in depth and circumference, the fact that, except in the stomach, the ulcers in question occur only in the lowest part of the oesophagus and in the first part of the duodenum, deserves special attention, for only in these parts can the contents in general be assumed to be acid, while they are alkaline in the whole of the remaining portion of the intestinal caual, whose vascular distribution is arranged in the same mode as that of the stomach, and which ought therefore, so far, as easily to become the seat of such an ulcerative process. The occurrence of the corrosive ulcer in the duodenum consequently forms an important point of support for the theory which is at present received by a great number of pathologists. In the experimental way, too, investigators have often succeeded in demonstrating the importance of irregularities of the circulation in the formation of ulcers of the stomach. L. Müller* and Panumt have (the former in rabbits, the latter in dogs) found extravasations of blood and loss of substance in the mucous membrane of the stomach after tying the vena portæ (Müller), or after artificially produced embolism in the arteries of the stomach (Panum). In the latter case embolism was met with only in the arterial branches which served to nourish the affected portions of the mucous membrane, while everywhere else it was absent. By these experiments it is proved that irregularities in the circulation may produce the morbid process here spoken of, without its following as a matter of course that there are no other causes capable of giving rise to the same effect.

The author observes, that from the infrequency of the occurrence of ulcer of the duodenum, the material at his disposal, which is derived partly from the writings of others, partly from an examination of the records of dissections kept in the medical division of Frederik's Hospital during a space of about twenty years -viz., from the 1st April,

or at the same time in the submucous tissue, which crust has the characteristic form and boundaries of the ulcer, gives rise to hæmorrhages, and sometimes very quickly (in the course of a fortnight) to perforation.

* Das corrosive Geschwür im Magen und Darmkanal, Erlangen, 1860, pp. 272 et seq.

+ Experim. Beitr. zur Lehre von der Embolie: Virchow's Archiv, 1862, xxv. pp. 488 et seq.