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Atlc^S fA IbS”
MEDICAL
LIBPAKy
M'^GILL UNIVERSITY
MONTREAL
1951
LONDON:
SAVILL & EDWARDS, PRINTERS, 4 , CHANDOS STREET,
COVENT GARDEN.
tm
PREFACE.
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The object of this work is to present to the student of medicine
and to the practitioner removed from the schools, a series of dis¬
sections demonstrating the relative anatomy of the principal
regions of the human body. Whatever title may most fittingly
apply to a work of this kind, whether it had better be styled
surgical or medical, regional, relative, descriptive, or topographical
anatomy, will matter little, provided its more salient or prominent
character be manifested in its own form and feature. The work,
as I have designed it, will itself show that my intent has been to
base the practical upon the anatomical, and to unite these where-
ever their mutual dependence was apparent.
That department of anatomical research to which the name
topographical strictly applies, as confining itself to the mere
account of the form and relative location of the several organs
comprising the human body, is almost wholly isolated from the
main questions of physiological and transcendental interest, and
cannot therefore be supposed to embrace those comprehensive
views which anatomy, taken in its widest signification as a
science, necessarily includes. While the anatomist limits himself
to describing the form and position of organs as they appear
exposed, layer after layer, by his dissecting instruments, he does
not pretend to soar any higher in the region of science than the
humble level of other mechanical arts, which merely appreciate
the fitting arrangement of things relative to one another, and
combinative for the particular design of the form, of whatever
species this may be, whether organic or inorganic—a ma n or a
machine. The descriptive anatomist of the human body aims at
no higher walk in science than this, and hence his nomenclature
remains, as it is, a barbarous jargon, barren of all truthful signifi¬
cation, inconsonant with nature, and blindly irrespective of the
cognitio certa ex principiis certis exorta.
Still, however unsuitable this nomenclature of descriptive
human anatomy proves to be, when used as an instrument for
expounding the objects of purer science, it does not appear to
disturb the medical and surgical practitioners so far as their wants
are concerned. By us the nomenclature, such as it is, is found
to answer conveniently enough the special subject. But when
once we pass into the fields of comparison in quest of the higher
generalizations, it is then we find how special names trammel our
progress by their rude and shallow meaning.
The anatomy of the human body when contemplated in com¬
parison with that of other species of animals, imposes upon the
mind the task of inductive reasoning. The relationary properties
of animal forms invite to comparison; this to induction; and upon
this rests the science. But from human anatomy, as from a par¬
ticular, we can never hope to infer one general proposition, how¬
ever much we labour in the study of it. The form of any species,
while standing per se, unrelated to its similars, can neither inter¬
pret itself nor be the exponent of other for ms . While restricted
I 0 the study of the isolated human form, the cramped judgment
ist waste in such narrow confine. It is only in the expansive
' e over aU all3dng and allied species that the intellect, having
scope for exercise, learns by comparison to overcome nature and
unveil her real character. When we have first experienced the
analogies and differentials of the many, we are then fitted, on
returning to the study of the one, to view this one of human type
under manifold points of interest, to which the eye of science was
not previously awakened. And if by comparison of the many
species, we arrive at the true signification of the human one^
\ ' v shall it not foUow that even practical human anatomy
may receive some benefit from the same process of analogical
reasoning ?
The practical anatomist has for his object the attainment of an
exact knowledge of the relative position of the several organs of
the human body. It is by the light of comparison that he is
enabled to judge how the integral parts combine for the whole
design. To the physician, comparison teaches in what close
relationship the thoracic organs appear to those of the abdomen.
To the surgeon, comparison demonstrates how structure blends
region with region, the neck with the axilla, the groin with the
thigh. To him who would combine both relationary practices of
medicine and surgery, comparison proves the necessity of studying
how all regions unite to produce an indissoluble entirety; and
hence it may be doubted whether he who pursues either mode of
practice wholly exclusive of the other, can do so with honest
purpose and large range of understanding, if he be not equally
well versed in the subject matter of both. It appears, in fact,
more triflingly fashionable than soundly reasonable, to seek to
define the line of demarcation between the special callings of
medicine and surgery, for it wiU ever be as vain an endeavour to
separate the one from the other, without extinguishing the vitality
of both, as it would be to sunder the trunk from the head, and
give to each a separate living existence. The necessary division
of labour is the only reason that ■ can be advanced in excuse of
specialisms, but it will be readily agreed to, that that practitioner
who has first laid within himself the foundation of a general
knowledge of matters relationary to his particular subject, will be
best enabled to pursue this according to the dictates of science.
Anatomy—the TvmQi amvTov in respect to presential form, is the
substratum or soil in which the tree of curative art must strike
common root, however numerously this art may branch into
specialisms. Anatomy studied comparatively is the nurse of
reason; and with this the parent tree must be cultivated, if we
would make its special branches bear the real fruit of science.
The human body in a state of health is the standard whereunto
we compare the same body in a state of disease. The knowledge
of the latter can only exist by the knowledge of the former, and
by the comparison of both.
Comparison may be fairly termed the pioneer to all certain
knowledge. It is a potent instrument—the'only one, in the hands
of the pathologist, as weU as in those of the philosophic generalizer
of anatomical facts, gathered through the extended survey of an
animal kingdom. We can best recognise the condition of a
dislocated joint after we have become well acquainted with the
contour of its normal state; all abnormal conditions are best
understood by contrasting them with those which we consider to
be normal in character. Every anatomist is a comparer in a
greater or lesser degree; and he is the greatest anatomist who
compares the most generally.
Impressed with this belief, I have been particular in imitating
the normal form of the human body taken as a whole, in order the
more clearly to express the relative position of its several regions,
and of the various organs contained in each of these. The subject
being relative anatomy, it was required to plan the several dissec¬
tions so that the student might be enabled to ascertain by one
comparative view the general bearings of each particular region
under notice. Illustration by figure is a medium by which this
subject may be presented to the understanding in more vivid
reality than it can be by any mode of written description.
The forms, especially of organic bodies, cannot be described
PREFACE.
without the aid of figures. Even the mathematical strength of
Euclid would avail nothing if shorn of his diagrams. Form being
the language in which nature bespeaks her presence, science alone
imitates nature by demonstrating her realities.
An anatomical illustration enters the understanding at once in
a direct passage, and is almost independent of the aid of written
language. A picture of form is a proposition which solves itself.
It is as an axiom encompassed in a frame-work of self-evident
truth. The best substitute for Nature herself, by which we may
teach the knowledge of her, is an exact representation of her form.
Every surgical anatomist will (if he examine himself) perceive
that, previously to undertaking the performance of an operation
upon the living body, he stands reassured and self-reliant in that
degree in which he is capable of conjuring up before his mental
vision a distinct picture of his subject. Mr. Liston could draw
the same anatomical picture mentally which Sir Charles Bell’s
handicraft could draw in presential reality of form. Camper and
- Scarpa were their own draughtsmen.
If there may be any novelty now-a-days possible to be reco¬
gnised upon the out-trodden track of human relative anatomy, it
can only be in truthful demonstrations well planned in aid of
practice. Under this view alone may the anatomist hope to add
anything new to the beautiful works of Cowper, Haller, Hunter,
Scarpa, Soemmering, and others. Except the human anatomist
turns now to what he terms the practical ends of his study, and
marshals his little knowledge to bear upon these ends, one may
proclaim anthropotomy to have worn itself out. Dissection can
do no more, except to repeat Cruveilhier. And that which
Cruveilhier has done for human anatomy, Miiller has accomplished
for the physiological interpretation of human anatomy; Burdach
has philosophised, and Magendie has experimented to the full
upon this theme, so far as it would permit. All have pushed the
subject to its furthest limits in one aspect of view. The narrow
circle is footworn. AU the needful facts are long since gathered,
sown, and known. We have been seekers after those facts from
the days of Aristotle. Are we to put off the day of attempting
interpretation for three thousand years more, to allow the human
physiologist time to slice the brain into more delicate atoms than
he has done hitherto, in order to coin more names, and swell the
dictionary? No! The work must now be retrospective, if we
would render true knowledge progressive. It is not a list of new
and disjointed facts that Science at present thirsts for; but she is
impressed with the conviction that her wants can alone be supplied
by the creation of a new and truthful theory,—a generalization
which the facts already known are sufficient to supply, if they
were well ordered, according to their natural relationship and
mutual dependence. “Le temps viendra peut-etre,” says Fon-
tenelle, “ que Ton joindra en un corps regulier ces membres 4pars;
et, s’ils sont tels qu’on le souhaite, ils s’assembleront en quelque
sorte d’eux-m^mes. Plusieurs verites separees, d^s qu’elles sont
en assez grand nombre, offrent si vivement a I’esprit leurs rapports
et leur mutuelle d4pendance, qu’il semble qu’apres les avoir
detach^es par une espece de violence les unes des autres, elles
cherchent natureUement k se reunir.”—(Preface sur I’utilit^ des
Sciences, &c.)
The comparison of facts already known must henceforward be
as the scalpel which we are to take in hand. We must return by
the same road on which we set out, and re-examine the things
and phenomena which, as novices, we passed by too lightly. The
travelled experience may now sit down and contemplate. This
endless search for new anatomical facts has exhausted the soul of
science. It must be now by the broad clarion sounds of laws and
systems, not by the narrow piping notes of isolated particulars and
dislocated phenomena, that we can ever hope to wake to attention
again her slumbering ear. In what direction are we now to search
for a new fibre of nerve or muscle, or a new process of bone ? For
what number of such facts are we still to rein in impatience and
acknowledge our need of these for the purpose of summing
together the whole encircling and satisfying account of a law?
That law which I have elsewhere demonstrated as governing the
development of skeletal forms may hkewise serve to give a general
answer to the quid estf of the nervous system. The womb of
anatomical science teems with the true interpretation of the law of
unity in variety; but the birth is delayed, owing to the parent
mind having become altogether practical. Though Aristotle,
Linnseus, Buffon, Cuvier, Geoffroy St. Hilaire, Leibnitz, and
Gdthehave prescribed officially, yet the present state of knowledge
proclaims that the unborn form of true physiology awaits some
future Newton to call it forth to life. Dissection has done its work.
The iron scalpel has already made acquaintance with not only the
greater parts, but even with the infinitesimals of the human body,
and reason confined to this contracted range of a subject perceives
herself to be imprisoned, and quenches her guiding light in despair.
Originality has here outlived itself; and discovery is a long-forgotten
enterprise, except as pursued in the microcosm on the field of the
microscope, which, however, it must be confessed, has drawn forth
demonstrations of objects as little in respect to practical importance
as they are in regard to physical dimensions.
The subject of our study, whichever it happen to be, may
appear exhausted of all interest, and the promise of valuable
novelty, owing to two reasons:—It may be, like descriptive human
anatomy, so cold, poor, and sterile in its own nature, and so barren
of product, that it will be impossible for even the genius of Pro¬
methean fire to warm it; or else, like existing physiology, the
very point of view from which the mental eye surveys the theme,
will blight the fair prospect of truth, distort induction, and clog-
up the paces of ratiocination. The physiologist of the present
day is too little of a comparative anatomist, and far too closely
enveloped in the absurd jargon of the anthropotomist to give us
hope that he wiU ever reveal any great truth for science, and
dispel the mists which stiU hang over the phenomena of the
nervous system. He is steeped too deeply in the base nomencla¬
ture of the antique school, and too indolent to question the import
of Pons, Commissure, Island, Taenia, Nates, Testes, Cornu, Hip-
pocamp. Thalamus, Vermes, Arbor Vitae, Respiratory Tract,
Ganglia of Increase, and all such phrase of unmeaning sound, ever
to be productive of lucid interpretation of the cerebro-spinal ens.
Custom alone sanctions his use of such names; but
“ Custom calls liim to it!
What custom wills; should custom always do it,
The dust on antique time would lie unswept,
And mountainous error be too highly heaped.
For truth to overpeer.”
Of the illustrations of this work I may state, in guarantee of
their anatomical accuracy, that they have been made by myself
from my own dissections, first planned at the London University
College, and afterwards realized at the Ecole Pratique, and School
of Anatomy, adjoining the Hospital La Piti6, Paris, a few years
since. As far as the subject of relative anatomy could admit of
novel treatment, rigidly confined to facts unalterable, I have en¬
deavoured to give it.
The surface of the living body is perused by the surgeon as a
map explanatory of the relative position of the organs beneath;
and to aid him in this respect the present dissections have been
made. We dissect the dead body in order to furnish the memory
with as clear an account of the structures of its living representa¬
tive as if this latter, which we are not allowed to analyse, were
' perfectly translucent, and directly demonstrative of its component
parts. J. M.
TABLE OF CONTENTS.
PREFACE,
INTKODUCTORY TO THE STUDY OF ANATOMY AS A SCIENCE.
COMMENTAEY ON PLATE 1.
THE FORM OF THE THORAX, AND THE RELATIVE POSITION OF ITS CONTAINED
PARTS—THE LUNGS, HEART, AND LARGER BLOODVESSELS.
The structure, mechanism, and respiratory motions of the thoracic apparatus.
Its varieties in form, according to age and sex. Its deformities. Applications to
the study of physical diagnosis.
COMMENTAEY ON PLATE II.
THE SURGICAL FORM OF THE SUPERFICIAL, CERVICAL, AND FACIAL REGIONS,
AND THE RELATIVE POSITION OF THE PRINCIPAL BLOODVESSELS,
NERVES, ETC.
The cervical surgical triangles considered in reference to the position of the
subclavian and carotid vessels, &c. Venesection in respect to the external jugular
vein. Anatomical reasons for avoiding transverse incisions in the neck. The parts
endangered in surgical operations on the parotid and submaxillary glands, &c.
COMMENTAEY ON PLATE III.
THE SURGICAL FORM OF THE DEEP CERVICAL AND FACIAL REGIONS,
AND THE RELATIVE POSITION OF THE PRINCIPAL BLOODVESSELS,
NERVES, ETC.
The course of the carotid and subclavian vessels in reference to each other, to
the surface, and to their respective surgical triangles. Differences in the form of the
neck in individuals of different age and sex. Special relations of the vessels.
Physiological remarks on the carotid artery. Peculiarities in the relative position
of the subclavian artery.
COMMENTAEY ON PLATE IV.
THE SURGICAL DISSECTION OF THE SUBCLAVIAN AND CAROTID REGIONS,
AND THE RELATIVE ANATOMY OF THEIR CONTENTS.
General observations. Abnormal complications of the carotid and subclavian
arteries. Eelative position of the vessels liable to change by the motions of the
head and shoulder. Necessity for a fixed surgical position in operations affecting
these vessels. The operations for tying the carotid or the subclavian at different
situations in cases of aneurism, &c. The operation for tying the innominate artery,
Eeasons of the unfavourable results of this proceeding.
COMMENTAEY ON PLATE V.
THE SURGICAL DISSECTION OF THE EPISTERNAL OR TRACHIAL REGION,
AND THE RELATIVE POSITION OF ITS MAIN BLOODVESSELS,
NERVES, ETC.
Varieties of the primary aortic branches explained by the law of metamorphosis.
The structures at the median line of the neck. The operations of tracheotomy and
laryngotomy in the child and adult. The right and left brachio-cephalic arteries
and their varieties considered surgically.
COMMENTAEY ON PLATE VI.
THE SURGICAL DISSECTION OF THE AXILLARY AND BRACHIAL REGIONS, DIS¬
PLAYING THE RELATIVE POSITION OF THEIR CONTAINED PARTS.
The operation for tying the axillary artery. Kemarks on fractures of the
clavicle and dislocation of the humerus in reference to the axillary vessels. The
operation for tying the brachial artery near the axilla. Mode of compressing this
vessel against the humerus.
COMMENTAEY ON PLATE VII.
THE SURGICAL FORMS OF THE MALE AND FEMALE AXILLA COMPARED.
The mammary and axillary glands in health and disease. Excision of these
glands. Axillary abscess. General surgical observations on the axilla.
COMMENTAEY ON PLATE VIII.
THE SURGICAL DISSECTION OF THE BEND OF THE ELBOW AND THE FOREARM,
SHOWING THE RELATIVE POSITION OF THE VESSELS AND NERVES.
General remarks. Operation for tying the brachial artery at its middle and
lower thirds. Varieties of the brachial artery. Venesection at the bend of the
elbow. The radial and ulnar pulse. Operations for tying the radial and ulnar
arteries in several parts.
COMMENTAEY ON PLATE IX.
THE SURGICAL DISSECTION OF THE WRIST AND HAND.
General observations. Superficial and deep palmar arches. Wounds of these
vessels requiring a ligature to be applied to both ends. General surgical remarks
on the arteries of the upper limb. Palmar abscess, &c.
COMMENTAEY ON PLATE X.
THE RELATIVE POSITION OF THE CRANIAL, NASAL, ORAL, AND PHARYNGEAL
CAVITIES, ETC.
Fractures of the cranium, and the operation of trephining anatomically con¬
sidered. Instrumental measures in reference to the fauces, tonsils, oesophagus, and
lungs.
COMMENTAEY ON PLATE XI.
THE RELATIVE POSITION OF THE SUPERFICIAL ORGANS OF THE THORAX
AND ABDOMEN.
Application to correct physical diagnosis. Changes in the relative position of
the organs during the respiratory motions. Changes effected by disease. Physio¬
logical remarks on wounds of the thorax and on pleuritic effusion. Symmetry of
the organs, &c.
COMMENTAEY ON PLATE XII.
THE RELATIVE POSITION OF THE DEEPER ORGANS OF THE THORAX
AND THOSE OF THE ABDOMEN.
Of the heart in reference to auscultation and percussion. Of the lungs, ditto.
Eelative capacity of the thorax and abdomen as influenced by the motions of the
diaphragm. Abdominal respiration. Physical causes of abdominal hernise.
Enlarged liver as affecting the capacity of the thorax and abdomen. Physiological
remarks on wounds of the lungs. Pneumothorax, emphysema, &c.
COMMENTAEY ON PLATE XIII.
THE RELATIONS OF THE PRINCIPAL BLOODVESSELS TO THE VISCERA OF
THE THORACICO-ABDOMINAL CAVITY.
Symmetrical arrangement of the vessels arising from the median thoracico-
abdominal aorta, &c. Special relations of the aorta. Aortic sounds. Aortic
aneurism and its effects on neighbouring organs. Paracentecis thoracis. Physical
causes of dropsy. Hepatic abscess. Chronic enlargements of the liver and spleen
as affecting the relative position of other parts. Biliary concretions. Wounds of
the intestines. Artificial anus.
COMMENTAEY ON PLATE XIV.
THE RELATION OF THE PRINCIPAL BLOODVESSELS OF THE THORAX AND
ABDOMEN TO THE OSSEOUS SKELETON.
The vessels conforming to the shape of the skeleton. Analogy between the
branches arising from both ends of the aorta. Their normal and abnormal condi¬
tions. Varieties as to the length of these arteries considered surgically. Measure¬
ments of the abdomen and thorax compared. Anastomosing branches of the thoracic
and abdominal parts of the aorta.
TABLE OF CONTENTS.
COMMENTARY ON PLATE XV.
THE RELATION OF THE INTERNAL PARTS TO THE EXTERNAL SURFACE.
In health and disease. Displacement of the lungs from pleuritic effusion.
Paracentecis thoracis. Hydrops pericardii. Puncturation. Abdominal and ovarian
dropsy as influencing the position of the viscera. Diagnosis of both dropsies.
Paracentecis abdominis. Vascular obstructions, and their effects.
COMMENTARY ON PLATE XVI.
THE SURGICAL DISSECTION OF THE SUPERFICIAL PARTS AND BLOODVESSELS
OF THE INGUINO-FEMORAL REGION.
Physical causes of the greater frequency of inguinal and femoral hernise. The
surface considered in reference to the subjacent parts.
COMMENTARY ON PLATE XVII.
THE SURGICAL DISSECTION OF THE FIRST, SECOND, THIRD, AND FOURTH
LAYERS OF THE INGUINAL REGION, IN CONNEXION WITH THOSE OF
THE THIGH.
The external abdominal ring and spermatic cord. Cremaster muscle—how
formed. The parts considered in reference to inguinal hernia. The saphenous
opening, spermatic cord, and femoral vessels in relation to femoral hernia.
COMMENTARY ON PLATE XVIII.
THE SURGICAL DISSECTION OF THE FIFTH, SIXTH, SEVENTH, AND EIGHTH
LAYERS OF THE INGUINAL REGION, AND THEIR CONNEXION WITH
THOSE OF THE THIGH.
The conjoined tendon, internal inguinal ring, and cremaster muscle, considered
in reference to the descent of the testicle and of the hernia. The structure and
direction of the inguinal canal.
COMMENTARY ON PLATE XIX.
THE DISSECTION OF THE OBLIQUE OR EXTERNAL, AND OF THE DIRECT OR
INTERNAL INGUINAL HERNIA.
Their points of origin and their relations to the inguinal rings. The triangle of
Hesselbach. Investments and varieties of the external inguinal hernia, its relations
to the epigastric artery, and its position in the- canal. Bubonocele, complete and
scrotal varieties in the male. Internal inguinal hernia considered in reference to
the same points. Corresponding varieties of both hernise in the female.
COMMENTARY ON PLATE XX.
THE DISTINCTIVE DIAGNOSIS BETWEEN EXTERNAL AND INTERNAL INGUINAL
HERNI.E, THE TAXIS, SEAT OF STRICTURE, AND THE OPERATION.
Both hernirn compared as to position and structural characters. The co-existence
of both rendering diagnosis difficult. The oblique changing to the direct hernia as
to position, but not in relation to the epigastric artery. The taxis performed in
reference to the position of both as regards the canal and abdominal rings. The
seat of stricture varying. The sac. The lines of incision required to avoid the
epigastric artery. Necessity for opening the sac.
COMMENTARY ON PLATE XXI.
DEMONSTRATIONS OF THE NATURE OF CONGENITAL AND INFANTILE
INGUINAL HERNIA, AND OF HYDROCELE.
Descent of the testicle. The testicle in the scrotum. Isolation of its tunica
vaginalis. The tunica vaginalis communicating with the abdomen. Sacculated
serous spermatic canal. Hydrocele of the isolated tunica vaginalis. Congenital
hernia and hydrocele. Infantile hernia. Oblique inguinal hernia. How formed
and characterized.
COMMENTARY ON PLATE XXII.
DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF INGUINAL HERNIiE
IN GENERAL.
Formation of the serous sac. Formation of congenital hernia. Hernia in the
canal of Nuck. Formation of infantile hernia. Dilatation of the serous sac.
Funnel-shaped investments of the hernia. Descent of the hernia like that of the
testicle. Varieties of infantile hernia. Sacculated cord. Oblique internal inguinal
hernia—cannot be congenital. Varieties of internal hernia. Direct external
hernia. Varieties of the inguinal canal.
COMMENTARY ON PLATE XXIII.
THE DISSECTION OF FEMORAL HERNIA AND THE SEAT OF STRICTURE.
Compared with the inguinal variety. Position and relations. Sheath of the
femoral vessels and of the hernia. Crural ring and canal. Formation of the sac.
Saphenous opening. Relations of the hernia. Varieties of the obturator and epigastric
arteries. Course of the hernia. Investments. Causes and situations of the stricture.
COMMENTARY ON PLATE XXIV.
DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF FEMORAL HERNIA ;
ITS DIAGNOSIS, THE TAXIS, AND THE OPERATION.
Its course compared with that of the inguinal hernia. Its investments and
relations. Its diagnosis from inguinal hernia, &c. Its varieties. Mode of per¬
forming the taxis according to the course of the hernia. The operation for the
strangulated condition. Proper lines in which incisions should be made. Necessity
for and mode of opening the sac.
COMMENTARY ON PLATE XXV.
THE SURGICAL DISSECTION OF THE PRINCIPAL BLOODVESSELS AND NERVES
OF THE ILIAC AND FEMORAL REGIONS.
The femoral triangle. Eligible place for tying the femoral artery. The
operations of Scarpa and Hunter. Remarks on the common femoral artery. Liga¬
ture of the external iliac artery according to the seat of aneurism.
COMMENTARY ON PLATE XXVI.
THE RELATIVE ANATOMY OF THE MALE PELVIC ORGANS.
Physiological remarks on the functions of the abdominal muscles. Effects of
spinal injuries on the processes of defecation and micturition. Function of the
bladder. Its change of form and position in various states. Relation to the peri¬
toneum. Neck of the bladder. The prostate. Puncturation of the bladder by
the rectum. The pudic artery.
COMMENTARY ON PLATE XXVII.
THE SURGICAL DISSECTION OF THE SUPERFICIAL STRUCTURES OF THE MALE
PERINEUM.
Remarks on the median line. Congenital malformations. Extravasation of
urine into the sac of the superficial fascia. Symmetry of the parts. Surgical boun¬
daries of the perinseum. Median and lateral^ important parts to be avoided in
lithotomy, and the operation for fistula in ano.
COMMENTARY ON PLATE XXVIII.
THE SURGICAL DISSECTION OF THE DEEP STRUCTURES OF THE MALE
PERINEUM ; THE LATERAL OPERATION OF LITHOTOMY.
Relative position of the parts at the base of the bladder. Puncture of the
bladder through the rectum and of the urethra in the perinseum. General rules
for lithotomy.
COMMENTARY ON PLATE XXIX.
THE SURGICAL DISSECTION OF THE MALE BLADDER AND URETHRA ; LATERAL
AND BILATERAL LITHOTOMY COMPARED.
Lines of incision in both operations. Urethral muscles—their analogies and
significations. Direction, form, length, structure, &c., of the urethra at different
ages. Third lobe of the prostate. Physiological remarks. Trigone vesical. Bas
fond of the bladder. Natural form of the prostate at different ages.
COMMENTARY ON PLATE XXX.
CONGENITAL AND PATHOLOGICAL DEFORMITIES OF THE PREPUCE AND
URETHRA; STRICTURES AND MECHANICAL OBSTRUCTIONS OF THE
URETHRA.
General remarks. Congenital phymosis. Gonorrhoeal paraphymosis and
phymosis. Effect of circumcision. Protrusion of the glans through an ulcerated
opening in the prepuce. Congenital hypospadias. Ulcerated perforations of
the urethra. Congenital epispadias. Urethral fistula, stricture, and catheterism.
Sacculated urethra. Stricture opposite the bulb and the membranous portion of
the urethra. Observations respecting the frequency of stricture in these parts.
Calculus at the bulb. Polypus of the urethra. Calculus in its membranous portion.
Stricture midway between the meatus and bulb. Old callous stricture, its form, &c.
Spasmodic stricture of the urethra by the urethral muscles. Organic stricture.
Surgical observations.
COMMENTARY ON PLATE XXXI.
THE VARIOUS FORMS AND POSITIONS OF STRICTURES AND OTHER OBSTRUC¬
TIONS OF THE URETHRA; FALSE PASSAGES; ENLARGEMENTS AND
DEFORMITIES OF THE PROSTATE.
General remarks. Different forms of the organic stricture. Co-existence
of several. Prostatic abscess distorting and constricting the urethra. Perforation
of the prostate by catheters. Series of gradual enlargements of the third lobe of
the prostate. Distortion of the canal by the enlarged third lobe—by the irregular
enlargement of the three lobes—by a nipple*shaped excrescence at the vesical orifice.
TABLE OF CONTENTS
COMMENTARY ON PLATE XXXII.
BEFORMITIES OF THE PROSTATE; DISTORTIONS AND OBSTRUCTIONS OF THE
PROSTATIC URETHRA.
Observations on the nature of the prostate—its signification. Cases of prostate
and bulb pouched by catheters. Obstructions of the vesical orifice. Sinuous
prostatic canal. Distortions of the vesical orifice. Large prostatic calculus.
Sacculated prostate. Triple prostatic urethra. Encrusted prostate. Fasciculated
bladder. Prostatic sac distinct from the bladder. Practical remarks. Impaction
of a large calculus in the prostate. Practical remarks.
COMMENTARY ON PLATE XXXIII.
DEFORMITIES OF THE URINARY BLADDER; THE OPERATIONS OF SOUNDING
FOR STONE; OF CATHETERISM AND OF PUNCTURING THE BLADDER
ABOVE THE PUBES.
General remarks on the causes of the various deformities, and of the formation
of stone. Lithic diathesis—its signification. The sacculated bladder considered in
reference to sounding, to catheterism, to puncturation, and to lithotomy. Polypi in
the bladder. Dilated ureters. The operation of catheterism. General rules to
be followed. Remarks on the operation of puncturing the bladder above the pubes.
COMMENTARY ON PLATE XXXIY.
THE SURGICAL DISSECTION OF THE POPLITEAL SPACE, AND THE POSTERIOR
CRURAL REGION.
Varieties of the popliteal and posterior crural vessels. Remarks on popliteal
aneurism, and the operation for tying the popliteal artery, in wounds of this vessel.
Wounds of the posterior crural arteries requiring double ligatures. The operations
necessary for reaching these vessels.
COMMENTARY ON PLATE XXXV.
THE SURGICAL DISSECTION OF THE ANTERIOR CRURAL REGION;
THE ANKLES AND THE FOOT.
Varieties of the anterior and posterior tibial and the peronseal arteries. The
operations for tying these vessels in several situations. Practical observations on
wounds of the arteries of the leg and foot.
CONCLUDING COMMENTARY.
ON THE FORM AND DISTRIBUTION OF THE VASCULAR SYSTEM AS A WHOLE;
ANOMALIES; RAMIFICATION; ANASTOMOSIS.
The double heart. Universal systemic capillary anastomosis. Its division, by
the median line, into two great lateral fields—those subdivided into two systems or
provinces viz., pulmonary and systemic. Relation of pulmonary and systemic
circulating vessels. Motions of the heart. Circulation of the blood through the
lungs and system. Symmetry of the hearts and their vessels. Development of
the heart and primary vessels. Their stages of metamorphosis simulating the per¬
manent conditions of the parts in lower animals. The primitive branchial arches
undergoing metamorphosis. Completion of these changes. Interpretation of the
varieties of form in the heart and primary vessels. Signification of their normal
condition. The portal system no exception to the law of vascular symmetry.
Signification of the portal system. The liver and spleen as homologous organs,
as parts of the same whole quantity. Cardiac anastomosing vessels. Vasa
vasorum. Anastomosing branches of the systemic aorta considered in refer¬
ence to the operations of arresting by ligature the direct circulation through the
arteries of the head, neck, upper limbs, pelvis, and lower limbs. The collateral
circulation. Practical observations on the most eligible situations for tying each
of the principal vessels, as determined by the greatest number of their anastomosing
branches on either side of the ligature, and the largest amount of the collateral
circulation that may be thereby carried on for the support of distal parts.
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COMMENTARY ON PLATE J.
THE FORM OF THE THORAX, AND THE RELATIVE POSITION OF TPIE LUNGS, HEART,
AND LARGER BLOODVESSELS.
In the human body there does not exist any such space as cavity,
pioperly so called. Every space is fully occupied by its contents.
The thorax is completely tilled by its own viscera, which, in mass,
take a perfect cast or model of its interior. The thoracic viscera
lie so closely compacted, that they in a great measure influence
the form and dimensions of each other. That space which the
lungs do not occupy is filled by the heart, &c., and vice versa,
Ihe thorax causes no vacuum in its interior by its motions of
either expiration or inspiration; neither do the lungs nor the heart
by contraction or dilatation. W^hen either of these organs requires
larger space, on account of its growth or its expansion, it imme¬
diately inhabits such space at the expense of neighbouring parts.
When the heart dilates, it encroaches on pulmonary space; and
when the lung expands, general space diminishes in the same
ratio.
The mechanism of respiration and circulation is cosmical as well
as animal in principle; and consists in a constant oscillatory nisus
to produce a vacuum, which, however, is never established. The
animal or vital force of the thorax and heart opposes the cosmical
force; and vainly strives to make exception to the irrevocable law
that nature abhors a vacuum^ This opposition between both
forces constitutes the respiratory act, and thus the thoracic appa¬
ratus (like a pendulum vibrating according to the counteraction
of the force centrifugal and the force centripetal) inspires and
expires in vibrative alternation, precisely indicative of the measure
of its own action and atmospheric reaction.
The thorax is that region of the trunk which the ribs bound
between the neck and abdomen. It contains the heart and lunefs:
and it IS traversed by the main bloodvessels, the air-tube, and the
oesophagus. The thorax, though giving passage to these parts,
forms a compartment closed at all points, and upon its peculiar
construction in this respect depends much of its efiiciency as a
pneumatic apparatus. Its shape is that of a symmetrical truncated
cone, 11, N N, Fig. 1, the apex of which is at the root of the neck, q,
the base being below, and forming the roof of the abdomen, p. The
walls of the thorax are formed partly of bone and muscle. The
osseous parts consist superiorly of seven complete girdles (formed
respectively by a dorsal vertebra, a pair of opposite ribs, and a
sternal piece) arranged in slanting superposition; inferiorly they are
formed of five asternal girdles, which leave the osseous thorax here
incomplete in front. All the intercostal spaces are closed by muscles
(intercostal), each of which is attached to the adjacent borders of
a lateral pair of ribs. The thorax is of much greater vertical
extent behind than in front. The sternum, h m. Figure 1, measures
the depth of the thorax anteriorly, the dorsal spine posteriorly. The
five asternal inferior ribs, by shortening gradually from above down¬
wards, cause this difierence between both vertical measurements.
The summit of the thorax, Q, is closed by the structures at the root
of the neck; the base is closed by the diaphragm, p, sloping back-
wai’ds and downwards from the sternum to the top of the lumbar
spine, and arching transversely from the borders of the false
ribs of one side to those of the other, N, m, n. The diaphragm forms,
at the same time, a moveable convex floor for the thorax, and a con¬
cave roof for the abdomen. The transverse and antero-posterior
diameters of the thorax increase gradually from its summit, 11, to
its base, n n. Its transverse is greater than its antero-posterior
diameter at all levels.
The external form of the thorax is somewhat obscured by the
soft parts which cover it. In regard to the absolute dimensions
of its upper part, we are particularly liable to err, in consequence of
its being here surrounded by the osseous and muscular parts which
form the framework of the shoulder apparatus. The width of the
thorax, 11, Figure 1 , w w. Figure 2 , between the shoulders is equal
only to the inner thirds of the clavicles and first sternal piece
inclusive. The middle and lower thoracic circumferences are more
readily definable beneath the surface. The walls of the thorax at
the sub-axillary regions are comparatively superficial.
The thorax is divided vertically through the median line into
two lateral chambers, which contain the right and left lungs. The
sternum in front, h m. Figure 1, and the dorsal spine behind, coin¬
cide with the median line. Each pulmonary compartment, p u, f e, is
lined by a serous membrane, (the pleura,) which forms a shut sac.
The two pleurae are absolutely distinct sacs. Their outer anterior
and posterior sides line the thoracic walls, inf; their bases cover
DESCRIPTION OF THE FIGURES OF PLATE 1 .
Figure 1.
A. Right Tentricle of the heart.
B. Origin of pulmonary artery.
C. Commencement of the systemic aorta, ascending part of aortic arch.
D. ■‘Pericardium investing the heart and the origins of the great blood-
vessels.
E. Mediastinal pleura, forming a second investment for the heart, blood¬
vessels, &c.
F. Costal pleura, seen to be continuous above with that which forms the
mediastinum.
G. Vena cava superior, entering pericardium to join V, the right auricle.
H. Upper third of sternum.
11. First ribs.
K K. Sternal ends of the clavicles.
L. Upper end of sternum.
M. Lower end of sternum.
N N. Fifth ribs.
0 0. Collapsed lungs.
P P. Arching diaphragm.
Q. Subclavian artery.
K. Common carotid artery, at its division into internal and external
carotids.
S S. Great pectoral muscles.
T T. Lesser pectoral muscles.
U. Mediastinal pleura of right side.
V. Right auricle of the heart.
Figure 2.
A. Right ventricle of the heart. A a Pericardium.
B. Pulmonary artery. B b Pericardium.
C. Ascending aorta. C c Transverse aorta.
D. Right auricle.
E. Ductus arteriosus in the loop of left vagus nerve, and close to phrenic
nerve of left side.
F. Superior vena cava.
G. Brachio-cephalic vein of left side.
H. Left common carotid artery.
I. Left subclavian vein.
K. Lower end of left internal jugular vein.
L. Right internal jugular vein.
M. Right subclavian vein.
N. Innominate artery—brachio-cephalic.
O. Left subclavian artery crossed by left vagus nerve.
P. Right subclavian artery crossed by right vagus nerve, whose inferior
laryngeal branch loops under the vessel.
Q. Right common carotid artery.
R. Trachea.
S. Thyroid body.
T. Brachial plexus of nerves.
U. Upper end of left internal jugular vein.
V V. Clavicles cut across and displaced downwards.
W W. The first ribs.
X X. Fifth ribs cut across.
Y Y. Right and left mammillae.
Z. Lower end of sternum.
COMMENTARY ON PLATE I.
the diaphragm, pp; their summits project into thejiepk somewhat
above the level of the first ribs, 1 1; and by their inner sides in con*
tact they form the mediastinum, U E, or vertical partition, which
extends from the root of the neck to the diaphragm, and from the
sternum to the dorsal spine. AU the thoracic organs are situated
between the mediastinal sides of the two pleural sacs. The heart and
lungs, by separating the mediastinal layers to a distance corre¬
sponding with their own respective dimensions, become invested
by these membranes; while each pleural sac remains still perfectly
closed on all sides. Each lung bearing its seroiis envelope (pleura
pulmonalis) into general apposition with those sides of the serous
sac (pleura costalis) which line the thoracic walls, thereby deprives |
the pleural sac of included space. The interior of each pleural
sac being represented by sides in contact, it therefore must follow
that all the thoracic space is mediastinal or interpleural.
The thoracic organs when examined from before backwards,
between the mediastinal sides of the pleura?, appear in the follow¬
ing order. Behind the sternum, the triangulares sterni muscles,
and remains of the thymus gland, separate the serous sacs at an
interval called anterior mediastinum; next, the heart and great
bloodvessels. A, g, c, b. Figure 1, separate them at a space called
middle mediastinum; behind this, the sacs meet and again become
separated, so as to invest the two lungs, o o, forming what may be
called pulmonary mediastinum, which, in fact, equals two-thirds of
the area of the thoracic chamber; behind the root of the lungs
the sacs again meet and separate in front of the dorsal vertebrm,
so as to form the posterior mediastinum, in which are lodged th^'
trachea, oesophagus, descending aorta, thoracic duct, vena azygos,
pneumogastric and sympathetic nerves, and lymphatic vessels.
The two lungs are of unequal size. The left is less than the
right by so much space as the heart occupies of the left pulmonary
compartment, more than of the right. The base of the heart, and
the great bloodvessels enveloped by the pericardium, are seated
behind the sternum, h m, but separated from this bone by the thin
edges of the lungs. The right auricle, v, is placed behind the third
intercostal space, close to the right side of the sternum, while the
apex of the left ventricle, e, reaches to the fifth intercostal space on
the left side, midway between the mammilla and margins of the
false ribs. The ascending part, c, of the aortic arch is placed behind
the middle third of the sternum, as wiU appear by its flattening
against this bone, when the heart is injected from the abdominal
aorta. The heart rests upon the tendon ous middle of the
diaphragm, and is bound to this situation by the pericardium, b
A a. Figure 2.
The thorax varies in form and capacity according to the
respiratory motions; and chiefly so at its base. Its summit is
scarcely at all affected in ordinary, and but little even in forced
respiration. The upper ribs are shorter and much less moveable
than the lower ribs. All the ribs slant downwards, describing
angles of varying degrees in respect to the spinal column. The
lower ribs are more oblique than the upper. Upon this difference
as to length and obliquity between the ribs above and below, it
can be demonstrated geometrically that while all are being elevated
and depressed during alternating inspiration and expiration, the
greater range of motion is performed by the lower ribs; and the
capacity of the thorax is chiefly altered opposite these. In forced
inspiration and expiration, the capacity of the thorax is by turns
increased and lessened in all diameters, but more particularly so
in the vertical. In ordinary inspiration, its capacity is almost
solely altered in the vertical diameter, and this is effected by the
tensive action of the diaphragm, which causes the abdominal
viscera to recede in the same degree as the lungs dilate. The
diaphragm and abdominal muscles act reciprocally in subservience
to the respiratory motion. In this correlation of organs, mani¬
fested throughout all parts of the animal economy, may be seen
one of the most striking proofs of the divinity of design. ^ The
diaphragm is passive in expiration; and merely relaxes in an
arched form upwards, following the recoil of the lungs.
The shape, relative proportions, and mobility of the thorax,
vary at different periods of life. In very early life, its antero-pos-
terior exceeds its transverse diameter, on account of the lungs
being small, and the heart and thymus gland being relatively
large. During this early period, also, we find the vertical diameter
to be comparatively short, owing to the small size of the lungs
and the largely developed state of the abdominal organs, particu¬
larly the liver, which occupies nearly the whole width of the
abdomen under the diaphragm. In the healthy, well-formed
adult male, the size of the thorax, compared with the abdomen, is
large, and corresponds with the voluminous lungs; the respiratory
muscles, too, are now fully developed, and the whole thoracic
apparatus presents an unequivocal sign of physical vigour, com¬
pared with which, as a standard, many pathological conditions
may be detected. In extreme old age, the thorax presents certain
characters which may be regarded as strand marks, indicating the
degree in which the vital tide has ebbed; the costal cartilages
become ossified, and the different pieces anchylosed, so that the
elasticity and mobility of the thorax fail, pari passu, with the
structural and functional decline of the lungs themselves.
Besides the pathological and congenital deformities of the
thorax, there are others which are the effects of ai't—the con¬
tinued pressure of the corset causes the long flexible asternal
cartilages to yield and dislocate permanently the liver, spleen, and
stomach upwards, so that the thoracic space becomes contracted,
the action of the diaphragm impeded, and the summits of the
lungs in consequence protrude considerably above the first ribs.
The lung being thus forced into contact with the subclavian
artery, q. Figure 1, and the other large vessels here situated, it
seems to me probable, that the b7'uit or murmur heard in chlorotic
patients is owing to the pulsatile action of these vessels upon the
top of the lung. The female adult thorax is naturally much wider
in the base than that of the adult male; and altogether exhibits
more of the infantile proportions. The female form, in general,
exhibits an intermediate stage of development between that of the
child and the male adult.
The form of the thorax and the relative position of its organs,
in their healthy state, require to be accurately determined, in
order to give precision to the practice of auscultation and per¬
cussion as means of diagnosing cases of thoracic disease. In
health, the lungs expand into contact with aU the costal parts of
the thoracic walls. On these parts being struck, the lung emits a
sound characteristic of its structure, and its respiratory murmur
is also discernible by the ear. But the pulmonary resonance
cannot be expected to be uniform over all the costal region, for it
must vary because of the variable thickness of the structures
which lie upon the thorax, and also of the lungs themselves,
between which the large compact mass of the heart is placed.
Over the region of the heart and that of the liver, which ascends
behind the lower ribs of the right side, the thin edges of the lungs
which overlap these organs, must yield a sound of a very different
(shallow) character to that emitted (deep) at the subaxillary and
neighbouring regions, where the lungs are thick. These facts, in
regard to the healthy sounds, demand therefore due consideration
while conducting our pathological investigation.
IT. E^oiliaTl
COMMENTARY ON PLATE II.
the surgical form of the superficial cervical and facial regions, and the relative
POSITION OF THE PRINCIPAL BLOODVESSELS, NERVES, Sic .
HEN the neck is extended in the surgical position. Figs. 1 and 2,
It assumes^ a quadrilateral shape, approaching to a square. The
sides of this region are formed anteriorly by the chin, larynx, and
top of the sternum; posteriorly by the occiput, trapezius muscle,
and top of the shoulder; superiorly, by the horizontal ramus of
the lower maxilla; and inferiorly, by the clavicle. The region
thus bounded is divided diagonally by the sterno-mastoid muscle
into two triangular spaces anterior and posterior. In the anterior
space, E 16, 6, Figure 2, are situated the common carotid artery,
its branches, and their accompanying nerves and veins. In the
posterior space, 9, 8, 6, are placed the outer parts of the subclavian
artery and vein, their branches, and the brachial and cervical
plexus of nerves. The forms of both these spaces are traceable
beneath the integuments in most individuals.
On removing the skin from the side of the neck we expose the
thin subcutaneous platysma muscle A a. Figure 1. This structure
will be observed to veil completely both triangles. Its fibres
are directed slantingly from the face downwards and outwards to
the upper part of the breast below the clavicle. Along its outer
border appears the subcutaneous external jugular vein. When
the platysma muscle is removed. Figure 2, the several parts which
determine the form of the cervical region are brought into view.
As these parts project on the superficies, and thereby serve for
guides to the situations of the vessels and nerves, their relative
positions should be well considered.
Between the clavicular and sternal parts, 7, 6, Figure 2, of the
sterno-mastoid muscle appears a small interval, deeply within
which the innominate artery will be found bifurcating into its
common carotid and subclavian branches. Here also the vagus
and sympathetic nerves, and a little more externally the internal
jugular vein, descend in front of the first part of the subclavian
artery. The lower part of the sterno-hyoid muscle, 5, and beneath
this the deep cervical fascia, close this interval behind the sterno-
mastoid muscle and overlie- these vessels and nerves. The sub¬
clavian artery, in arching outwards over the middle of the first
rib, passes behind the anterior scalenus muscle. As the clavicular
portion of the sterno-mastoid muscle lies in front of the scalenus,
the depth of the artery in this place Avill be seen to be considerably
greater than elsewhere. The common carotid ascends the neck,
under cover of the sternal portion of the sterno-mastoid muscle;
and beneath this the sterno-hyoid, thyroid, and omo-hyoid
muscles and cervical fascia will also be found to overlap the lower
half of that vessel. The internal jugular vein descending on the
outer side of the carotid artery, and the subclavian vein crossing
inwards between the clavicle and scalenus muscle, join behind
the sterno-clavicular articulation, and form the right innominate
vein, which enters the thorax between the first rib and the inno-
minate artery.
The posterior cervical triangle, 9, 8, 7, Figure 2, is bounded
anteriorly by the sterno-mastoid muscle, b; inferiorly by the
clavicle; and posteriorly by the splenius, 9, and trapezius
muscles, 8. The cervical fascia is stretched across this space, and
requires to be dissected off so as to expose the muscles, vessels,
and nerves. The fascia here consists of two layers:—a superficial
one, which covers the muscles, and a deep layer, which passes
beneath these, and sheaths the principal vessels and nerves. On
DESCRIPTION OF THE
Figure 1.
AAA. Subcutaneous platysma myoides muscle, lying on the face, neck,
and upper part of chest, and covering the structures contained in
the two surgical triangles of the neck.
B. Lip of the thyroid cartilage.
C. Clavicular attachment of the trapezius muscle.
D. Some lymphatic bodies of the posterior triangle.
E. External jugular vein.
F. Occipital artery, close to which are seen some branches of the occipi¬
talis minor nerve of the cervical plexus.
G. Auricularis magnus nerve of the superficial cervical plexus.
H. Parotid gland.
I. Temporal artery, with its accompanying vein.
K. Zygoma.
L. Masseter muscle, crossed by the parotid duct, and some fibres of
platysma.
M. Facial vein.
N. Buccinator muscle.
O. Facial artery seen through fibres of platysma.
P. Mastoid half of sterno-mastoid muscle.
Q. Locality beneath which the commencements of the subclavian and
carotid arteries lie.
R. Locality of the subclavian artery in the third part of its course.
S. Locality of the common carotid artery at its division into internal and
external carotids.
Figure 2.
A. Subclavian artery passing beneath the clavicle, where it is crossed
by some bloodvessels and nerves.
B. Sternal attachment of the sterno-mastoid muscle, marking the situa¬
tion of the root of common carotid.
C. Common carotid at its point of division, uncovered by sterno-mastoid.
D. External carotid artery branching into lingual, facial, temporal, and
occipital arteries.
E. Internal carotid artery.
F. Temporo-maxillary branch of external carotid artery.
FIGURES OF PLATE II.
G. Temporal artery and vein, with some ascending temporal branches
of portio-dura nerve.
H. External jugular vein descending from the angle of the jaw, where it
is formed by the union of temporal and maxillary veins.
I. Biachial plexus of nerves in connexion with a, the subclavian artery.
K. Posterior half of the omo-hyoid muscle.
L. Transversalis colli artery.
M. Posterior scapular artery.
N. Scalenus anticus muscle.
O. Lymphatic bodies of the posterior triangle of neck.
P. Superficial descending branches of the cervical plexus of nerves.
Q. Auricularis magnus nerve ascending to join the portio-dura.
R. Occipital artery, accompanied by its nerve, and also by some branches
of the occipitalis minor nerve, a branch of cervical plexus.
S. Portio-dura, or motor division of seventh cerebral nerve.
T. Parotid duct.
U. Facial vein.
V. Facial artery.
W. Submaxillary gland.
X. Digastric muscle.
Y. Lymphatic body.
Z. Hyoid bone.
1. Thyroid cartilage.
2. Superior thyroid artery.
3. Anterior jugular vein.
4. Hyoid half of omo-hyoid muscle.
5. Sterno-hyoid muscle.
6. Top of the sternum.
7. Clavicle.
8. Trapezius muscle.
9. Splenius capitis and colli muscle.
10. Occipital half of occipito-frontalis muscle.
11. Levator auris muscle. .
12. Frontal half of occipito-frontalis muscle.
13. Orbicularis occuli muscle.
14. Zygomaticus major muscle. ,
15. Buccinator muscle.
16. Depressor anguli oris muscle.
COMMENTARY ON PLATE II.
removing the superficial fascia from the posterior triangle, we
meet with descending branches of the cervical plexus of nerves, p,
and several lymphatic glands, o. The omo-hyoid muscle, k, will
be now seen to divide this space into two parts, a superior and an
inferior. In the latter appear the outer part of the subclavian
artery and the brachial plexus of nerves. This interval is named
the posterior inferior triangle. It is bounded in front by the
mastoid muscle, above by the omo-hyoid muscle, and below by the
clavicle. The deep layer of fascia lies across this small space and
conceals the subclavian artery and nerves. It is here that the
operation of tying the subclavian artery, in cases of axillary
aneurism, is recommended to be performed. The posterior superior
triangle is the space above the omo-hyoid muscle, k, and between
the mastoid, b, and trapezius muscles, 8. It contains the branches
of the cervical plexus of nerves, p q, the greater number of the
lymphatic glands, o o, and numerous small veins embedded in much
cellularmembrane. In muscular subjects, the parts which bound both
these spaces can be discerned beneath the integuments during life.
The more important structures situated in the large posterior
triangle, may now be brought into view by dissecting the deep
fascia from the subclavian artery and brachial plexus of nerves.
The natural position of the omo-hyoid muscle need not be disturbed
in this proceeding. The external jugular vein, h, on being traced
in its course obliquely downwards and backwards over the middle
of the mastoid muscle, will be found to enter the posterior inferior
triangle. In this place the vein, after being joined by one or two
large branches coming from beneath the trapezius muscle, enters
the subclavian vein behind the clavicle. In addition to the venous
branches, the transversalis colli artery, l, will generally be found
to cross the subclavian in the posterior inferior triangle. By
turning these vessels aside, the subclavian artery, a, may be seen
emerging deeply from under the scalenus muscle, n, and having
on its outer side the brachial plexus of nerves, i. The posterior
scapular branch, m, comes off from the subclavian artery in this
situation. On considering now the general relations of the sub¬
clavian artery in this part of its course, it will be seen to traverse
the angle formed by the sterno-mastoid muscle and the clavicle.
The vessel here appears for only an inch or so in extent; it lies
deeply; and its upper part, near the scalenus, is deeper than its
lower part near the middle of the clavicle.
The anterior cervical triangle has its base represented above by
the lower maxilla, and its apex below by the top of the sternum, 6.
The chin and larynx bound this space anteriorly, while the sterno-
mastoid muscle describes its posterior boundary. This region is
also divided into two compartments by the anterior half of the
omo-hyoid muscle, 4, ascending obliquely from beneath the middle
of the mastoid muscle to its attachment to the hyoid bone. The
lower space contains the anterior jugular and other veins lying
upon the sterno-hyoid and thyroid muscles, and beneath these the
trachea and thyroid body, the relative position of which parts wiH
be best seen in the dissection of the episternal region. The upper
space is triangular in form; its base is described by the lower
jawbone, and its apex is formed by the decussation of the sterno-
mastoid and anterior belly of the omo-hyoid muscles on a level
with the cricoid cartilage. Here the common carotid, c, first
appears from under the sterno-mastoid muscle, and after ascending
to the level of the upper margin of the thyroid cartUage, divides
into the external, n, and internal carotid branches, e.
The precise locality at which the common carotid bifurcates is
in general opposite to the upper margin of the thyroid cartilage.
The skin, platysma, and superficial fascia alone cover the sheath
of the carotid in this place. The sheath is formed by the deep
cervical fascia under the sterno-mastoid muscle. In some in¬
stances, however, the sheath of the vessel is overlaid by a con¬
siderable quantity of adipose tissue, in which are embedded
lymphatic glands, and many small veins and nerves. The facial
vein, u, sometimes passes in front of the carotid to join the internal
jugular vein. This vein, which descends on the outer side of the
artery, is here usually covered by the mastoid muscle. When
this muscle presents of wasted proportions, the entire sheath
containing both vessels appears uncovered by it in this situation.
When the mastoid muscle is largely developed, it wiU be found to
cover the artery as well as the vein.
The common carotid bifurcating opposite the thyro-hyoid interval
sends its branches radiating in all directions beneath the angle of
the lower jaw. The sterno-mastoid muscle passing obliquely
backwards and upwards to the mastoid process, leaves all the
vessels and nerves uncovered at this situation. At their points
of origin, both the external and internal carotid branches, e d,
may be reached with equal facility, since they are alike uncovered
by the muscles. Further upwards, however, both vessels become
overlaid by the digastric and stylo-hyoid muscles; and while
ascending the temporo-maxillary interval, they become more
deeply situated, and more complicated with the neighbouring
parts. The internal carotid lies deeper than the external carotid
in the temporo-maxillary interval. Here both vessels are covered
by the parotid gland, and are closely accompanied by many
important nerves. The internal carotid ascends close in front of
the vertebral column, while the external carotid is directed forwar(Is
from this part, and sends its branches, 2, downwards, to the thyroid
body; forwards to the tongue; obliquely upwards and forwai’ds
to the face, v; and vertically upwards, g e, to the temple,
pharynx, occiput, and ear. The temporal artery, g, is superficial,
and may be effectually compressed against the zygoma, or opened
above this point; the facial branch, v, maybe compressed where
it lies superficially upon the lower jawbone in front of the masseter
muscle. The internal carotid may be compressed backwards
against the vertebral columA. The internal jugular vein lies close
to the outer side of this vessel in the temporo-maxillary fossa.
The external jugular vein, ii. Figure 2, commences in the parotid
gland, and descends obliquely over the mastoid muscle in company
with the auricularis magnus nerve, q. Figure 2; g. Figure 1.
The vein is subcutaneous in its whole course, and may be readily
incised in any situation. Where the vessel is supported by the
middle of the mastoid muscle is the safest place for perfoixning
this operation. The vein should not be incised transversely, lest
the platysma muscle, A a. Figure 1, by withdrawing the orifices
from each other, render it difficult to arrest the hemorrhage. All
incisions at the front and sides of the neck should be made, if
possible, in the direction of the fibres of the platysma; for, when
this muscle is divided transversely, the sides of the wound are liable
to part asunder during the healing process and leave an unsightly
cicatrix.
The position of the carotid artery and jugular vein protects
these vessels, in many instances, against the suicidal act as gene¬
rally attempted. The incision, from the forepart of the larynx,
requires to be made very deeply in order to reach these vessels.
The cutting instrument is, in some instances, resisted by the
laryngeal pieces being completely ossified.
The anatomical relations of the parotid, ii. Figure 1, and sub¬
maxillary glands, w. Figure 2, are so important that when either
of these parts requires to be extirpated, some principal vessel or
nerve will almost unavoidably be injured in the operation. The
temporo-maxiUary branch of the external carotid artery, with its
accompanying vein, passes through the parotid gland. The internal
carotid artery and jugular vein lie immediately beneath it. The
portio-dura nerve, s. Figure 2, joined by the ascending auricular
branffi of the cervical plexus, and by some branches of the
inferior maxillary nerve, forms a plexus in its substance. When
the gland itself, or some, one of the lymphatic bodies in connexion
with It, has to be excised, the temporo-maxHlary artery and the
root of the facial will be exposed to danger in the operation. The
portio-dura nerve cannot possibly escape being divided, either
wholly or in part; and this will occasion paralysis of all or some
of those muscles Y^hich are supplied by this nerve. The mas¬
seter, buccinator, and^ both pterygoid muscles being furnished
with nerves from a different source, will not be affected. The
orbicularis muscle supplied principaUy by the portio-dura becomes
paralysed; though not completely, owing to its having some
ternmal branches of the third or motor-occuli nerve distributed
0 1- he submaxdlary gland, w, is traversed by the facial
artery and vein, v, u,. Figure 2. This gland lies upon the linoTial
nerve and artery, where these are about to pass under cover of
muscle, immediately above the greater cornu of
the hyoid bone. In connexion with this gland are generaUy found
several small lymphatic bodies.
/
/
M ^ . Eanbait lith. Pmiters.
COMMENTARY ON
PLATE III.
THE SURGICAL FORM OF THE DEEP CERVICAL AND FACIAL REGIONS, AND THE RELATIVE
POSITION OF THE PRINCIPAL BLOODVESSELS, NERVES, &c.
While the neck is extended in the surgical position. Figures
1 and 2, its superficial structures may be removed without changing
its quadrilateral form. But the sterno-mastoid muscle, which
served to divide the neck into the anterior and posterior triangles,
having been dissected off, these two spaces appear thrown into one
common region. The principal vessels and nerves being thereby
exposed in their entire extent, their general and special relations
may be now regarded, at one and the same time, with practical
advantage. The diagonal line which the sterno-mastoid described
in the neck will be seen to be represented by the carotid vessels
extending between the sterno-clavicular articulation and the
temporo-maxillary fossa.
The general course of the carotid artery and internal jugular
vein being diagonally upwards and backwards through the neck,
they will be noticed as traversing the posterior side of the anterior
triangle, h 8 a, Figure 1, and likewise the anterior side of the pos¬
terior triangle, 5 z y. Occupying thus the line of junction between
the two spaces, it will appear that these vessels cannot be correctly
described as being contained in the anterior one. The subclavian
artery, arising from the same vessel as the carotid, takes its course
in relation to the clavicle which represents the base of the pos¬
terior space. The angle formed between the clavicle and sterno-
mastoid muscle nearly corresponds in degree and position with
the angle formed between the subclavian and carotid arteries, and
still more nearly with that formed by the subclavian and internal
jugular veins. The clavicle lies horizontal, while the subclavian
artery curves somewhat upwards from the inner end to the middle
of this bone. This difference between the position of the clavicle
and the subclavian artery is owing to the fact, that the latter is
raised above the level of the former by the middle of the first rib,
over which it passes. In practice, therefore, it will be always
safer to regard the position of the subclavian vessels in reference
to the clavicle, or base of the posterior triangle; for, in fact, they
cannot be strictly said to be contained in that space.
DESCRIPTION OF THE FIGURES OF PLATE III.
Figure 1.
A. Innominate artery at its point of bifurcation.
B. Subclavian artery crossed by the vagus nerve.
C. Common carotid artery with the vagus nerve at its outer side, and the
descendens noni nerve lying on it.
D. External carotid artery.
E. Internal carotid artery with the descendens noni nerve lying on it.
F. Lingual artery passing under the fibres of the hyo-glossiis muscle.
G. Tortuous facial artery.
H. Temporo-maxillary artery.
I. Occipital artery crossing the internal carotid artery and jugular vein.
K. Internal jugular vein crossed by some branches of the cervical plexus,
which join the descendens noni nerve.
L. Spinal accessory nerve, which pierces the sterno-mastoid muscle, to be
distributed to it and the trapezius.
M. Cervical plexus of nerves giving off the phrenic nerve to descend the
neck on the outer side of the internal jugular vein and over the
scalenus muscle.
N. Vagus nerve between the carotid artery and internal jugular vein.
O. Ninth or hypoglossal nerve distributed to the muscles of the tongue.
P P. Branches of the brachial plexus of nerves.
Q. Subclavian artery in connexion with the brachial plexus of nerves.
R R. Post scapular artery passing through the brachial plexus.
S. Transversalis humeri artery.
T. Transversalis colli artery.
U. Union of the posterior scapular and external jugular veins, which enter
the subclavian vein by a common trunk.
V. Posterior half of the pmo-hyoid muscle.
W. Part of the subclavian vein seen above the clavicle.
X. Scalenus muscle separating the subclavian artery from vein.
Y. Clavicle.
Z. Trapezius muscle.
1. Sternal origin of sterno mastoid muscle of left side.
2. Clavicular origin of sterno-mastoid muscle of right side turned down.
3. Scalenus posticus muscle.
4. ' Splenius muscle.
5. Mastoid insertion of sterno-mastoid muscle.
0*. Internal maxillary artery passing behind the neck of lower jaw-bone.
7. Parotid duct.
8. Genio-hyoid muscle.
9. Mylo-hyoid muscle, cut and turned aside.
10. Superior thyroid artery.
11. Anterior half of omo-hyoid muscle.
12. Sterno-hyoid muscle, cut.
13. Sterno-thyroid muscle, cut.
Figure 2.
A. Root of the common carotid artery.
B. Subclavian artery at its origin.
C. Trachea.
D. Thyroid axis of the subclavian artery.
E. Vagus nerve crossing the origin of subclavian artery.
F. Subclavian artery at the third division of its arch.
G. Posterior scapular branch of the subclavian artery.
H. Transversalis humeri branch of subclavian artery.
I. Transversalis colli branch of subclavian artery.
K. Posterior belly of omo-hyoid muscle, cut.
L. Median nerve branch of brachial plexus. .
M. Musculo-spiral branch of same plexus.
N. Anterior scalenus muscle.
O. Cervical plexus giving off the phrenic nerve, which takes tributary
branches from brachial plexus of nerves.
P. Upper part of internal jugular vein.
Q. Upper part of internal carotid artery.
R. Superior cervical ganglion of sympathetic nerve.
S. Vagus nerve lying external to sympathetic nerve, and giving off t its
laryngeal branch.
T. Superior thyroid artery.
U. Lingual artery separated by hyo-glossus muscle from —
V. Lingual or ninth cerebral nerve.
W. Sublingual salivary gland.
X. Genio-hyoid muscle.
Y. Mylo-hyoid muscle cut and turned aside.
Z. Thyroid cartilage.
1. Upper part of sterno-hyoid muscle.
2. Upper part of omohyoid muscle.
3. Inferior constrictor of pharynx.
4. Cricoid cartilage.
5. Crico-thyroid muscle.
6. Thyroid body.
7. Inferior thyroid artery of thyroid axis.
8. Sternal tendon of sterno-mastoid muscle turned down.
9. Clavicular portion of sterno-mastoid muscle turned down.
10. Clavicle.
11. Trapezius muscle.
12. Scalenus posticus muscle.
13. Rectus capitis anticus major muscle.
14. Stylo-hyoid muscle turned aside.
15. Temporal artery.
16. Internal maxillary artery.
17. Inferior dental branch of fifth cerebral nerve.
18. Gustatory branch of fifth cerebral nerve.''
19. External pterygoid muscle.
20. Internal pterygoid muscle.
21. Temporal muscle cut, to show the deep temporal branches of fifth
cerebral nerve.
22. Zygomatic arch.
23. Buccinator muscle, with buccal nerve and parotid duct.
24. Masseter muscle cut on the lower maxilla.
25. Middle constrictor of pharynx.
COMMENTARY ON ELATE III.
Close behind the right sterno-clavicular junction, is situated
the innominate artery, ab. Figs. 1, 2, dividing into the subclavian
and carotid branches. On its outer side appears the innominate
vein, formed by the union of the subclavian and internal jugular
veins. Between these vessels the vagus nerve, e, and the cardiac
branches of the sympathetic nerve, descend in front of the root of
the subclavian artery. The vessels and nerves are here succes¬
sively overlapped by the cervical fascia, and the sternal ends of
the hyoid, thyroid, and mastoid muscles. The two former muscles,
18, 12, Fig. 1, in passing from this place upwards and forwards
to the larynx, leave the carotid artery, vagus nerve, and internal
jugular vein, ascending immediately under cover of the sterno-
mastoid muscle, in the direction of the temporo-maxillary fossa.
Between the sternum and angle of the lower jaw, the carotid
artery, vein, and nerve, hold in respect to each other the same
relative position—the vein lying along the outer side of the artery,
while the vagus nerve descends between them. The carotid
vessels, by receding from the anterior median line, in the
same degree as they ascend the cervical region, cause a much
greater interval to occur between them and the foreparts of the
chin and larynx, than exists between them and the top of the
sternum. In the female, whose larynx is always smaller than
that of the male, the dilference as to the intervals here mentioned
is not so great. In the infant, the larynx is of so small a size,
that it scarcely projects beyond the plane of the carotid vessels.
The internal jugular vein is for its entire length covered by the
sterno-mastoid muscle. The carotid artery, lying beneath the
anterior margin of this muscle, becomes first exposed opposite the
upper part of the thyroid cartilage, in consequence of the muscle
inclining from this place backwards to the mastoid process. The
two vessels, ic g. Figure 1, with the vagus nerve between them, are
enclosed in a common sheath derived from the deep layer of the
cervical fascia. Within the sheath, the vessels are isolated from
each other by septa. Between the base of the skull and the
level of the os hyoides, the vessels and nerve lie in close apposi¬
tion. From the latter point downwards to the sterno-clavicular
junction, the vein gradually recedes outwards from the artery,
while the vagus nerve follows this vessel more closely than it does
the vein. At the root of the neck, an interval of an inch (more or
less) separates the vein from the artery, while the vagus nerve
appears midway betAveen them.
The length of the common carotid must vary, of course, accord¬
ing to the level at which it arises from the innominate trunk, and
also according to that at which it divides into the internal and
external carotid branches. In general, the length of the right
common carotid is considerable, and ranges from the sternal end
of the clavicle to the upper margin of the thyroid cartilage.
Between these points, the vessel very seldom gives off any im¬
portant branch; and it is chiefly on this account that the application
of a ligature to it leads more frequently to a favourable issue
than does the like operation performed upon the subclavian
artery, whidi gives off large branches at very short intervals
throughout its whole course.
The common carotid artery has the sympathetic nerve, r Fig 2
descending close to its inner side. The vagus nerve passes along
the outer side of this vessel, while the descendens noni nerve lies
upon its forepart. In placing a ligature around the middle of the
common carotid, great care is required, so as to exclude these
nerves. The branch of the ninth nerve sometimes descends
within the sheath of the artery, sometimes upon the sheath.
The trunk of the external carotid is in all instances very short-
and in many, can scarcely be said to exist, in consequence of the
superior thyroid, lingual, facial, temporal, pharyngeal, and occi¬
pital branches springing directly and separately from around the
same point of the common carotid. Even when the external
carotid appears of its usual length, it is, compared with the in¬
ternal carotid, but as a mere offshoot of the parent trunk. The
internal carotid is, on the contrary, little less in calibre than the
common carotid, and seems to be the proper continuation of this
mam vessel upwards along the series of the cervical and cephalic
vevtehcB The internal jugular vein lies parallel with this main
arterial vessel, from the base of the skull to the root of the neck.
It appears to me, therefore, that this so-called external carotid
consists only of a group of branches, representing, as it Avere, the
visceral arteries of the face and neck; and, like all other vessels of
this class, is of no great surgical importance.
The carotid artery may be compressed baclnvards against the
vertebral column more effectually at its middle third than else¬
where. From this part of the vessel, the external carotid branch
arises. Above and beloAV this branch, the main carotid gives off
no other of any consequence. The upper third of the carotid,
OAving to its deep position in the temporo-maxillary fossa, and the
important parts here in close connexion with it, may be considered
as surgically inaccessible.
The arch of the subclavian artery, b, q. Figure 1, extends
from the sternal end of the clavicle to the middle of this bone,
beneath Avhich it passes into the axillary space. The highest part
of the arch is generally an inch or so above the sternal third of
the clavicle, and rests upon the first rib behind the scalenus
muscle. Its highest is also its deepest part. The arch is divided
into three surgical portions—namely, that Avhich is internal to
the scalenus; that Avhich is behind this muscle, and that Avhich is
external to it. From each of its three parts, Avhich are respec¬
tively very short, large branches arise, and hence the generally
unfavourable results of the operation of tying this vessel. It is
crossed at all points by large veins, principal nerves, and by its
oAvn branches; and hence arises the great difficulty of exposiim it
in this operation. Its inner portion is in contact Avith the summit
of the pulmonary sac, and is overlaid by the vagus and sympa¬
thetic nerves, and by the great jugular vein. Here it gives off
the thyroid axis in front, the internal mammary beloAv, the ver¬
tebral above, and the superior intercostal branch behind. Its middle
portion is covered by the scalenus muscle, Avhich Avould require
to be divided in order to reach the vessel. In this place the
phrenic nerve descends obliquely iiiAvards from the front of the
scalenus to that of the vessel. Its tliii-d jAortion is crossed by
the lower end of the external jugular and tributai-y A'eins, and
also by nerves of the brachial plexus, p p, passing close to its
outer side. The large posterior scapular, and occasionally other
branches, arise from the vessel in this situation. Beneath the
arch of the artery the subclavian vein joins the great iufmlai-
behind the clavicle. ’ ^
The great depth of the middle third of the subclavian artery
may be knoAvn by considering the structures which lie in front of
It. The sternal end of the claAncle is round and thick; the
jugular and subclavian veins are, Avhen distended, vei-y laro-e • and
the scalenus muscle is fleshy. These parts together occupy at
least an inch and a half of space, and this is the depth of the
middle of the artery, from the anterior surface. This portion
o the subclavian lies on a deeper plane than the loAver end of
the carotid artery.
The length of the inner portion of the arch of tlie subclavian
artery, b. Figure 2, is seldom more than an inch, and very fre-
quently less. Even this short interval of tl.e vessel is rendered
unavailable for the application of a ligature by the number of
lar^ branches above-mentioned, which arise fi-om it. The leiWh
0 1 s middle portion equals only the widtli of the first rib, mid
on both sides of this, large branches arise. The outer portion of
arch is not only longer and more accessible than the other imrts
but more free of branches than these, and lienee the greater
ftTnlJ f 4ect to
c ensus anile T
alenus and the clavicle ,t appears short, stiU the actual length
of the vessel between collateral branches is very considerable Us
"a?:::!*'' * -d 1
it will ^ importance arises. Hence
u ™ll appear, that when this part becomes the subject of an operT
The Lbcla-ri ' midway between these two branches.
the le"r\™”’i ” front of
muscle No ^ '*’'md this
muscle Now and then the artery perforates the scalenus- and
muscle-TitHhevel”"*’ “ front of this
PLATE IV.
I
COMMENTARY ON
THE SURGICAL DISSECTION OF THE SUBCLAVIAN AND CAROTID REGIONS, AND THE RELATIVE
ANATOMY OF THEIR CONTENTS.
A PERFECT knowledge of the practical anatomy of any region of
the body can only be attained by stud 5 dng the relationship of
its parts as they appear in the order of superposition, and as
occupying the same plane in each layer or stratum. In the
opposite figures are represented both those modes of relationship
among the several parts. A portion of each of the more super¬
ficial structures has been left in the position it naturally presents
overlying those Avhich are more deeply placed. The skin, fascia,
muscles, vessels, bones, and nerves, in each of the cervical tri¬
angles, are thus brought at the same time under notice, and this
is absolutely necessary with a view to explain the stages of the
operations now about to be considered.
The depth of a bloodvessel or nerve from the surface will be
found to vary, not only in difierent parts of the same region
of the individual, but in the same part of the same gion rein
different individuals. It is necessary to make this remark,
because the vessel or neiwe, in both instances, will be seen
to be overlaid by the same number and kind of structures.
The causes of this variation as to depth are:—1st, that each of
these structures differs in thickness in several parts of the same
region in one body, and even in the like situation of a corre¬
sponding region in different bodies. A vessel being also liable to
change of place and relations, according to the degree of mobility
of the neighbouring parts, it is therefore required to give a fixed
position to the subject of operation.
In Figure 1 is shown the relative position of the colnmon
carotid artery near its bifurcation, opposite the thyroid cartilage.
At this place, the vessel is overlaid by the. following structures,
numbered from the superficies:—1st, the skin and adipose mem¬
brane, the latter varying in thickness in different individuals; 2nd,
the platysma muscle, e l, which is here identified with the super¬
ficial fascia, covering the sterno-mastoid; 3rd, the deep fascia,
which appears covering the sheath of the vessels and passing
beneath the sterno-mastoid; 4th, the sheath of the vessels, q,
which is a duplication of the deep fascia, and upon which the
descendens noni nerve is seen to lie. Here, though the vessel is
not covered by the sterno-mastoid, yet it occupies the same plane
as the deep side of this muscle. Lower down, though the vessel
gets under cover of the sterno-mastoid, it does not lie deeper from
the surface of the neck than it does above. The parts by which
the artery is occasionally liable to be complicated in this situation
are these—viz., the internal jugular vein, usually on the outer
side of the artery, may be found covering it, or a number of veins
congregating from the neck and face may form a plexus upon it,
or a chain of lymphatic bodies in greater number than usual may
conceal its position. Though such facts as these cannot be known
to exist, except during the stages of the operation required
for exposing the vessel, yet it is necessary to be aware of their
possible occurrence.
The motions of the head upon the neck, or of these upon the
trunk, or of the lower maxilla and larynx upon the neck, influence
more or less the relative anatomy of the carotid vessels. In
order to give these vessels the relations which, while' operating
upon them, we expect them to have, it is necessary to incline the
head in the position of Figure 2. In this Avay the common
carotid will generally be found lying from under cover of the
sterno-mastoid muscle, opposite the thyroid cartilage. A little
lower down the anterior margin of this muscle overlaps it, and
according as we have to make search for the vessel nearer the
sterno-clavicular junction, it Avill be found more and more cen¬
trally overlaid by the muscle. If the carotid, or any of its
branches, be divided by a wound, the rule is to tie both ends of
the vessel in the wound. The situation of an aneurism must
determine the proper place where a ligature is to be passed
around the vessel so affected. If the aneurism arise from the
carotid opposite the thyroid cartilage, the vessel must be exposed
and tied midway between this situation and the innominate
artery. Here an incision is to be made corresponding with the
anterior border of the sterno-mastoid muscle, and the above-men¬
tioned structures successively divided. The mastoid muscle requires
to be relaxed, by inclining the head towards its sterno-clavicular
insertion, so that it may be more easily retracted outwards from the
vessel. The cellular membrane and layers of fasciae having been
carefully incised, and any large veins which are met with, turned
DESCRIPTION OF THE FIGURES OF PLATE IV.
Figure 1.
A. Common carotid at its place of division.
B. External carotid.
C. Internal carotid, with the descending branch of the ninth nerve lying-
on it.
D. Facial vein entering the internal jugular vein.
E. Sterno-mastoid muscle, covered by—
F. Part of the platysma muscle.
G. External jugular vein.
H. Parotid gland, sheathed over by the cervical fascia.
I. Facial vein and artery seen beneath the facial fibres of the platysma.
K. Submaxillary salivary gland.
L. Upper part of the platysma muscle cut.
M. Cervical fascia cut.
N. Sterno-hyoid muscle.
O. Omo-hyoid muscle.
P. Sterno-thyroid muscle.
Q. Fascia proper of the vessels.
R. Layer of the cervical fascia beneath the sterno-mastoid muscle.
S. Portion of the same fascia.
T. External jugular vein injected beneath the skin.
U. Clavicle at the mid-point, where the subclavian artery passes beneath it.
V. Locality of the subclavian artery in the 'third part of its course.
W. Prominence of the trapezius muscle.
X. Prominence of the clavicular portion of the sterno-cleido-mastoid muscle.
Y. Place indicating the interval between the clavicular and sternal inser¬
tions of sterno-cleido-mastoid muscle.
Z. Projection of the sternal portion of the sterno-cleido-mastoid muscle.
Figure 2.
A. Clavicular attachment of the sterno-mastoid muscle lying over the
internal jugular vein, &c.
B. Subclavian artery in the third part of its course.
C. Vein formed by the union of external jugular, scapular, and other veins.
D. Scalenus anticus muscle stretching over the artery, and separating it
from the internal jugular vein.
E. Posterior half of omo-hyoid muscle.
F. Inner branches of the brachial plexus of nerves.
G. Clavicular portion of trapezius muscle.
H. Transversalis colli artery.
I. Layer of the cervical fascia, which invests the sterno-mastoid and
trapezius muscles.
K. Lymphatic bodies lying between two layers of the cervical fascia.
L. Descending superficial branches of the cervical plexus of nerves.
M. External jugular vein seen under the fascia which invests the sterno-
mastoid muscle.
N. Platysma muscle cut on the body of sterno-mastoid muscle.
O. Projection of the thyroid cartilage.
P. Layer of the cervical fascia lying beneath the clavicular portion of the
sterno-mastoid muscle.
Q. Layer of the cervical fascia continued from the last over the subclavian
artery and brachial plexus of nerves.
COMMENTARY ON PLATE IV.
aside, the omohyoid muscle will appear in the upper part of the
wound crossing the vessel, or, it may be, the aneurism. The
thyroid and hyoid muscles will generally be seen in the lower
part of the wound, overlapping the vessel, and they require to be
turned forwards. The pulsation of the vessel will now indicate
its position. The fascia and sheath are to be opened upon it for
half an inch on its anterior side, so as to avoid the jugular vein,
and then the ligature is to be passed around the middle of the
vessel, it matters not in what direction, so that the accompanying
nerves be not included, or the vein punctured.
When the common carotid requires a ligature to be placed
upon it, opposite the thyroid cartilage, the same number of parts
have to be divided. In this place the vessel may be more readily
reached, as it does not lie deeply under cover of the sterno-mastoid
muscle. Here the jugular vein and vagus nerve will be found
closer to the artery than lower down in the neck.
In Figure 2 is represented the relative anatomy of the sub¬
clavian artery in the third or outer part of its course. The
structures which overlie the vessel in this situation are the same
in number and kind as those which cover the carotid. The skin
and adipose membrane, superficial fascia and platysma muscle,
and the deep fascia, with the posterior belly of the omohyoid
muscle, are the parts successively exposed in the operation for
tying the subclavian artery, between the scalenus muscle and the
middle of the clavicle. In Figure 1, the letters z, x, t, v, u, are
placed upon the track of the arch of the vessel. The parts which are
occasionally met with, as ofiering impediments in the steps of the
operation, are these—viz., a number of lymphatic bodies which may
be found lying upon the fascia, or beneath this in close relation to
the artery; or the subclavian vein may rise above the level of the
clavicle and rest upon the artery; or the clavicle may be so
elevated over this vessel, by an aneurism in the axilla, as to com¬
pletely conceal it; or the brachial plexus of nerves may be found
surrounding the artery; or the shoulder veins joining the end of
the external jugular may form a plexus over it; or a branch of
the thyroid axis (supra scapular) may cross in front of it.
Besides these varieties, the muscles which bound the subclavian
triangle (trapezius and sterno-mastoid) may be so unusually
broad as to contract this space very much; while the omohyoid
may lie so low as to be in front of the artery.
As the clavicle follows the several motions of the shoulder, it
thereby influences materially the form of the posterior cervical
triangle, and the relative position of the subclavian artery. The
shoulders of some individuals are naturally more pendent than
those of others. An axillary aneurism, too, may be of so large
a size as to keep the shoulder permanently elevated. Whatever
be the relative position of the parts in their natural or diseased
state, it win be found that, according to the degree in which the
shoulder can be depressed backwards, the greater will be the
extent of the artery above the clavicle and the more superficial
the vessel will become.
The operation for tying the outer part of the subclavian artery
IS to be performed in the following way:—The patient is to be
laid supine, with the shoulder depressed as much as possible, and
the head inclined to the opposite side. The position of the artery
having been noted, the skin is to be drawn down tensely over the
clavicle, and incised upon this part for three or four inches, the
middle of the incision being made to correspond with the prominent
middle of the bone, under which the artery passes. The skin
being allowed to retract upwards over the course of the vessel,
the platysma and fascia are next to be divided to an equal extent,
avoiding the lower end of the external jugular vein, near the
outer edge of the cleido-mastoid muscle. If this muscle be broader
than usual, some of its fibres will have to be divided. The cel¬
lular membrane and deep fascia are next to be incised, with due
caution, so as not to injure the artery or the jugular vein... The
outer edge of the scalenus is now to be sought. The position of
this muscle having been ascertained by the point of the finger,
the rib into which it is inserted is then to be felt for, and upon
this, behind the scalenus, the artery will be found pulsating.
Here, the lower nerves of the brachial plexus may be felt as tense
cords in contact with the outer side of the artery. Here, also,
most usually, the large posterior scapular branch arises from the
artery. The point at which this branch arises is generally so
close to the scalenus, that, as the main artery cannot be tied
above it, the ligature must be applied in a situation as far below
its origin as possible—^that is, close to the clavicle. In passing
the ligature around the artery from within outwards, too much
caution cannot be exercised in so directing the point of the instru¬
ment as to exclude the large brachial nerves.
The middle portion of the arch of the subclavian artery is
inaccessible, unless by dividing the scalenus muscle. The im¬
portant phrenic nerve lies upon this muscle. This part of the
vessel being the deepest of the three, and scarcely ever more than
half an inch long between the origins of large collateral branches,
no reasonable hope exists that a ligature applied to it can be
followed by happy results.
The inner portion of the arch of the right subclavian artery has
been tied in cases of aneurism affecting its outer portion. The
shortness of the artery between the scalenus muscle and its
point of origin from the innominate trunk, its great depth, the
important parts which cover it, and the large branches which
arise from it, are circumstances all combining to render the appli¬
cation of a ligature to this part of the vessel the most difficult and
at the same time the most unsuccessful of all similar operations
in surgery. This operation is only to be undertaken as a choice
of two evils—either to expose and tie the subclavian artery in
this situation, attended with almost insurmountable difficulty, and
small hopes of a favourable result; or to expose and tie the in-
. nominate artery instead—a proceeding attended with equal diffi¬
culty, as weak hopes of a successful issue, and, in addition, the
evils consequent upon the arrest to the circulation through the
common carotid branch. The same parts are required to be
divided in the operations for reaching both these vessels. The
skin is to be incised horizontally upon the inner third of the
clavicle, and another vertical incision is to be made along the
inner edge of the sternal part of the mastoid muscle. This muscle
is to be separated from its steimo-clavicular attachments; the cel¬
lular tissue behind it is to be cleared, so as to expose the sternal
ends of the hyoid and thyroid muscles: these have next to be
divided. Beneath them will appear the strong fascia, lying in
front of the vessels and nerves; and this is to be cautiously
divided upon a director. If the subclavian artery is the one to be
tied, perhaps the more eligible situation for applying the ligature
IS at a point as near as possible to the scalenus; for the collateral
current of blood through the thyroid axis, vertebral, and mammary
branches, cannot be so great a cause of disturbance as that through
the common carotid would be to a ligature placed near this vessel.
If the innominate artery is that which requires to be tied, the
ligature should be placed close below its bifurcation. As the lung
rises into apposition with both these arteries, there is always great
danger of opening the pleura whUe the instrument is being passed
around either of these vessels.
The right subclavian artery varies as to its place of origin. In
some instances, it has been found to spring from the left side of
the aortic arch; in others, separately, from the first part of the
aorta; in others, from the back of the innominate artery. In
these cases, it is found to be more deeply placed than usual.
The subclavian artery is now and then found complicated with
short supernumerary ribs, jutting from the seventh, sixth, or fifth
cervical vertebra, and giving to this region of the skeleton an
appearance in aU respects similar to that where the asternal ribs
degenerate into the lumbar vertebrm. The carotid arteries, too,
I have observed (in aged subjects) to be occasionally complicated
by a shaft of bone representing the ossified stylo-hyoid ligament.
One or both of these varieties in the human skeleton are normal
and constant in different species of the lower animals.* All the
anomalies of form, both as regards the vascular, the muscular,
and the osseous systems of the human body, are analyzed by com¬
parison through the animal series.
■ ^ t ■ T , -“Jay nave lor usin a sumical
point of view, I confidently assert (standing upon the groundwork of facts
and realities) that the only true explanation which can ever be given of
them and of the law of development which produces them, and all skeletal
forms throughout the vertebrated classes of animals, I have already set forth
originally in my work on the “ Archetype Skeleton.” To Professor Owen’s
work, “ Homologies of the Vertebrate Skeleton,” I beg to refer the scientific
COMMENTAKY ON PLATE V.
THE SURGICAL DISSECTION OF THE EPI-STERNAL OR TRACHEAL REGION, AND THE
RELATIVE POSITION OF ITS MAIN BLOODVESSELS, NERVES, &c.
The law of symmetry governs the development of aU forms
throughout the animal kingdom. Symmetry especiaHy charac¬
terizes the human body. The general median line of the human
form maiks the junction of the two ecjual and similar sides. Every
structure or organ which appears single or azygos at the median
line is an instance of halves united. All lateral organs or struc¬
tures are instances of halves disunited from their fellows of the
opposite side. No lateral organ can be symmetrical, because it is
a half; and therefore it follows that the essential signification of
symmetry is two similar things in union or in disunion. Even in
surgery this law is required to be observed, for as lateral parts
have their counterparts, the several operations performed in
respect to one side of the body have to be conducted in a similar
manner on the other.
The vascular as well as the osseous skeleton displays the law of
symmetry; but while the latter ofiers no exception to this law,
the former presents a few, and these, it will be observed, take
place at the median line, which is the seat of metamorphosis. All
parts Avhich occupy this centre have already undergone a symme¬
trical modification in respect to number—plurality has been fused
into unity; while all parts which tend towards this centre appear
ready to undergo the like change. Behind the right sterno¬
clavicular junction, c. Figure 1, appears a, the innominate common
trunk of the right carotid and subclavian arteries. Behind the
left sterno-clavicular junction, q. Figure 2, the left carotid and
subclavian arteries appear, having separate origins in the aortic
arch. These vessels, on either side of the median line, present an
example of non-symmetry in the degree of two to one, and this is
their more general form in the human body. Like all general
rules, however, this one has its exceptions; and in these we dis¬
cover Nature reverting from her secondary law, by which she
individuates the species to her primary law, which is characterized
as uniformity and symmetiy.
The changes wrought amongst the vessels arising from the
aortic arch are simply such as affect their number. Submitting
them aU to general comparison, they appear to me to yield the
following explanation of their nature:—Two or more of them,
originally separate, coalesce at their origins; and according to the
variety of that union, their species are produced. When union
occurs between two branches on one side of the median line, the
common trunk thus formed becomes non-symmetrical with the
separate condition of the opposite pair of vessels. Such an
“ innominate" branch may happen on either one side or the other,
or on both together. The two adjacent carotids, when uniting,
form a central symmetrical common trunk, while the subclavian
arteries arise on either side of it separately. If union happen on
neither side of the median line, nor at this situation, all the four
aortic branches will appear separate; and this I consider to be
their original condition in uniform series. When to this, as a
standard, we compare all special modifications of these vessels,
as instanced, not only in the human body, but as they are pre¬
sented in the individuals of the four vertebrated classes, they will
be found to bear the above-mentioned interpretation.
The special law which modifies the uniform series of four distinct
aortic branches to that condition which the human body usually
exhibits, appears to me to signify simply this—-the brachial and
cephalic branches on the right side of the median line coalesce to
form the artery named “ nameless,'^ whilst on the left side the cor¬
responding pair of vessels remain separate. AU the varieties of
the innominate artery speak in support of this view. These
varieties form a graduated series, showing the difierent phases in
which the union has taken place between the two vessels of the
right side. The length of the common trunk varies according to
the degree of union. On the other hand, I observe that all the
varieties to the normal separate condition of the two vessels on
the left side form, in like manner, a graduated series, exhibiting
the various phases of their union. It is true that there are some
states of these vessels which do not appear to come within the
compass of this generalization; but the integrity of this, so far as
it extends, they cannot afiect. On considering these facts in
regard to practice, we may discover a reason why operations
upon these primary median vessels are foUowed by fatal conse¬
quence, as a common rule, to which a favourable issue is indeed
a rare, if ever any exception.
In many instances, the innominate artery. A, Figure 1, is of
such extraordinary length, that its point of bifurcation rises for an
inch, or even more, above the sternal end of the clavicle. In other
cases, this vessel bifurcates at its origin in the aortic arch.
Between these extremes, as to length, the vessel varies infini-
tesimaUy.
The innominate artery lies closer to the right than the left
carotid and subclavian arteries do to' the left sterno-clavicular
junction. This difference as to the depth of the vessels on either
side of the median line depends upon the position of the aortic
arch, from which they arise. The arch of the aorta, rising to a
level with the upper margin of the second costal cartilages, lies
obliquely in the thorax, between the right side of the sternum
and the left of the dorsal spine. The innominate artery, arising
from the first or forepart of the arch, occupies a plane anterior to
that of the left carotid, which arises from the arch next in oi-der,
while this vessel stands anterior to the left subclavian artery,
which springs from the deeper part of the arch. These vessels.
DESCRIPTION OF THE FIGURES OF PLATE V.
Figuee 1.
A. Innominate artery, at its point of bifurcation.
B. Eight internal jugular vein, joining the subclavian vein.
C. Sternal end of the right clavicle.
D. Trachea.
E. Right sterno-thyroid muscle, cut.
F. Right sterno-hyoid muscle, cut.
G. Right sterno-mastoid muscle, cut.
a. Right vagus nerve, crossing subclavian artery.
b. Anterior jugular vein, piercing the cervical fa;scia to join the subclavian
vein. ^
Figuee 2.
A. Common carotid artery of left side.
B. Left subclavian artery, having, h, the vagus nerve, between it and a.
C. Lower end of left internal jugular vein, joining—
D. Left subclavian vein, which lies anterior to d, the scalenus anticus
muscle.
E. Anterior jugular vein, coursing beneath sterno-mastoid muscle and
over the fascia.
F. Deep cervical fascia, enclosing in its layers,/// the several muscles.
G. Left sterno-mastoid muscle, cut across, and separated from g g, its
sternal and clavicular attachments.
H. Left sterno-hyoid muscle, cut.
I. Left sterno-thyroid muscle, cut.
K. Right sterno-hyoid muscle.
L. Right sterno-mastoid muscle.
M Trachea.
N. Projection of the thyroid cartilage.
O. Place of division of common carotid.
P. Place where the subclavian artery passes beneath the clavicle.
Q. Sternal end of the left clavicle.
COMMENTARY ON PLATE V.
ascending, in this order and relative position, to the epi-sternal
region, appear in this situation at different depths from the
anterior surface, those on the left side being deeper than those
on the right. The great veins, like the arteries, in approaching
the median line, suffer a metamorphosis by union. Behkid the
sterno-clavicular junctions, the great jugular and subclavian veins
of either side unite symmetrically in front of the arteries, and form
the right and left innominate veins. These, in forming the single
superior vena cava, which descends on the right of the aorta,
become non-symmetrical, the right vessel being much shorter than
the left. The left innominate vein passes across the median line
obliquely in front of the aortic vessels, behind the upper part of
the sternum; while the right descends perpendicularly on its own
side, and is here joined by the left vessel. The single vena cava,
formed by the union of the two innominate veins, terminates in
the right auricle of the heart. The vagus nerves on either side
exhibit peculiarities of relation, according to the metamorphosis
which the vessels appear to have undergone at the median line.
The right vagus sends its inferior laryngeal branch looping under
the root of the subclavian artery, and behind the carotid, while the
nerve itself enters the thorax on the outer side of the innominate
artery. The left vagus descends between the separate trunks of
the left carotid and subclavian arteries, and sends its inferior
laryngeal branch around the arch of the aorta in the thorax.
The parts which occupy the median line of the neck being
distinctly prominent on the surface, enable us to determine with
much exactness their relative positions. Those parts numbered
from above downwards appear in the following order—the chin,
os hyoides, thyroid, and cricoid cartilages, thyroid body on the
forepart of the trachea, and below this body the sternum. Above
the sternum appears a central depression formed between the
lower ends of the two sterno-mastoid muscles. On removing the
skin from this place, we expose the parts which determine its
form. The epi-sternal depression now appears bounded on either
side by the sternal tendons of the mastoid muscles, n, G, and
behind by the pairs of sterno-hyoid and thyroid muscles. These
are ensheathed by layers of the cervical fascia, ff. The layer
of 'fascia which is behind these muscles is of considerable
density. By removing the muscles and fascia, we expose the
thyroid body lying upon the trachea, and overlapping by its
outer borders the carotid arteries of either side. These vessels
will be now observed to lie close to the sides of the trachea
below, and, as they ascend to a level with the larynx, to be here
separated from each other at a much wider interval. The carotid
arteries beside diverging in their ascent, recede from the front of
the neck backwards, while the laryngo-tracheal apparatus, occu¬
pying a central position between these vessels, will be seen in its
descent to recede from the front of the neck backwards. On
a level with the top of the sternum, the trachea passes deeply
between and behind the great arteries. The trachea is here said
to incline rather to the right side of the median line, but this
appearance is owing to the innominate artery. A, Figure 1, lying
obliquely in front of it. On considering these general relations
of the larynx and trachea, it will appear, that the nearer to the
larynx tracheotomy is performed, the less liable are the vessels to
suffer injury, provided the median line directs the operation.
At the median line of the neck, the larynx and upper end of
the trachea are subcutaneous. Between the thyroid and cricoid
cartilages occurs an interval closed by a fibrous membrane, and
guarded in front by the pair of small crico-thyroid muscles.
Below this interval appear three or four of the upper rings
of the trachea, and below these the thyroid body covers the
trachea as low down as the top of the sternum. Between the
larynx and the sternum, the sterno-hyoid and thyroid muscles,
enclosed by the layers of cervical fascia, overlie these several
points lateraUy, and touch each other by their inner borders.
Regarding the relative position of these’ parts, in respect to the
trachea, it must appear that the most eligible situation for per¬
forming tracheotomy is at the centre of the upper part of the
tube, where it is most superficial, immediately below the cricoid
cartilage. If the operation be performed at any point below this
place, the instrument will have to penetrate the thyroid-body;
and considering how liable this structure is to vary in size, and
what large vessels traverse its substance, besides the depth at
which the trachea lies behind it, the dangers thus incurred become
evident. Below the thyroid body, the trachea is inaccessible^ on
account of its great depth, its being so closely embraced by the
carotid arteries, and also because of the frequency Avith Avhich large
thyroid vessels are found to'lie in front of it, having their origin
in the aortic arch and their termination in great veins entering the
heart. The larynx in the action of deglutition draws the thyroid
body upwards from the sternum, for the space of an inch or so, but
still no one who is acquainted with the anatomy of the parts, Avill
attempt to snatch an opportunity for opening the tube at this
interval, where it is but for a moment accessible, Avhile the
operation may he performed Avith ease, safety, and effect beloAV
the cricoid cartilage.
Laryngotomy is performed at the crico-thyroid interval, which
may be felt as a small depression at the median line, heloAV the
thyroid cartilage. In this place, and in front of the adjacent
part of the trachea, the only vessels liable to be met with
crossing the incision, made vertically for an inch in length, are
one or two small branches of the superior thyroid artery, and
perhaps some of the upper branches of the anterior jugular vein.
The trachea, whilst being incised, may be steadied by pressing the
larynx. Lower doAvn, the trachea, being more moveable, is apt to
swerve from the point of the cutting instrument, and thereby
endanger the carotid vessels. In the infant, the trachea lies closer
betAveen the carotid arteries; and being relatively smaller, more
mobile, and shorter than that of the adult, tracheotomy is more
difficult to perform in the former subject.
On comparing the aortic branches on either side of the epi-
sternal region, it AviU appear that those of the left side (more
especially the subclaAuan artery) lie deeper from the surface than
those of the right, and hence that the left vessels are less favour¬
ably circumstanced for being exposed in an operation. This
disadvantage, in respect to the left vessels, is however more than
counterbalanced by the fact, that the right subclavian and carotid
arteries spring generally from a common trunk. If an aneurism
arise from either of the vessels of the right side, a ligature AviU have
to be placed upon the innominate artery, thus cutting off the cir¬
culation, as well of the branch affected, as of the branch which is
not; whereas the separate aortic origins of the two left vessels
allow of the ligature being applied to that vessel alone which is
diseased. Again, as the left vessels are of smaller calibre than
the innominate, and as betAveen their origins and the points where
they give off their first branches, they present a longer interval
than those of the right side, there appears a greater probability
of the ligature holding undisturbed Avhen applied to the former.
Whenever, therefore, the right vessels happen to arise separately
from the aorta, such peculiarity is to be regarded more as an
advantage than otherwise.
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COMMENTARY ON PLATE VI.
the surgical dissection of the axillary and brachial regions, displaying the
RELATIVE ORDER OF THEIR CONTAINED PARTS.
ACH surgical region has but artificial boundaries. Thes
oun anes being m most instances described by moveable parts
will hence be found to influence, not only the form and dimension
of the region itself, but in some respects the relative position of th
several structures which it contains. The clavicle is an exampl
of this kind of conventional boundary. This bone serves to indi
cate the ideal line of separation between the lateral cervical regioi
and the axilla; but as it is a part which freely obeys the action
of the neighbouring muscles, it will, according to its motions, b
observed to vary the areas of both these regions, contracting tha
0 the one in the same ratio as it increases that of the other. Ii
the same degree as the clavicle happens to vary the dimensions o:
the cervical and axillary regions, will it also vary the length o:
those parts^ of the main vessels which are described as bein^
located m either region, above and below its own level. It there
fore becomes necessary to fix this bone in the horizontal position
while we describe regions and structures whose forms, dimensions
and relative situations, are, for practical purposes, allowed to bi
chiefly determined in reference to it. The clavicle being placec
in the position of r. Fig. 1, those portions of the vessels (sub¬
clavian) which are above its level occupy the cervical region,
while those portions which intervene between this bone and tht
folds of the axilla, o K, traverse the axillary region. Below the
axilla, the vessels become brachial.
The axillary space may be opened in front by dividing (between
the middle of the clavicle and the anterior fold of the armpit) the
following parts in succession—^viz., the slrin and subcutaneous
adipose tissue, the great pectoral muscle, hk, Fig. 1, the lesser
pectoral muscle, l i, together with the fascise which invest these
anteriorly and posteriorly. Immediately surrounding the vessels
Avill next be found the process of fascia, which for ms a sheath for
them. On removing the cellular membrane, the sheath of the
vessels, and the middle third of the clavicle, we expose the main
vessels and nerves traversing the cervical and axillary regions.
The relations which the clavicle, R, Fig. 1, holds to the subclavian
and axillary portions of these vessels and nerves may be now seen
at one view.
Immediately behind the inner third of the clavicle appears the
subclavian vein, a. Fig. 1. Behind the vein is the anterior
scalenus muscle, inserted into the middle of the first rib. Behind
this muscle is situated the subclavian artery, b, arching over the
first rib, R. The oblique position of the rib causes the artery
here to rise to a higher level in the neck than the vein. When
arrived behind the middle of the clavicle, the artery appears with
the vein close to its inner side, and with the cervical plexus of
nerves on its outer side. The vessels and nerves holding this
relative position pass now from under the clavicle, R, and the
subclavius muscle, e, into the axillary region.
The axilla is conical in form. It assumes this shape only while
the arm is abducted, and while the osseous and muscular parts
remain entire. The apex of the axilla. Fig. 1, is at the root of
the neck, and is formed by the clavicle, r, and the subclavius
muscle, E, in front and above, and by the upper part of the
scapula and thorax, externally and internally. The subclav an
vessels, a b, and nerves enter the axilla between these parts,
which form its apex. The base of the axilla is below, looking
towards the arm; and is formed by the pectoralis major muscle,
k H, in front, and by the latissimus dorsi, o, and teres muscles, p,
behind. The base is closed by the dense fascia which stretches
between these muscles. Here the axillary vessels, a &, pass out to
the arm, and become brachial, a* b*. ’ The anterior side of the
axilla is formed by the great pectoral muscle, h k, and the lesser,
Li; the inner side by the serratus magnus muscle, m. Fig. 2,
attached to the ribs; whilst the outer and posterior sides are
formed by the scapula and upper part of the humerus, together
with the muscles connected to these bones.
The axilla gives lodgment to a complicated mass of bloodvessels,
nerves, and lymphatic glands, embedded in a large quantity of
loose cellular and adipose tissues. All the arteries here found are
given olf from the axillary artery, and accompanying these appear
numerous veins, which enter the axillary vein. The brachial
plexus of nerves, while passing through the axilla, gives off*
numerous branches to the surrounding muscles. Nerves from
other sources also traverse this place. The cephalic vein, s.
Figure 1, joins the axillary vein, after passing through the cel¬
lular interval between the deltoid, g, and pectoral muscles, h.
description of the figures of plate VI.
Figure 1.
Figure 2.
A. Subclavian vein, crossed by a branch of the brachial plexus given to the
subclavius muscle ; the axillary vein ; the basilic vein, having
the internal cutaneous nerve lying on it.
B. Subclavian artery, lying on f, the first rib; Z>, the axillary artery;
the brachial artery, accompanied by the median nerve and venae
comites.
C. Brachial plexus of nerves; the median nerve.
D. Anterior scalenus muscle.
E. Subclavius muscle.
F F. First rib.
G. Clavicular attachment of the deltoid muscle.
H. Humeral attachment of the great pectoral muscle.
I. A layer of fascia, encasing the lesser pectoral muscle.
K. Thoracic half of the great pectoral muscle.
L. Coracoid attachment of the lesser pectoral muscle.
L*. Coracoid process of the scapula.
M. Coraco-brachialis muscle.
N. Biceps muscle.
O. Tendon of the latissimus dorsi muscle, crossed by the intercosto-
humeral nerves.
P. Teres major muscle, on which and o is seen lying Wrisberg’s nerve.
Q. Brachial fascia, investing the triceps muscle.
R B. Scapular and sternal ends of the clavicle.
S. Cephalic vein, coursing between the deltoid and pectoral muscles, to
enter at their cellular interval into the axillary vein beneath e, the
subclavius muscle.
A. Axillary vein, cut and tied; a, the basilic vein, cut.
B. Axillary artery; by brachial artery, in the upper part of its course,
having, A, the median nerve, lying rather to its outer side; Z>% the
artery in the lower part of its course, with the median nerve to its
inner side.
C. Subclavius muscle.
C*. Clavicle.
D. Axillary plexus of nerves, of which i is a branch on the coracoid
border of the axillary artery; e, the musculo-cutaneous nerve,
piercing the coraco-brachialis muscle; /, the ulnar nerve; mus-
culo-spiral nerve; hy the median nerve; z, the circumflex nerve.
E. Humeral part of the great pectoral muscle.
F. Biceps muscle.
G. Coraco-brachialis muscle.
H. Thoracic, half of the lesser pectoral muscle.
I. Thoracic half of the greater pectoral muscle.
K. Coracoid attachment of the lesser pectoral muscle.
K*. Coracoid process of the scapula.
L. Lymphatic glands.
M. Serratus magnus muscle.
N. Latissimus dorsi muscle.
O. Teres major muscle.
P. Long head of triceps muscle.
Q. Inner condyle of humerus.
COMMENTARY ON PLATE VI.
The basilic vein, a*, appears, from its large size and direction,
to be the proper continuation of the axillary vein, a, on the inner
side of the arm.
The axillary vein, a, lies sidelong with and in front of the
artery, 5, while the axillary nerves, D t?. Figure 2, form a plexus
around this vessel. The axillary plexus of nerves does not exhibit
a form and arrangement exactly similar in any two bodies; but,
in general, it will be found to embrace the axillary artery so
closely as to render it very difficult to expose and tie this vessel
in the dead, much less the living body. In Figure 2, the
axiUary artery, b, is seen to have on its outer side a large nerve, d,
from which thoracic branches are given off in front of the vessel,
to pass behind the lesser pectoral muscle, h. The nerve d divides
then into two branches: one the musculo-cutaneous, e, which
pierces, G, the coraco-brachialis muscle; and the other, which
forms one of the roots of the median nerve, h. Next to the
median nerve, which lies upon the artery, appears the ulnar
nerve, /, on the inner side of this vessel. The musculo-spiral
nerve, y, and the circumflex nerve, ^, together with the sub¬
scapular nerve, lie immediately behind the artery. The internal
cutaneous nerve and the nerve of Wrisberg are seen to arise from
the ulnar nerve,/! Small thoracic nerves appear given off from
different points of the plexus, and two of the intercosto-humeral
nerves are seen to cross the axilla to the integuments of the upper
part of the arm.
The branches which arise from the axillary artery are the three
thoracic, the subscapular, and the anterior and posterior circum¬
flex. These vessels vary very much, both as to number, size, and
place of origin. The subscapular branch, q. Figure 2, is perhaps
the most constant of them all, in respect to size and relative
position. Its point of origin from the axillary artery corresponds,
in general, to the interval between the latissirnus dorsi tendon and
the humeral insertion of the subscapular muscle. I have, however,
observed it arising from all parts of the main vessel.
The course of the main vessels and nerves in the axilla, can
be indicated with sufficient accuracy by a line drawn from the
middle of the clavicle, be. Figure 1, along the interval between
the deltoid and pectoral muscles to the inner border of the biceps
muscle, N. Corresponding with this line, and situated midway
between the clavicle and anterior fold of the axilla, may be felt,
even in the living subject, the coracoid process, l*, of the scapula.
The axiUary artery will be found passing close to the inner side
of the coracoid process, and under cover of the lesser pectoral
muscle, L, which arises from it. An operation for tying the axillary
artery can only be required in case of wounds; for if this vessel
be affected with aneurism, then the subclavian artery becomes the
subject of operation; and even when the aneurism arises from the
brachial artery, it would seem preferable (all circumstances con¬
sidered) to tie the main vessel either above or below the a xill a ,
than in this place. The depth at which the vessel lies from the
forepart of the body — the close relationship which it has to
the axillary plexus of nerves, and to the axillary vein — the
great number of its branches which cross the necessary line of
incision—and the uncertainty of flnding a sufficiently clear in¬
terval of the vessel between the origins of those branches where
the ligature might be safely applied—are cogent reasons forbidding
the operation.
In some instances the axillary artery is found to be double,
owing to its having divided into the brachial branches. The
vessel has never been seen to divide, in this manner, as high
up as the clavicle.
In considering the position of the subclavian vessels, a, b.
Figure 1, in relation to the clavicle, e, it may be observed how,
when this bone happens to be fractured at its middle, the circu¬
lation in these vessels will be impeded. The clavicle forms an
arch, under which the vessels pass from the neck to the axilla.
When the bone is broken across, it loses its arching form, and
thereby the vessels become subjected to pressure. This will be
the result, whatever relative position the two fragments be made
to assume, through the agency of the muscles inserted into them.
If the two fragments lie in apposition, the subclavius muscle
will depress both upon the vessels. If either fragment rides over
the other, that which is the lower will be forced against the
vessels. The weight of the limb, aided by the contraction of the
subclavius muscle, which is principally attached to the outer half
of the clavicle, causes this part in general to sink below the level
of the inner sternal half. The subclavius muscle becomes, by
reason of its position, a principal agent in frustrating our
endeavours to effect a proper adjustment of the broken ends of
the clavicle. The action of this muscle upon the fractured bone
here is similar to that of the pronator teres and quadratus muscles
in fractures of the forearm.
When the head of the humerus is dislocated forwards beneath
the coracoid process of the scapula, l, it puts upon the stretch
the pectoralis minor muscle, and forces out of their proper position
the axillary vessels and nerves. The latter structures always
suffer pressure when the head of the humerus is displaced into
the axilla. In these accidents the limb suffers more or less para¬
lysis, and its circulation is in some degree impeded.
The main vessels and nerves, in passing from the axilla to the
arm, assume the name brachial. In their course through the
arm, they lie comparatively superficial, being covered only by the
integuments and fascia. Near the axilla the artery wiU be found
passing along the inner border of the coraco-brachialis muscle.
The artery (it should be well remembered) does not come into
apposition with the biceps till it has arrived at the middle of the
arm. The median nerve, c*. Figure 1, and two veins (comites)
closely accompany the artery, between the axilla and the bend
of the elbow. The artery, vente cqmites, and median nerve are
enclosed in the same sheath. This structure is formed of a fold
of the common fascia, which invests the muscles. The basilic
vein, a*, accompanied by the internal cutaneous nerve, takes a
course parallel with and close to the brachial artery. The fascia
alone separates these two vessels. Between the lower border of
the axilla and the middle of the arm, the artery passes in close
relationship with the ulnar and musculo-spiral nerves, as well as
the median nerve. In this situation the median nerve will be
found lying to the outer side or in front of the artery; the ulnar
nerve lying to the inner side of the sheath of the vessel, and the
musculo-spiral nerve behind the sheath. From the middle of the
arm doAvnwards, the vessel and nerves take different directions.
The ulnar nerve separates from the artery to pass behind the
inner condyle of the humerus, the musculo-spiral nerve winds
behind the shaft of this bone to gain the outer side of the arm,
while the median nerve crosses in front of the artery to gain its
inner side, and in this relative position both traverse the bend of
the elbow and enter the forearm. The two most considerable
branches which arise from the brachial artery are the superior
and inferior profundus. The .first. Figure 2, is given off from the
brachial near the axilla, and follows the musculo-spiral nerve.
The latter arises at the middle of the arm, and accompanies the
ulnar nerve.
In the operation for tying the brachial artery near the nxilla
or in the upper third of the arm, the incision is to be made cor¬
responding to the inner border of the coraco-brachialis muscle.
The incision, therefore, should be commenced at a point midway
between the two folds of the axilla, and extended along the outer
side of the basilic vein, for two or three inches down the arm.
The fascia being next divided, the sheath of the artery, with the
ulnar and musculo-spiral nerves in contact with it, will be found
slightly overlapped by the inner margin of the coraco-brachialis
muscle. When the sheath is opened, the artery will be seen,
having the ven^ comites oh either side, and the median nerve
lying upon it. The ligature may now be passed around the
artery, taking care to exclude the veins and nerves.
The brachial artery, in its whole course, will be seen to have
a close relation to the osseous axis of the limb. The vessel
therefore, in all parts may be compressed against bone so effec¬
tually as to stop pulsation at the wrist. In the upper part of the
arm, the vessel, lying along the inner side of the humerus, requires
that the compression be made from within outwards. In the lower
third of the arm, the vessel winds in front of the bone, and com¬
pression should accordingly be made from before backwards.
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VII.
COMMENTARY ON PLATE
THE SURGICAL FORMS OF THE
MALE AND FEMALE AXILLA COMPARED.
Between corresponding regions of the body in both sexes t
discern some degree of differential character'; and yet Z ^
mi lem to anatomical comparison we find them to be con
posed of parts identical in structure and form, and having
re ative position absolutely similar in both. The same regions .
the male and female being in this degree homologous, we a,
nduced to inquire upon what depend those features which ser.
such distinction? On comparing both regions and the corn
sponding parts of each, we find the sexual differences to aris
so e y by reason of the same organ being developed to a large
size m one sex than in the other. The female mamma is a pie
or u y eve oped glandular organ, which, compared with th
male mamlla signifies that this latter is minus as to quantity
unevolved, ri^imentary. This diversity, which defines the sexua
chararter of beings of the same species, is but a link in that chaii
0 ^ differential gradation which extends throughout the whol
animal kingdom.
The male and female axillae contain respectively the same
number and species of organs; and on contrasting the two regions,
we find that the difference between the outward contours of both
is principally owing to the enlarged mammary gland which in the
female. Figure 2, overhangs and masks the axillary border of the
great pectoral muscle, e.
While the dissected axilla is viewed from below (the arm being
raised from the side), it appears as a conical recess, bounded
laterally by the upper part of the arm and the thorax; and antero-
posteriorly by the large muscles which, arising from the thorax
back and front, become inserted into the neck of the humerus.
The bloodvessels and nerves will now be observed to traverse the
axillary space along its outer wall, and to have a much closer
relation to the arm externally than to the side of the thorax inter¬
nally. The thickness of its fleshy anterior wall, formed by the
two pectoral muscles, major and minor, e e. Figure 1, is very
great;.and hence it will appear that the depth at which the
axillary artery lies beneath these muscles, must render it a very
difficult task for the operator to expose and tie this vessel at an
incision, of the prescribed length, made through the parts from
before.
The bloodvessels of the axilla follow the motions of the arm;
and, according to the position assumed by the limb, these vessels
are made to describe various curves, more or less removed from the
side of the thorax. While the arm hangs close to the side, the
axillary space does not (properly speaking) exist; and in this
position, the axillary vessels and nerves make a general uniform j
curve from the clavicle at the point k. Figure 2, to the inner side
of the arm, the concavity of the curve being turned towards the
thoracic side. But when the arm is abducted from the side, and
elevated, the vessels which are destined to supply the limb follow
it, and in this position they take, in reality, a serpentine course,
the first curve of which is concave in respect to the thorax, and
reaches from the clavicle, k, to the head of the humerus; and the
next is that bend which the head of the humerus, projecting into
the axilla in the elevated position of the member, forces them to
make around itself on their way to the inner side of the arm. As
the vessels have a closer relation to the arm than to the thorax,
they may be readily compressed against the upper third of the
humerus by the finger, passed into the axilla, and still more effec¬
tually if the arm be raised, for by this motion the tuberous head
of the humerus wiU be rotated downwards against them.
The axillary vessels and nerves are bound together by a fibrous
sheath derived from the membrane called costo-coracoid; and the
base or humeral outlet of the axfila, described by the muscles
c, K, E, G, Figure 1, is closed by a part of the fascial membrane,
y, extended across from the pectoral muscle, e^ anteriorly to the
latissimus dorsi muscle, k, posteriorly. When the arm is raised
from the side as represented in the figures, the axillary vein, a, over¬
lies the artery, b, and also conceals most of the principal nerves.
In order to show some of these nerves in contact with the artery
itself, the axillary vein has been drawn a little apart from them.
The axilla gives lodgment to numerous lymphatic glands of
various size, some of which are supplied by small vessels given off
directly from the main artery, others by vessels of similar size
derived from its principal thoracic branches. These glands appear
to be more numerous in the female axilla. Figure 2, than in that
of the male. Figure 1. The greater number of them are gathered
together along the axillary border of the great pectoral muscle; and
in this situation, /q they may be felt (when affected with scirrhus)
to form large nodulated masses, which in some instances occupy the
whole axillary space, and cause an impediment to the motions of
the shoulder joint, as also to the circulation of the neighbouring
vessels. The cervical glands will generally be found diseased at
the same time.
The contractile motions of the pectoral muscle of the male
body, E, Figure 1, are readily distinguishable beneath the inte¬
guments; and the manner in which it determines the form of the
pectoral region, and bounds the axillary space anteriorily is, in
this sex, well defined. In the female, on the contrary, we observe
that though the pectoral muscle holds the same relative position
as it does in the male, the external form of the pectoral region
DESCRIPTION OF THE FIGURES OF PLATE VII.
Figure 1.
A. Axillary vein, drawn apart from the artery, to show the nerves lying
between both vessels. On the bicipital border of the vein is seen
the internal cutaneous nerve; on the tricipital border is the nerve
of Wrisberg, communicating with some of the intercosto-humeral
nerves; a, the common trunk of the venae comites, entering the
axillary vein.
B. Axillary artery, crossed by one root of the median nerve; basilic
vein, forming, with the axillary vein, a.
C. Coraco-brachialis muscle.
D. Coracoid head of the biceps muscle.
E. Pectoralis major muscle.
F. Pectoralis minor muscle.
G. Serratus magnus muscle, covered by the axillary fascia, and perfo¬
rated, at regular intervals, by the nervous branches, called intercosto-
humeral.
H. Conglobate gland, crossed by the nerve called external respiratory”
of Bell, distributed to the serratus magnus muscle. This nerve
descends from the cervical plexus.
I. Subscapular artery.
K. Tendon of latissimus dorsi muscle.
L. Teres major muscle.
Figure 2.
A. Axillary vein.
B. Axillary artery.
C. Coraco-brachialis muscle.
D. Short head of the biceps muscle.
E. Pectoralis major muscle.
F. Mammary gland, seen in section.
G. Serratus magnus muscle.
H. Lymphatic gland; h h, other glands of the lymphatic class.
I. Subscapular artery, crossed by the intercosto-humeral nerves, and
descending parallel to the external respiratory nerve. Beneath
the artery is seen a subscapular branch of the brachial plexus, given
to the latissimus dorsi muscle.
K. Locality of the subclavian artery.
L. Locality of the brachial artery at the bend of the elbow.
COMMENTARY ON PLATE VII.
depends principally upon the existence of the enlarged mammary
gland, and the adipose tissue in Avhich this organ is embedded.
The female breast consisting of the integuments, adipose tissue,
and gland, varies in size and shape in different individuals; hut the
difference in these respects is not so much owing to the variable
dimensions of the true glandular part as to the variable quantity
of the ceUular-adipose substance surrounding this organ. The
mammary gland is nearly hemispherical in form, convex in front,
flattened posteriorly. It is enveloped in a firm capsule of con¬
densed cellular membrane, which binds all its lobes and lobules
together into one mass, isolated from neighbouring parts. All the
lactiferous ducts concentre towards the middle of the gland, and
at this place they enter the nipple, Avhich projects from the
cutaneous surface. The ducts open at the summit of the nipple by
separate orifices. The mammary gland may be classed among the
tegumentary organs. It is retained in its position chiefly by the
skin, which forms a pouch to receive it. In the virgin state of the
organ, its base is applied to the fascia covering the pectoral muscle;
but the connecting medium between the two parts consists merely
of lax cellular membrane, which yields with the weight of the
gland in the maternal state, and allows it to faU apart from the
side of the chest. The gland having assumed this pendent posi¬
tion, is then uninfluenced by the motions of the pectoral or
other muscles; but when it becomes the seat of scirrhus, this
contracts adhesions Avith the pectoral muscle, and then the organ
is rendered comparatively fixed. The retraction of the nipple, in
scirrhus of the breast, is occasioned by the lactiferous ducts
acting as bridles between the part and the disease. As the male
breast is mammiform, having the gland in a rudimentary stage
of development, so we occasionally observe it manifesting a
physiological function in imitation of that of the female organ.
The mammary gland of the male is not unfrequently the seat of
scirrhus, like that of the female.
When it is required to excise the mammary gland from the
male or female breast, this operation (if the disease be confined to
the structure of the gland or to the parts in its immediate vicinity)
may be performed with the confidence that no important vessels
or nerves will he found crossing the lines of section, however made.
But when the axillary glands partake of the same disease as is
found in the breast, they, also requiring to be extirpated, will
render the operation proportionately more difficult, according as
they approach into nearer pi'oximity to the axillary vessels and
nerves. It demands the greatest caution, in dissecting out these
glands, to preserve the main axillary artery from being wounded.
The best means of avoiding this accident is to abduct the arm as
widely as possible from the side, for thereby the vessels and nerves
become in some measure AvithdraAvn from the seat of operation.
The axilla becomes very frequently the seat of morbid groAvths,
which, Avhen happening to be situated beneath the dense axillary
fascia, and haAung attained to a large size, press upon the vessels
and nerves of this region, and cause very great inconvenience.
Adipose and other kinds of tumours occurring in the axilla beneath
the fascia, and in close contact with the main vessels, have been
known to obstruct these to such a degree, that the collateral or
anastomotic circulation had to be set up for the support of the
limb. When abscesses occur in the axilla, beneath the fascia,
this structure will hinder the matter from pointing; and it is
required, therefore, to open it freely by a timely incision, so as to
prevent the matter undermining the neighbouring parts. While
opening an axillary abscess, due regard should be had to the
position of the vessels and nerves. The limb requires to be
abducted from the side, and as the vessels taka, a direction parallel
with the humerus, the point of the instrument should penetrate in
the opposite way—towards the side of the thorax. The axillary
vessels and nerves being thus liable to pressure from the presence
of large tumours happening in their neighbourhood, will suggest
to the practitioner the necessity for fashioning of a proper form
and size all apparatus, which in fracture or dislocation of the
shoulder bones are required to bear forcibly against the axillary
region.
The relative anatomy of the several parts (bones, ligaments,
muscles, &c.) comprising the shoulder apparatus, forms a study of
very great practical importance. The shoulder joint being the
most moveable of all others, is necessarily surrounded by numerous
and powerful muscles; and it is found on experience that when
the bones suffer fracture or dislocation, these muscles become the
principal obstacle to the readjustment of the disunited parts.
The axilla is a situation intimately concerned in these accidents.
It becomes distorted on their occurrence, and in it the relath^e
position of the disunited parts may be most readily detected by
the touch.
Of all the other joints, that of the shoulder is, perhaps, the most
liable to dislocation; and of these accidents the most frequent
variety which happens to it, is that Avhere the head of the
humerus is displaced dovmwards into the axilla. These facts
may be accounted for anatomically. All joints Avhich are con¬
structed to perform the motion of circumduction, enjoy this freedom
of action at the expense of insecurity—such is the laAv in physics.
The shoulder joint is formed to perform this kind of motion in a
Avider range than any other joint of the skeleton, and hence its
greater liability to luxation. The glenoid articular facet of the
scapula is necessarily shallow, and of smaller diameters than the
globular head of the humerus, so as to alloAV the latter to move in
circumduction; and in every motion of this sort the bones are
subject to disarticulation. But in animal mechanics, we observe,
that when the safety of parts is thus sacrificed in some measure for
the gain of motion of one kind, the structural weakness becomes
fortified by a compensative motion of another kind. The scapula
being moveable upon the thorax is thereby allowed to oppose its
articular face to that of the humerus freely in aU directions except
one—namely, that of abdmtion. During this motion of the arm.
Figures 1 and 2, the scapula remains comparatively fixed, and
this explains the greater frequency of luxations of the humerus
downwards into the axilla than in other directions.
COMMENTARY ON PLATE VIII.
THE SURGICAL DISSECTION OF THE BEND OF THE ELBOW AND THE FOREARM, SHOWING THE RELATIVE
POSITION OF THE ARTERIES, VEINS, NERVES. &c.
The farther a surgical region happens to be removed from the
centre of the body, the less likely is it that accidents or opera¬
tions which involve such region will alFect the life immediately.
The limbs undergo all kinds of mutilation, both by accident and
intention, and yet the patient survives; but when the like happens
at any region of the trunk of the body, life will be directly
and seriously threatened. It seems, therefore, that in the same
degree as the living principle diverges from the body’s centre into
the outstanding members, in that degree is life weakened in
intensity; and just as, according to physical laws, the ray of
light becomes less and less intense by the square of the distance
fiom the central source, so the» vital ray,' or vis, loses momentum
in the same ratio as it diverges from the common central line to
the periphery.
The relative anatomy of any region becomes a study of more
or less interest to the surgeon, according to the degree of impor¬
tance attaching to the organs which it contains, and to the fre¬
quency with which these are exposed to accident. The bend of
the elbow gives passage to c. Figure 1, the main artery of the
arm, in the neighbourhood of which vessel are situated the veins
B, D, E, E. AU these vessels are accompanied by nerves, and that
which lies sidelong with the artery is of principal importance,
being destined for distribution over the greater part Mf the hand.
The relative situations of these parts demand therefore a careful
study, in order that while performing an operation in reference
to one of them, we may be prepared to preserve the others from
injury.
The course of the brachial artery along the inner border of the
biceps muscle is comparatively superficial from the border of the
axilla to the bend of the elbow. In the whole of this course the
artery is covered by the fascia, which structure alone separates it
from the basilic vein, b, and the internal cutaneous nerve. A
duplicature of the common fascia forms a proper sheath for the
artery. In this sheath are also -enclosed the median nerve, d.
Figure 1, and the venas comites making frequent loops around the
vessel. The brachial artery and median nerve have different
relative positions in their course down the arm. The course of
the median nerve, D, Figure 2, is straight, while that of the artery,
c, is undulating. Above, near the axilla, the artery lies close to
the outer side of the nerve, in the middle of the arm it is close to
the inner side of the nerve, and at the bend of the elbow the vessel
is again situated on the outer side of the nerve, but removed from
this at a small distance. As these changes in the relative posi¬
tion of the nerve and art.ery at the upper, the middle and lower
parts of the arm, are pretty constant, it is of practical importance
that they be remembered, for the nerve is to be taken as a guide
to the place of the artery.
When it is required to tie the brachial artery at the junction of
the middle with the lower third of the arm, it should be recollected
that here the vessel generally crosses under the median nerve, to
gain the middle of the bend of the elbow, while the basilic vein, b,
lies more directly over its course. The position of this vein
having been ascertained by pressing it above with the point of the
finger, an incision of sufficient length (an inch and half, or two
inches) should be made through the skin between the basilic vein
and the inner border of the biceps, and directed towards the
humerus or axis of the limb. The cellular membrane is next to
be divided, so as to expose the fascia; and while this is being done,
care should be taken to avoid cutting the internal cutaneous
nerves. The fascia is then to be divided on a director passed
beneath it; and the sheath of the vessel being thereby brought
into view, is to be incised in the same way. The median nerve
will now be seen as a tense whitish cord in front of the artery,
and on being relaxed by bending the forearm, the ligature
(excluding the venae comites) is to be passed ai’ound the vessel.
In the operation for exposing the brachial artery in the lower
third of the arm, the ulnar nerve, D, Figure 2, will not be seen, as
this passes, at some distance from the vessel, towards the inner
condyle of the humerus. In the upper part of the arm, the ulnar
nerve lies rather close to the inner side of the artery, and here it
may appear through the incision, and be mistaken for the median
nerve.
There are some varieties in.the relative position of the brachial
artery and accompanying nerves with which the operator should
be acquainted. Those which are of more frequent occurrence are
the following:—1st, the median nerve, d, Figure 2, may lie
beneath the artery, in the middle and lower thirds of the arm, or
may course in company with the ulnar nerve, J, somewhat re¬
moved from the inner side of the vessel; 2ndly, the brachial
artery may course apart from the inner border of the biceps
muscle, and leave the median nerve, d. Figure 2, appearing alone
in this situation; 3rdly, both the principal artery and the median
nerve may course at some distance from the inner side of the
biceps, A, Figure 2, while in this situation there is only to be
found a smaller vessel (the radial), which happens to arise from
the brachial higher up in the arm than usual; 4thly, the brachial
artery and median nerve may pass beneath a portion of the
brachialis anticus muscle, E, Figure 2, in which case they would
not appear at the usual place of incision; Sthly, there may be
found two or even three arteries accompanying the median nerve,
DESCRIPTION OF THE FIGURES OF PLATE VIII.
Figure 1.
A. Fascia covering the biceps muscle.
B. Basilic vein, with the internal cutaneous nerve.
C. Brachial artery, with the vense comites.
D. Cephalic vein, with the external cutaneous nerve ; d, the
median nerve.
E. A communicating vein, joining the venae comites.
F. Median basilic vein. ,
G. Lymphatic gland.
H. Radial artery at its middle.
I. Radial artery of the pulse.
K. Ulnar artery, with ulnar nerve.
L. Palmaris brevis muscle.
Figure 2.
A. Biceps muscle.
B. Basilic vein, cut.
C. Brachial artery.
D. Median nerve; d, the ulnar nerve.
E. Brachialis anticus muscle; e, the internal condyle.
F. Origin of radial arteiy.
G. Supinator radii longus muscle.
H. Aponeurosis of the tendon of the biceps muscle.
I. Pronator teres muscle.
K. Flexor carpi ulnaris muscle.
L. Flexor carpi radialis muscle.
M. Palmaris longus muscle.
N. Radial artery, at its middle, with the radial nerve, on its outer side.
O. Flexor digitorum sublimis.
P. Flexor pollicis longus.
Q. Median nerve.
R. Lower end of radial artery.
S. Low'er end of ulnar artery, in company with the ulnar nerve.
T. Pisiform bone.
U. Extensor metacarpi pollicis.
COMMENTARY ON PLATE VIIL
in consequence of the main artery having divided in the upper
third of the arm.
At the bend of the elbow, the brachial artery passes exactly
midway between the inner condyle of the humerus, and the
outer margin of G, the supinator radii longus muscle. The parts
which cover the vessel, c, Figure 2, in this situation, are these—
viz., some cellular membrane immediately surrounds it where it lies
in front of the brachialis anticus muscle, and between its two
venee comites, one of which separates the artery from the median
nerve. Above these is stretched the dense fibrous band, h.
Figure 2, which connects the tendon of the biceps to the fascia of
the forearm. Upon this band of fascia lies the median basilic
vein, F B, Figure 1, accompanying which are seen some branches
of the internal cutaneous nerve. The skin which covers the bend
of the elbow being thin and delicate in texture, and the sub¬
cutaneous adipose tissue in which the veins are embedded being
loose and soft, allow these vessels, while distended, to be discerned
beneath the surface. If it become necessary to tie the artery in
this situation, the relative position of the above-mentioned parts
must determine the line of incision, and the depth to which this
should be carried. The skin and fascia having been divided on
the external side of the basilic vein, the artery will be found
between the biceps tendon and the outer border of the pronator
teres muscle. The outer margin of the pronator is recommended
to be taken as a guide to the artery; but since this muscle
varies as to width in different individuals, there will (while the
vessel is fixed in its place) occur intervals of varying degrees
between them. The inner border of the tendon of the biceps lies
parallel with and close to the artery; and if the incision be made
to correspond with this line, the superficial veins and nerves,
together with the median nerve, will be less exposed to injury.
If the brachial artery happen to be punctured by accident in this
situation, and the haemorrhage cannot be permanently stanched
by compression, the wound should be enlarged, and both ends
of the vessel tied.
The bend of the elbow being the place usually chosen for per¬
forming venesection, it is required that we pay particular attention
to the relations between the superficial and more deeply-seated
parts, in order to ensure the safety of the latter in this operation.
In Figure 1, it will be seen that the basilic vein, f b, has to be
turned aside, and the fibrous band derived from the biceps tendon
to be divided, so as to expose the brachial artery, c. As the
basilic vein is the one in which the puncture is most generally
made, the fact that the artery lies so close beneath this vessel
necessitates that the instrument should not be entered deeply in
this situation. But the utmost caution in this respect will not in
aU instances prevent the occurrence of arterial htemorrhage, for it
not unfrequently happens that a large artery (the ulnar or the
radial), arising from the brachial, higher than usual, passes above
the fascia in company with the superficial veins, and takes a sub¬
cutaneous course to gain its usual position at the wrist. I have
noticed a well-marked instance in which the ulnar artery for its
whole length pulsated thus superficially in the living subject.
The internal cutaneous nerve accompanies the basilic vein, and
branches over the fascia of the inner and fore part of the forearm.
The external cutaneous nerve (perforans Casserii) appears in con¬
nexion with the median cephalic vein, and branches over the
fascia on the outer border of the forearm. The numerous
branches of both these nerves interlace with the veins; and those
which pass in front of these vessels at the bend of the ann are
liable to be divided in venesection. This operation may be per¬
formed upon the median cephalic vein, always with greater safety
to the brachial artery than upon the median basilic.
In order to distend the veins, n, b, f, for venesection, their
ascending circulation requires to be arrested by a ligature passed
around the arm at some part above. To effect this object, a
moderate pressure will be sufiicient. If the pressure of the
ligature be too great, the circulation of the artery will be
obstructed, and the vfeins, not receiving the recurrent blood, will
remain undistended. If the pressure be too slight, the circulation
in the veins will not be impeded sufficiently to cause them to
swell below.
Whichever of the veins at the bend of the elbow be chosen for
bloodletting, it will appear, on referring to Figures 1 and 2, that
by making the section according to the longitudinal axis of the
vessel, we may best secure the safety of the more important neigh¬
bouring points. In this way, the vein may be incised with greater
precision than if the instrument be directed so as to cut transversely.
While the vein is being incised in the latter mode, it is apt to
swerve from the point of the instrument, and if there should
happen to be any important artery passing in a subcutaneous
course close by, this vessel will be exposed to danger. By the
longitudinal section, the nerves likewise have a better chance of
escaping injury, for these parts traverse the limb in a direction
parallel with the veins.
The brachial artery usually divides, at the bend of the elbow,
into the radial, the ulnar, and the inter-osseous branches. The
point F, Figure 2, is the common place of division, and this will
be seen to be somewhat below the level of the inner condyle, e.
From the place where the radial and ulnar arteries spring, these
vessels traverse the forearm, in general under cover of the super¬
ficial muscles and fascia, but occasionally upon both these
structures. The radial artery, f n. Figure 2, takes a compara¬
tively superficial course along the radial border of the forearm,
and is accompanied, for the upper two-thirds of its length, by the
radial branch of the musculo-spiral nerve, seen in Figure 2 at the
outer side of the vessel. The supinator radii longus muscle over¬
laps, with its inner border, both the radial artery and nerve. At
the situation of the radial pulse, i. Figure 1, the artery is not
accompanied by the nerve, for this latter will be seen, in Figure 2,
to pass outward, under the tendon of the supinator muscle, to the
integuments.
The ulnai^artery, whose origin is seen near F, Figure 2, passes
deeply beneath the superficial flexor muscles, L m K, and the
pronator teres, i, and first emerges from under cover of these at
the point o, from which point to s. Figure 2, the artery may be
felt, in the living body, obscurely beating as the ulnar pulse. On
the inner border of the ulnar artery, and in close connexion with
it, the ulnar nerve may be seen looped round by small branches of
the vessel.
The radial and ulnar arteries may be exposed for the purpose
of having a ligature applied to them in any part of their course;
but of the two, the radial vessel can be reached with greater
facility, owing to its comparatively superficial situation. The
inner border of the supinator muscle, g. Figure 2, is the guide to
the radial artery; and the outer margin of the flexor carpi ulnaris
muscle, K, Figure 2, indicates the locality of the ulnar artery.
Both arteries, i, k. Figure 1, at the wrist, lie beneath the fascia.
If either of these vessels require a ligature in this region of the
arm, the operation may be performed with little trouble, as a
simple incision made over the track of the vessels, through the
skin and the fascia, will readily expose each.
Whenever circumstances call for placing a ligature on the
ulnar artery, as it lies between the superficial and deep flexor
muscles, in the region of i l m. Figure 2, the course of the vessel
may be pretty accurately indicated by a line drawn from a central
point of the forearm, an inch or so below the level of the inner
condyle—viz., the point f, and carried to the pisiform bone, t.
By an incision made to correspond with this line, we divide
obliquely the superficial flexors; and, on a full exposure of the
vessel in this situation, the median nerve will be seen to cross the
artery at an acute angle, in order to gain the midplace in the
wrist at Q. The ulnar nerve, d, Figure 2, after passing behind
the inner condyle, e, does not come into apposition with the ulnar
artery until both arrive at the place o, about three inches above
the wrist. It will, however, be considered an awkward pro¬
ceeding to subject to transverse section so large a mass of muscles
as the superficial flexors of the forearm, when the vessel may be
more readily reached elsewhere, and perhaps with equal advantage
as to the locality of the ligature.
When either the radial or ulnar artery happens to be divided
in a wound, it becomes necessary to tie both ends of the vessel,
for these will be found to bleed alike in consequence of the free
anastomosis of the two arteries in the hand.
3 .
M. iJc . Haniaxt lith. Printers
COMMENTARY ON PLATE IX.
THE SURGICAL DISSECTION OF THE WRIST AND HAND.
A MEMBER of such vast importance as the human hand necessarily
claims a high place in regard to surgery. The hand is typical
of the mind. It is the material symbol of the immaterial spirit.
It is the prime agent of the will; and it is that instrument by
which the human intellect manifests its presence in creation.
The human hand has a language of its own. While the tongue
demonstrates the thought through the word, the hand realizes
and renders visible the thought through the work. This organ,
therefore, by whose fitness of form the mind declares its own
entity in nature, by the invention and creation of the thing, which
is, as it were, the mind’s autograph, claims a high interest in
surgical anatomy; and accordingly the surgeon lays it down as a
rule, strictly to be observed, that when this beautiful and valuable
member happens to be seriously mutilated, in any of those various
accidents to which it is exposed, the prime consideration should
be, not as to the fact of how much of its quantity or parts it can
be deprived in operation, but rather as to how little of its quantity
should it be deprived, since no mechanical ingenuity can fashion
an apparatus, capable of supplying the loss of a finger, or even of
one of its joints.
The main bloodvessels and nerves of the arm traverse the front
aspect of the wrist, and are distributed chiefly to supply the
palmar surface of the hand, since in the palm are to be found a
greater variety and number of structures than are met with on the
back of the hand. The radial artery. A, Figure 1, occupies (as its
name indicates) the radial border of the forepart of the wrist, and
the ulnar artery, c. Figure 1, occupies the ulnar border; both
vessels in this region of their course lie parallel to each other;
both are comparatively superficial, but of the two, the radial
artery is the more superficial and isolated, and thereby occasions
the radial pulse. The anatomical situation of the radial artery
accounts for the fact, why the pulsation of this vessel is more
easily felt than that of the ulnar artery.
The radial vessel. A, Figure 1, at the wrist, is not accompanied
by the radial nerve; for this nerve, c, Figure 3, passes from the
side of the artery, at a position, c. Figure 3, varying from one to
two or more inches above the wrist, to gain the dorsal aspect of
the hand. The ulnar artery, c. Figure 1, is attended by the ulnar
nerve, n, in the wrist, and both these pass in company to the
palm. The ulnar nerve, n e, lies on the iilnar border of the
artery, and both are in general to be found ranging along the
radial side of the tendon of the flexor carpi ulnaris muscle, T, and
the pisiform bone, G. The situation of the radial artery is midway
between the flexor carpi radialis tendon, i, and the outer border of
the radius. The deep veins, called comites, lie in close connexion
with the radial and ulnar arteries. When it is required to lay bare
the radial or ulnar artery, at the wrist, it will be sufficient for that
object to make a simple longitudinal incision (an inch or two in
length) over the course of the vessel A or c. Figure 1, through the
integument, and this incision will expose the fascia, which forms a
common investment for aU the structures at this region. When
this fascia has been cautiously sht open on the director, the vessels
win come into view. The ulnar artery, however, lies somewhat
concealed between the adjacent muscles, and in order to bring this
vessel fully into view, it will be necessary to draw aside the tendon
of the flexor ulnaris muscle, T.
The radial artery, a. Figure 2, passes external to the radial
border of the wrist, beneath the extensor tendons, B, of the thumb;
and after winding round the head of the metacarpal bone of the
thumb, as seen at e. Figure 3, forms the deep palmar arch e.
Figure 2. This deep palmar arch lies close upon the fore-part of the
carpo-metacarpal joints; it sends off branches to supply the deeply
situated muscles, and other structures of the palm; and from it are
also derived other branches, which pierce the interosseal spaces, and
appear on the back of the hand. Fig. 3. The deep palmar arch, e.
Figure 2, inosculates with a branch of the ulnar artery, i. Figure
2, whilst its dorsal interosseal branches. Figure 3, communicate
freely with the dorsal carpal arch, which is formed by a branch of
the radial artery E, Figure 3, and the terminal branch of the pos¬
terior interosseous vessel.
DESCRIPTION OF THE FIGURES OF PLATE IX.
Figure 1.
A. Radial artery.
B. Median nerve; 5 J its branches to the thumb and fingers.
C. Ulnar artery, forming f, the superficial palmar arch.
D. Ulnar nerve; Eee, its continuation branching to the little and ring
fingers, &c.
G. Pisiform bone.
H. Abductor muscle of the little finger.
I. Tendon of flexor carpi radialis muscle.
K. Opponens pollicis muscle. ‘
L. Flexor brevis musele of the little finger.
M. Flexor brevis pollicis muscle.
N. Adductor pollicis muscle.
00 0 0. Lumbricales muscles.
P P P P. Tendons of the flexor digitorum sublimis muscle.
Q. Tendon of the flexor longus pollicis muscle.
R. Tendon of extensor metacarpi pollicis.
S. Tendons of extensor digitorum sublimis; ppp, their digital prolonga¬
tions.
T. Tendon of flexor carpi ulnaris.
U. Union of the digital arteries at the tip of the finger.
Figure 2.
A. Radial artery.
B. Tendons of the extensors of the thumb.
C. Tendon of extensor carpi radialis.
D. Annular ligament.
E. Deep palmar arch, formed by radial artery giving olf c, the artery of
the thumb.
F. Pisiform bone.
G. Ulnar artery, giving off the branch i to join the deep palmar arch e of
the radial artery.
H. Ulnar nerve; A, superficial branches given to the fingers. Its deep
palmar branch is seen lying on the interosseous muscles, M m.
K. Abductor minimi digiti.
L. Flexor brevis minimi digiti.
M. Palmar interosseal muscles.
N. Tendons of flexor digitorum sublimis and profundus, and the lumbri¬
cales muscles cut and turned down.
O. Tendon of flexor pollicis longus.
P. Carpal end of the metacarpal bone of the thumb.
Figure 3.
AAA. Tendons of extensor digitorum communis; a^, tendon overlying
that of the indicator muscle.
B. Dorsal part of the annular ligament.
C. End of the radial nerve distributed over the back of the hand, to two
of the fingers and the thumb.
D. Dorsal branch of the ulnar nerve supplying the back of the hand and
the three outer fingers.
E. Radial artery turning round the carpal end of the metacarpal bone of
the thumb.
F. Tendon of extensor carpi radialis brevis.
G. Tendon of extensor carpi radialis longus.
H. Tendon of third extensor of the thumb.
I. Tendon of second extensor of the thumb.
K. Tendon of extensor minimi digiti joining a tendon of extensor communis.
COMMENTARY ON PLATE IX.
The ulnar artery, c, Figure 1, holds a direct and superficial
course, from the ulnar border of the forearm through the "wrist;
and still remains superficial in the palm, where it forms the super¬
ficial palmar arch, r. From this arch arise three or four branches
of considerable size, which are destined to supply the fingers. A
little abo"v^e the interdigital clefts, each of these digital arteries
divides into two branches, which pass along the adjacent sides of
two fingers—a mode of distribution which also characterises the
digital branches of the median, hb^ and ulnar nerves, ee. The su¬
perficial palmar arch of the ulnar vessel anastomoses with the deep
arch of the radial vessel. The principal points of communication
are, first, by the branch, (ramus profundus,) i. Figure 2, which
passes between the muscles of the little finger to join the deep arch
beneath the long flexor tendons. 2nd, by the branch (superficialis
volfe) which springs from the radial artery. A, Figure 1, and
crosses the muscles of the ball of the thumb, to join the terminal
branch of the superficial arch, r. Figure 1. 3rd, by another ter¬
minal branch of the superficial arch, which joins the arteries of the
thumb, derived from the radial vessel, as seen at Figure 2.
The frequent anastomosis thus seen to take place between the
branches of the radial, the ulnar, and the interosseous arteries in
the hand, should be carefully borne in mind by the surgeon. The
continuity of the three vessels by anastomosis, renders it very
difficult to arrest a heemorrhage occasioned by a wound of either of
them. It "wiU be at once seen, that when a haemorrhage takes place
from any of these larger vessels of the hand, the bleeding wiU not be
commanded by the application of a ligature to either the radial,
the ulnar, or the interosseous arteries in the forearm; and for this
plain reason, "vdz., that though in the arm these arteries are sepa¬
rate, in the hand their communication renders them as one.
If a hsemorrhage therefore take place from either of the palmar
vessels, it "will not be sufficient to place a ligature around the
radial or the ulnar artery singly, for if r. Figure 1, bleeds, and
in order to arrest that bleeding we tie the vessel c. Figure 1, stiU
the vessel f "wiU continue to bleed, in consequence of its com¬
munication with the vessel e. Figure 2, by the branch 1, Figure 2,
and other branches above mentioned. If e. Figure 2, bleeds, a
ligature applied to the vessel A, Figure 2, wiU not stop the flow of
blood, because of the fact that e anastomoses with g, by the
branch i and other branches, as seen in Figs. 1 and 3.
Any considerable hasmorrhage, therefore, which may be caused
by a wound of the superficial or deep pahnar arches, or their
branches, and which Ave are unable to arrest by compression, ap¬
plied directly to the patent orifices of the vessel, will in general
require that a ligature be applied to both the radial and ulnar ar¬
teries at the "wrist; and it occasionally happens that even this pro¬
ceeding wiU not stop the flow of blood, for the interosseous arteries,
which also communicate "with the vessels of the hand, may stdl
maintain the current of circulation through them. These inter¬
osseous arteries being branches of the ulnar artery, and being given
otf from the vessel at the bend of the elbow, if the bleeding be still
kept up from the vessel wounded in the hand, after the ligature of
the ulnar and radial arteries is accomplished, are in aU probabi¬
lity the channels of communication, and in this case the brachial
artery must be tied. A consideration of the above-mentioned
facts, proper to the normal distribution of the vessels of the upper
extremity, -will explain to the practitioner the cause of the diffi¬
culty which occasionally presents itself, as to the arrest of
haemorrhage from the vessels of the hand. In addition to these
facts he Avill do well to remember some other arrangements of
these vessels, which are liable to occur; and upon these I sb^l l
offer a few observations.
While I "vdew the normal disposition of the arteries of the arm
as a whole, (and this view of the whole great fact is no doubt
necessary, if we would take within the span and compass of the
reason, all the lesser facts of which the whole is inclusive,) I find
that as one main vessel (the brachial) divides into three lesser
branches, (the ulnar, radial and interosseous,) so, therefore, when
either of these three supplies the haemorrhage, and any difficulty
arises preventing our ha-nng access at once to the open orifices
of the wounded vessel, we can command the flow of blood by
applying a ligature to the main trunk—the brachial. If this mea¬
sure fail to command the bleeding, then we may conclude that
the wounded vessel (whichever it happen to be, whether the
radial, the ulnar, or the interosseous) arises from the brachial
artery, higher up in the arm than that place whereat we applied
the ligature. To this variety as to the place of origin, the ulnar,
radial, and interosseous arteries are indmduaUy liable.
Again, as the single brachial artery divides into the three arte¬
ries of the forearm, and as these latter again unite into what may
(practically speaking) be termed a single vessel in the hand, in
consequence of their anastomosis, so it is obvious that in order to
command a bleeding from any of the pahnar arteries, we should
apply a ligature upon each of the vessels of the forearm, or upon
the single main vessel in the arm. When the former proceeding
fails we have recourse to the latter, and Avhen this latter fails (for
fail it will, sometimes) we then reasonably arrive at the conclu¬
sion that some one of the three vessels of the forearm springs
higher up than the place of the ligature on the main brachial
vessel.
But however varied to the normal locality of their origin, at
the bend of the elbow, these vessels of the forearm may at times
manifest themselves, still one point is quite fixed and certain, "vdz.,
that they communicate with each other in the hand. Hence,
therefore, it becomes e"vddent, that in order to command, at once
and effectually, a bleeding, either from the palmar arteries, or
those of the forearm, we attain to a more sure and successful
result, the nearer we approach the fountain head and place
a ligature on it—^the brachial artery. It is true that to stop
the circulation through the main vessel of the limb is always
attended with danger, and that such a proceeding is never to
be adopted but as the lesser one of Hvo great hazards. It
is also true that to tie the main brachial artery for a hsemorrhage
of any one of its terminal branches, may be doing too much, while
a milder course may serve; or else that even our tying the
brachial may not suffice, owing to a high distribution of the ves¬
sels of the arm, in the axilla, above the place of the ligature.
Thus doubt as to the safest measure, viz., that which is sufficient
and no more, enveils the proper place whereat to apply a ligature
on the principal vessel; but whatever be the doubt as to this par¬
ticular, there can be none attending the follo"wing rule of conduct,
"dz., that in all cases of hjemorrhage, caused by wounds of the
vessels of the upper limb, we should, if at all practicable, endea¬
vour to stop the flow of blood from the divided vessels in the
wound itself^ by ligature or otherwise; and both ends of the
dmded vessel require to be tied. Whenever this may be done,
we need not trouble ourselves concerning the anomaly in vascular
distribution.
The superficial palmar arch, e. Figure 1, lies beneath the dense
palmar fascia; and whenever matter happens to be pent up by this
fascia, and it is necessary that an opening be made for its exit, the
incision should be conducted at a distance from the locality of the
vessel. When matter forms beneath the palmar fascia, it is liable,
owing to the unyielding nature of this fibrous structure, to burrow
upwards into the forearm, beneath the annular ligament D, Figures
1 and 2. All deep incisions made in the median line of the fore¬
part of the "wrist are liable to wound the median nerve b. Figure
1. When the thumb, together with its metacarpal bone, is being
amputated, the radial artery e. Figure 3, which "winds round near
the head of that bon^, may be wounded. It is possible, by care¬
ful dissection, to perform this operation "without dividing the radial
vessel.
COMMENTARY ON PLATE X.
THE RELATIVE POSITION OF THE CRANIAL, NASAL. ORAL, AND PHARYNGEAL CAVITIES. &c.
On making a section (verticaUy through tlie median line) of the
cramo-facial and cervico-hyoid apparatus, the relation which these
structures bear to each other in the osseous skeleton reminds me
strongly of the great fact enunciated by the philosophical ana¬
tomists, that the facial apparatus manifests in reference to the
cranial structures the same general relations which the hyoid
apparatus bears to the cervical vertebra, and that these relations
are similar to those which the thoracic apparatus bears to the
dorsal vertebra. To this anatomical fact I shaU not make any
further allusions, except in so far as the acknowledgment of it
shall serve to illustrate some points of surgical import.
The" cranial chamber, a a h. Figure 1, is continuous with the
spinal canal c. The osseous envelope of the brain, called cal¬
varium, z B, holds serial order with the cervical spinous processes,
E I, and these with the dorsal spinous processes. The dura-matral
lining membrane, A A a*, of the cranial chamber is continuous
with the lining membrane, c, of the spinal canal. The brain is
continuous with the spinal cord. The intervertebral foraiiiina of
the cervical spine are manifesting serial order with the cranial
foramina. The nerves which pass through the spinal region of this
series of foramina above and below c are continuous with the nerves
which pass through the cranial region. The anterior boundary,
D I, of the cervical spine is continuous with the anterior boundary,
Y F, of the cranial cavity. And this common serial order of
osseous parts—viz., the bodies of vertebraB, serves to isolate the
cranio-spinal compartment from the facial and cervical passages.
Thus the anterior boundary, y f d i, of the cranio-spinal canal is
also the posterior boundary of the facial and cervical cavities.
Now, as the cranio-spinal chamber is lined by the common
dura-matral membrane, and contains the common mass of nervous
structure, thus inviting us to fix attention upon this structure as a
whole, so we find that the frontal cavity, z, the nasal cavity, x w,
the oral cavity, 4, 5, s, the pharyngeal and oesophageal passages 8 Q,
are lined by the common mucous membrane, and communicate so
freely with each other that they may be in fact considered as
forming a common cavity divided only by partially formed septa,
such as the one, u v, which separates to some extent the nasal
fossa from the oral fossa.
As owing to this continuity of structure, visible between the
head and spine, we may infer the liability which the affections of
the one region have to pass into and implicate the other, so like¬
wise by that continuity apparent between all compartments of the
DESCRIPTION OF THE FIGURES OF PLATE X.
Figure 1.
A A. The dura-matral falx; a*, its attachment to the tentorium.
B. Torcular Herophili.
C. Dura-mater lining the spinal canal.
D D*. Axis vertebra.
E E^. Atlas vertebra.
F F^. Basilar processes of the sphenoid and occipital bones.
G. Petrous part of the temporal bone.
H. Cerebellar fossa.
11*. Seventh cervical vertebra.
K K^. First rib surrounding the upper part of the pleural sac.
LL*. Subclavian artery of the right side overlying the pleural sac.
M M^. Right subclavian vein.
N. Eight (jommon carotid artery cut at its origin.
O. Trachea.
P. Thyroid body.
Q. (Esophagus.
R. Genio-hyo-glossus muscle.
S. Left tonsil beneath the mucous membrane.
T. Section of the lower maxilla.
U. Section of the upper maxilla.
V. Velum palati in section.
W. Inferior spongy bone.
X. Middle spongy bone.
Y. Crista galli of oethmoid bone.
Z. Frontal sinus.
2. Anterior cartilaginous part of nasal septum.
3. Nasal bone.
4. Last molar tooth of the left side of lower jaw.
5. Anterior pillar of the fauces.
6. Posterior pillar of the fauces.
7. Genio-hyoid muscle.
8. Opening of Eustachian tube.
9. Epiglottis.
10. Hyoid bone.
11. Thyroid bone.
12. Cricoid bone.
13. Thyroid axis.
14. Part of anterior scalenus muscle.
15. Humeral end of the clavicle.
16. Part of posterior scalenus muscle.
Figure 2.
A. Zygoma.
B. Articular glenoid fossa of temporal bone.
C. External pterygoid process lying on the levator and tensor palati
muscles.
D. Superior constrictor of pharynx.
E. Transverse process of the Atlas.
F. Internal carotid artery. Above the point f, is seen the glosso-pharyngeal
nerve; below r, is seen the hypoglossal nerve.
G. Middle constrictor of pharynx.
H. Internal jugular vein.
I. Common carotid cut across.
K. Rectus capitis major muscle.
L. Inferior constrictor of pharynx.
M. Levator anguli scapulae muscle.
N. Posterior scalenus muscle.
O. Anterior scalenus muscle.
P. Brachial plexus of-nerves.
Q. Trachea.
R R. Subclavian artery.
S. End of internal jugular vein.
T. Bracheo-cephalic artery.
U U^. Roots of common carotid arteries.
V. Thyroid body.
W. Thyroid cartilage.
X. Hyoid bone.
Y. Hyo-glossus muscle.
Z. Upper maxillary bone.
2. Inferior maxillary branch of fifth cerebral nerve.
3. Digastric muscle cut.
4. Styloid process
5. External carotid artery.
6 6. Lingual artery.
7. Roots of cervical plexus of nerves.
8. Thyroid axis; 8*, thyroid artery, between which and q, the trachea, is
seen the inferior laryngeal nerve.
9. Omo-hyoid muscle cut.
10. Sternal end of clavicle.
11. Upper rings of trachea, which may with most safety be divided in
tracheotomy.
12. Cricoid cartilage.
13. Crico thyroid interval where laryngotomy is performed.
14. Genio-hyoid muscle.
15. Section of lower maxilla.
16. Parotid duct.
17. Lingual attachment of styloglossus muscle, with part of the gustatory
nerve seen above it.
COMMENTARY ON PLATE X.
face, fauces, oesophagus, and larynx, we may estimate how the
pathological condition of the one region will concern the others.
The cranium, owing to its comparatively superficial and unde¬
fended condition, is liable to fracture. When the cranium is
fractured, in consequence of force applied to its anterior or
posterior surfaces, a or b. Figure 1, the fracture will, for
the most part, be confined to the place whereat the force has
been applied, provided the point opposite has not been driven
against some resisting body at the same time. Thus when the
point B is struck by a force sufficient to fracture the bone,
Avhile the point A is not opposed to any resisting body, then b
alone will yield to the force applied; and fracture thus occurring
at the point B, will have happened at the place where the applied
force is met by the force, or weight, or inertia of the head itself.
But when b is struck by any ponderous body, Avhile A is at the
same moment forced against a resisting body, then A is also liable
to suffer fracture. If fracture in one place be attended with
counter-fracture in another place, as at the opposite points A and b,
then the fracture occurs from the force impelling, while the
counter-fracture happens by the force resisting.
Now, in the various motions which the cranium A A B performs
upon the top of the cervical spine C, motions backwards, forwards,
and to either side, it wiU foUow that, taking c as a fixed point,
almost all parts of the cranial periphery will be brought vertical
to c in succession, and therefore whichever point happens at the
moment to stand opposite to c, and has impelling force applied
to it, then c becomes the point of resistance, and thus counter¬
fractures at the cranial base occur in the neighbourhood of c.
When force is applied to the cranial vertex, whilst the body is in
the erect posture, the top of the cervical spine, E D c, becomes
the point of resistance. Or if the body fall from a height
upon its cranial vertex, then the propelling force Avill take effect
at the junction of the spine with the cranial base, whilst the
resisting force wiU be the ground upon which the vertex strikes.
In either case the cranial base, as well as the vertex, will be liable
to fracture.
The anatomical form of the cranium is such as to obviate a
frequent liability to fracture. Its rounded shape diffuses, as is
the case with all rotund forms, the force which happens to strike
upon it. The mode in which the cranium is set upon the cervical
spine serves also to diffuse the pressure at the points Avhere the
two opposing forces meet—viz., at the first cervical vertebra e
and the cranial basilar process f. This fact might be proved
upon mechanical principle.
The tegumentary envelope of the head, as well as the dura-
matral lining, serves to damp cranial vibration consequent upon
concussion; while the sutural isolation of the several component
bones of the cranium also prevents, in some degree, the extension
of fractures and the vibrations of concussion. The contents of the
head, like the contents of aU hollow forms, receive the vibratory
influence of force externally applied. The brain receives the con¬
cussion of the force applied to its osseous envelope; and when this
latter happens to be fractured, the danger to life is not in propor¬
tion to the extent of the fracture here, any more than elsewhere
in the skeleton fabric, but is solely in proportion to the amomit
of shock or injury sustained by the nervous centre.
When it is required to trephine any part of the cranial envelope,
the points which should be avoided, as being in the neighbourhood
of important bloodvessels, are the following—the occipital pro¬
tuberance, B, Avithin which the “ torcular Herophili” is situated,
and from this point passing through the median line of the vertex
forwards to z the frontal sinus, the trephine should not be applied,
as this line marks the locality of the superior longitudinal sinus.
The great lateral sinus is marked by the superior occipital ridge
passing from the point b outwards to the mastoid process. The
central point b of the side of the head. Figure 2, marks the locality
of the root of the meningeal artery within the cranium, and from
this point the vessel branches forwards and backwards over the
interior of the cranium.
The nasal fossae are situated on either side of the median parti¬
tion formed by the vomer and cartilaginous nasal septum. Both
nasal fossae are open anteriorly and posteriorly; but laterally they
do not, in the normal state of these parts, communicate. The two
posterior nares answering to the two nasal fossae open into the
upper part of the bag of the pharynx at 8, Figure 1, which marks
the opening of the Eustachian tube.
The structures observable in both the nasal fossae absolutely
correspond, and the foramina which open into each correspond
likeAvise. AH structures situated on either side of the median
line are similar. And the structure Avhich occupies the median
line is itself double, or duality fused into symmetrical unity. The
osseous nasal septum is composed of tAVO laminae laid side by side.
The spongy bones, x w, are attached to the outer waU of the nasal
fossa, and are situated one above the other. These bones are
three in number, the uppermost is the smaUest. The outer waU
of each naris is grooved by three fossae, caUed meatuses, and these
are situated betAveen the spongy bones. Each meatus receives one
or more openings of various canals and cavities of the facial
apparatus. The sphenoidal sinus near f opens into the upper
meatus. The frontal, z, and maxiUary sinuses open into the
middle meatus, and the nasal duct opens into the inferior sinus
beneath the anterior inferior angle of the lower spongy bone, w.
In the living body the very vascular fleshy and glandular
Schneiderian membrane Avhich lines all parts of the nasal fossa
almost completely fiUs this cavity. When pol}q)i or other groAvths
occupy the nasal fossaj, they must gain room at the expense of
neighbouring parts. The nasal duct may have a bent probe intro¬
duced into it by passing the instrument along the outer side of the
floor of the nasal fossa as far back as the anterior inferior angle of
the loAver spongy bone, w, at Avhich locality the duct opens. An
instrument of sufficient length, Avhen introduced into the nostrils
in the same direction, avHI, if passed backAvards through the
posterior nares, reach the opening of the Eustachian tube, 8.
While the jaAvs are closed, the tongue, R, Figure 1, occupies the
oral caAoty almost completely. When the jaAvs are opened they
form a caAoty between them equal in capacity to the degree at
which they are sundered from each other. The back of the
pharynx can be seen Avhen the jaAvs are AAodely opened if the
tongue be depressed, as r. Figure 1. The hard palate, u, Avhich
forms the roof of the mouth, is extended further backwards by the
soft palate, v, which hangs as the loose velum of the throat
betAveen the nasal fossa) above and the fauces beloAV. BetAveen the
velum palati, v, and the root of the tongue, we may readily discern,
when the jaAvs are open, tAvo ridges of arching form, 5, 6, on either
side of the fauces. These prominent arches and their feUows are
named the piUars of the fauces. The anterior piUar, 5, is formed
by the submucous palato-glossus muscle; the posterior piUar, 6, is
formed by the palato-pharyngeus muscle. Between these pill a rs,
5 and 6, is situated the tonsil, s, beneath the mucous membrane.
WTien the tonsils of opposite sides become inflamed and suppurate,
an incision may be made into either gland Avithout much chance
of wounding the internal carotid artery; for, in fact, this vessel
Hes somewhat removed from it behind. In Figure 2 that point of
the superior constrictor of the phaiynx, marked d, indicates the
situation of the tonsil gland; and a considerable interval avIU be
seen to exist betAveen n and the internal carotid vessel E.
If the head be throAvn backwards the nasal and oral cavities
AviU look almost verticaUy towards the pharyngeal pouch. When
the juggler is about to “ SAvaUoAv the SAVord,” he throAvs the head
back so as to bring the mouth and fauces in a straight line AA/ith
the pharynx and oesophagus. And when the surgeon passes the
probang or other instruments into the oesophagus, he finds it
necessary to give the head of the person on Avhom he operates the
same inclination backwards. When instruments are being passed
into the oesophagus through the nasal fossa, they are not so likely
to encounter the rima glottidis beloAV the epiglottis, 9, as Avhen
they are being passed into the oesophagus by the mouth. The
glottis may be always avoided by keeping the point of the instru¬
ment pressing against the back of the pharynx during its passage
doAATiwards.
When in suspended animation we endeavour to inflate the lungs
through the nose or mouth, we should press the larynx, 10,11,12,
baclcAvards against the vertebral column, so as to close the
oesophageal tube.
COMMENTARY ON PLATE XL
THE RELATIVE POSITION OF THE SUPERFICIAL, ORGANS OF THE THORAX AND ABDOMEN.
In the osseous skeleton, the thorax and abdomen constitute a
common compartment. We cannot, while we contemplate this
skeleton, isolate the one region from the other by fact or fancy.
The only difference which I can discover between the regions
called thorax and abdomen, in the osseous skeleton, (consider¬
ing this body morphologically,) results, simply, from the cir¬
cumstance that the ribs, which enclose thoracic space, have no
osseous counterparts in the abdomen enclosing abdominal space,
and this difference is merely histological. In man and the mam¬
malia the costal arches hold relation with the pulmonary organs,
and these costae fail at that region where the ventral organs are
located. In birds, and many reptiles, the costal arches enclose
the common thoracico-abdominal region, as if it were a common
pulmonary region. In fishes the costal arches enclose the tho¬
racico-abdominal region, just as if it were a common abdominal
region. I merely mention these general facts, to show that costal
enclosure does not actually serve to isolate the thorax from the
abdomen in the lower classes of animals; and on turning to the
human form, I find that this line of separation between the two
compartments is so very indefinite, that, as pathologists, we are
very liable to err in our diagnosis between the diseased and the
healthy organs of either region, as they lie in relation with the
moveable diaphragm or septum in the living body. The contents
of the whole trunk, of the body from the top of the sternum to the
perineum are influenced by the respiratory motions; and it is
most true that the diaphragmatic line, H F H*, is alternately occu¬
pied by those organs situated immediately above and below it
during the performance of these motions, even in health.
The organs of the thoracic region hold a certain relation to each
other and to the thoracic walls. The organs of the abdomen hold
likewise a certain relation to each other and to the abdominal
parietes. The organs of both the thorax and the abdomen have a
certain relation to each other, as they lie above and below the
diaphragm. In dead nature these relations are fixed and readily
ascertainable, but in living, moving nature, the organs influence this
relative position, not only of each other, but also of that which they
bear to the cavities in which they are contained. This change of
place among the organs occurs in the normal or healthy state of
the living body, and, doubtless, raises some difficulty in the way
of our ascertaining, with mathematical precision, the actual state
of the parts which we question, by the physical signs of percussion
and auscultation. In disease this change of place among these
organs is increased, and the difficulty of making a correct diagnosis
is increased also in the same ratio. For when an emphysematous
lung shall fully occupy the right thoracic side from b to l, then g,
the liver, will protrude considerably into the abdomen beneath the
right asternal ribs, and yet will not be therefore proof positive
that the liver is diseased and abnormally enlarged. Whereas, on
the other hand, when G, the liver, is actually diseased, it may
occupy a situation in the right side as high as the fifth or sixth
ribs, pushing the right lung upwards as high as that level; and.
therefore, while percussion elicits a dull sound over this place thus
occupied, such sound will not be owing to a hepatized lung but to
the absence of the lung caused by the presence of the liver.
In the healthy adult male body, Plate XI., the two lungs, D D,
whilst in their ordinary expanded state, may be said to range over
aU that region of the trunk of the body which is marked by the
sternal and asternal ribs. The heart, e, occupies the thoracic
centre, and part of the left thoracic side. The heart is almost
completely enveloped in the two Irmgs. The only portion of the
heart and pericardium, which appears uncovered by the lung on
opening the thorax, is the base of the right ventricle, e, situated
immediately behind the lower end of the sternum, where this bone
is joined by the cartilages of the sixth and seventh ribs. The
lungs range perpendicularly from points an inch above b, the first
rib, downwards to l, the tenth rib, and obliquely downwards and
backwards to the vertebral ends of the last ribs. This space varies
in capacity, according to the degree in which the lungs are ex¬
panded within it. The increase in thoracic space is attained,
laterally, by the expansion of the ribs, c l; and vertically, by
the descent of the diaphragm, h, which forces downwards the
mass of abdominal viscera. The contraction of thoracic space is
caused by the approximation of aU the ribs on each side to each
other; and by the a cent of the diaphragm. The expansion of the
lungs around the heart would compress this organ, were it not
that the costal sides peld laterally while the diaphragm itself
descends. The heart follows the ascent and descent of the
diaphragm, both in ordinary and forced respiration.
But however much the lungs vary in capacity, or the heart as
to position in the respiratory motions, still the lungs are always
closely applied to the thoracic walls. Between the pleura costalis
and pulmonalis there occurs no interval in health. The thoracic
parietes expand and contract to a certain degree ; and to that same
degree, and no further, do the lungs within the thorax expand and
contract. By no effort of expiration can the animal expel aU. the
air completely from its lungs, since, by no effort of its own, can it
contract thoracic space beyond the natural limit. On the other
hand, the utmost degree of expansion of which the lungs are
capable, exactly equals that degree in which the thoracic waUs
are dilatable by the muscular effort; and, therefore, between the
extremes of inspiration and expiration, the lungs stUl hold closely
applied to the costal parietes. The air within the lungs is separated
from the air external to the thorax, by the thoracic parietes. The
air within and external to the lungs communicate at the open glottis.
When the glottis closes and cuts off the communication, the res¬
piratory act ceases—^the lungs become immovable, and the tho¬
racic waUs are (so far as the motions of respiration are concerned)
rendered immovable also. The muscles of respiration cannot,
ther fore, produce a vacuum between the pulmonic and costal
pleura, either while the external air has or has not access to the
lungs. Upon this fact the mechanism of respiration mainly
depends; and we may see a stiU further proof of this in the
DESCRIPTION OF THE FIGURES OF PLATE XL
A. Upper bone of the sternum.
B B*. Two first ribs.
C C*. Second pair of ribs.
D D*. Right and left lungs.
E. Pericardium, enveloping the heart—the right ventricle.
F. Lower end of the sternum.
G G*. Lobes of the liver.
H H*. Right and left halves of the diaphragm in section. The right half
separating the right lung from the liver; the left half separating the
left lung from the broad cardiac end of the stomach.
11*. Eighth pair of ribs.
K K*. Ninth pair of ribs.
L L*. , Tenth pair of ribs.
M M* The stomach ; M, its cardiac bulge; M*, its pyloric extremity.
N. The umbilicus.
0 0*. The transverse colon.
P P*. The omentum, covering the transverse colon and small intestines.
Q. The gall bladder.
R R*. The right and left pectoral prominences.
S S*. Small intestines.
COMMENTARY ON PLATE XL
circumstance that, when the thoracic, parietes are pierced, so as to
let the external air into the cavity of the pleura, the lung collapses
and the thoracic side ceases to exert an expansile influence over
the lung. When in cases of fracture of the rib the lung is wounded,
and the air of the lung enters the pleura, the same efiect is produced
as when the external air was admitted through an opening in the
side.
When serous or purulent eflusion takes place within the cavity
of the pleura, the capacity of the lung becomes lessened according
to the quantity of the efiiision. It is more reasonable to expect
that the soft tissue of the lung should yield to the quantity of fluid
within the pleural cavity, than that the rigid costal walls should
give way outwardly; and, therefore, it seldom happens that the
practitioner can discover by the eye any strongly-marked differ¬
ence between the thoracic walls externally, even when a consider¬
able quantity of either serum, pus, or air, occupies the pleural sacs.
In the healthy state of the thoracic organs, a sound charac¬
teristic of the presence of the lung adjacent to the walls of the
thorax may be ehcited by percussion, or heard during the respira¬
tory act through the stethoscope, over all that costal space ranging
anteriorly between b, the first rib, and i k, the eighth and ninth
ribs. The respiratory murmur can be heard below the level of
these ribs posteriorly, for the lung descends behind the arching
diaphragm as far as the eleventh rib.
When fluid is efiused into the pleural cavity, the ribs are not
moved by the intercostal muscles opposite the place occupied
by the fluid, for this has separated the lung from the ribs. The
fluid has compressed the lung; and in the same ratio as the lung
is prevented from expanding, the ribs become less moveable.^-. The
presence of fluid in the pleural sac is discoverable by dulness on
percussion, and, as might be expected, by the absence of the re¬
spiratory murmur at that locality which the fluid occupies. Fluid,*
when efiused into the pleural sac, will of course gravitate; and its
position win vary according to the position of the patient. The
sitting or standing posture will therefore suit best for the exami¬
nation of the thorax in reference to the presence of fluid.
Though the lungs are closely applied to the costal sides at aU
times in the healthy state of these organs, still they slide freely
within the thorax during the respiratory motions—forwards and
backwards—over the serous pericardium, e, and upwards and do^vn-
wards along the pleura costalis. The length of the adhesions
which supervene upon pleuritis gives evidence of the extent of
these motions. When the lung becomes in part solidified and
impervious to the inspired air, the motions of the thoracic parietes
opposite to the part are impeded. Between a solidified lung and
one which happens to be compressed by efiused fluid it requires
no small experience to distinguish a difference either by percussion
or the use of the stethoscope. It is great experience alone that
can diagnose hydropericardium from hypertrophy of the substance
of the heart by either of these means.
The thoracic viscera gravitate according to the position of the
body. The heart in its pericardial envelope sways to either side
of the sternal median hne according as the body lies on this or
that side. The two lungs must, therefore, be alternately affected
as to their capacity according as the heart occupies space on either
side of the thorax. In expiration, the heart, e, is more uncovered
by the shelving edges of the lungs than in inspiration. In pneumo¬
thorax of either of the pleural sacs the air compresses the lung,
pushes the heart from its normal position, and the space which
the air occupies in the pleura yields a clear hoUow sound on percus-
sion, whilst, by the ear or stethoscope apphed to a corresponding
part of the thoracic walls, we discover the absence of the respiratory
murmur.
The transverse diameter of the thoracic cavity varies at diffe¬
rent levels from above downwards. The diameter which the two
first ribs, b b*, measure is the least. That which is measured by
the two eighth ribs, 11 *, is the greatest. The perpendicular depth
of the thorax, measured anteriorly, ranges from a, the top of the
sternum, to e, the xyphoid cartilage. Posteriorly,"the perpendicular
range'of the thoracic cavity measures from the spinous process of
the seventh cervical vertebra above, to the last dorsal spinous
process below. In full, deep-drawn inspiration in the healthy
adult, the ear applied to the thoracic walls discovers the re¬
spiratory murmur over aU the space included within the above-
mentioned bounds. After extreme expiration, if the thoracic walls
be percussed, this capacity will be found much diminished; and the
extreme limits of the thoracic space, which during full inspiration
yieldecK clear sound, indicative of the presence of the lung, will now,
on percussion, manifest a dull sound, in consequence of the absence
of the lung, which has receded from the place previously occupied.
Omng to the conical form of the thoracic space, the apex of
which is measured by the first ribs, b b*, and the basis by 11*, it
will be seen that if percussion be made directly from before, back¬
wards, over the pectoral masses, r r*, the pulmonic resonance will
not be elicited. When we raise the arms from the side and percuss
the thorax between the folds of the axillte, where the serratus
magnus muscle alone intervenes between the ribs and the skin, the
pulmonic sound will answer clearly.
At the hypochondriac angles formed between the points f, l, n,
on either side the lungs are absent both in inspiration and expira¬
tion. Percussion, when made over the surface of the angle of
the right side, discovers the presence of the liver, gg*. When
made over the median hne, and on either side of it above the
umbilicus, N, we ascertain the presence of the stomach, m m*. In
the left hypochondriac angle, the stomach may also be found to
occupy this place whohy.
Beneath the umbihcus, n, and on either side of it as far out¬
wards as the lower asternal ribs, k l, thus ranging the abdominal
parietes transversely, percussion discovers the transverse colon,
0, p, 0 . The small intestines, s s*, covered by the omentum, p*,
occupy the hypogastric and iliac regions.
The organs situated within the thorax give evidence that they
are developed in accordance to the law of symmetry. The lungs
form a pair, one placed on either side of the median line. The
heart is a double organ, formed of the right and left heart. The
right lung differs from the left, inasmuch as we find the former
divided into three lobes, while the latter has only two. That place
which the heart now occupies in the left thoracic side is the place
Avhere the third or middle lobe of the left lung is wanting. In
the abdomen we find that.most of its organs are single. The liver,
stomach, spleen, colon, and small intestine form a series of single
organs: each of these may be cleft symmetrically. The kidneys
are a pair.
The extent to which the ribs are bared in the figure Plate XL
marks exactly the form and transverse capacity of the thoracic
walls. The diaphragm, h h*, has had a portion of its forepart cut
off, to show how it separates the thin edges of both lungs above
from the hver, g, and the stomach, m, below. These latter organs,
although occupying abdominal space, rise to a considerable height
behind kl, the asternal ribs, a fact which should be borne in
mind when percussing the walls of the thorax and abdomen at
this region.
COMMENTAEY ON PLATE XII.
THE RELATIVE POSITION OF THE DEEPER ORGANS OF THE THORAX AND THOSE OF
THE ABDOMEN.
The size or capacity of the thorax in relation to that of the
abdomen varies in the individual at different periods of life. At
an early age, the thorax, compared to the abdomen, is less in pro¬
portion than it is at adult age. The digestive organs in early
age preponderate considerably over the respiratory organs;
whereas, on the contrary, in the healthy and well-formed adult,
the thoracic cavity and organs of respiration manifest a greater
relative proportion to the ventral cavity and organs. At the adult
age, when sexual peculiarities have become fully marked, the
thoracic organs of the male body predominate over those of the
abdomen, whilst in the female form the ventral organs take pre¬
cedence as to development and proportions. This diversity in the
relative capacity of the thorax and abdomen at different stages of
development, and also in persons of different sexes, stamps each
individual with characteristic traits of physical conformation; and
it is required that we should take into our consideration this normal
diversity of character, while conducting our examinations of indi¬
viduals in reference to the existence of disease.
The heart varies in some measure, not only as to size and
weight, but also as to position, even in healthy individuals of the
same age and sex. The level at which the heart is in general
found to be situated in the thorax is that represented in Plate XII.,
where the apex points to the sixth intercostal space on the left
side above k, while the arch of the aorta rises to a level with c,
the second costal cartilage. In some instances, the heart may be
found to occupy a much lower position in the thorax than the one
above mentioned, or even a much higher level. The impulse of
the right ventricle, F, has been noticed occasionally as correspond¬
ing to a point somewhat above the middle of the sternum and the
intercostal space between the fourth and fifth left costal cartilages;
while in other instances its beating was observable as low down as
an inch or more below the xiphoid cartilage, and these variations
have existed in a state of health.
Percussion over the region of the heart yields a dull flat sound.
The sound is dullest opposite the right ventricle, f ; whilst above
and to either side of this point, where the heart is overlapped by
the anterior shelving edges of both lungs, the sound is modified
in consequence of the lung’s resonant qualities. The heart-
sounds, as heard through the stethoscope, in valvular disease, will,
of course, be more distinctly ascertained at the locality of f, the
right ventricle, which is immediately substernal. While the body
lies supine, the heart recedes from the forepart of the chest; and
the lungs during inspiration expanding around the heart will render
its sounds less distinct. In the erect posture, the heart inclines
forwards and approaches the anterior wall of the thorax. When
the heart is hypertrophied, the lungs do not overlap it to the same
extent as when it is of its ordinary size. In the latter state,
the elastic cushion of the lung mufiles the heart’s impulse. In the
former state, the lung is pushed aside by the overgrown heart,
the strong muscular walls of which strike forcibly against the ribs
and sternum.
The thorax is separated from the abdomen by the moveable
diaphragm. The heart, F E, lies upon the diaphragm, L L*. The
liver, M, lies immediately beneath the right side of this muscular
septum, L*, while the bulging cardiac end of the stomach, 0, is in
close contact with it on the left side, l*. As these three organs are
attached to the diaphragm — the heart by its pericardium, the
stomach by the tube of the oesophagus, and the liver by its sus¬
pensory ligaments — it must happen that the diaphragm while
descending and ascending in the motions of inspiration and ex¬
piration wifi, communicate the same alternate motions to the
organs which are connected with it.
In ordinary respiration the capacity of the thorax is chiefly
affected by the motions of the diaphragm; and the relative position
which this septum holds with regard to the thoracic and abdominal
chambers will cause its motions of ascent and descent to influence
the capacity of both chambers at the same time. When the lungs
expand, they follow the descent of the diaphragm, which forces
the abdominal contents downwards, and thus what the thorax
gains in space the abdomen loses. When the lungs contract, the
diaphragm ascends, and by this act the abdomen gains that space
which the thorax loses. But the organs of the thoracic cavity
perform a different office in the economy from those of the
abdomen. The air which fiUs the lungs is soon again expired,
whilst the ingesta of the abdominal viscera are for a longer period
retained; and as the space, which by every inspiration the thorax
gains from the abdomen, would cause inconvenient pressure on the
distended organs of this latter cavity, so we find that to obviate this
inconvenience, nature has constructed the anterior parietes of the
abdomen of yielding material. The muscular parietes of the abdo¬
men relax during every inspiration, and thus this caffity gains
that space which it loses by the encroachment of the dilating
lungs.
The mechanical principle upon which the abdominal chamber is
constructed, enables it to adjust its capacity to such exigence or
pressing necessity as its own visceral organs impose on it, from
time to time; and the relation which the abdominal cavity bears
to the thoracic chamber, enables it also to be compensatory to
this latter. When the inspiratory thorax gains space from the
abdomen, or when space is demanded for the increasing bulk of
the alimentary canal, or for the enlarging pregnant uterus; or
when, in consequence of disease, such as dropsical accumulation,
more room is wanted, then the abdominal chamber supplies the
demand by the anterior bulge or swell of its expansile muscular
parietes.
The position of the heart itself is affected by the expansion of
description of the figures of plate xii.
A. Upper end of the sternum.
B B.* First pair of ribs.
CC.* Second pair of ribs.
D. Aorta, with left vagus and phrenic
nerves crossing
its transverse arch.
E. Root of pulmonary artery.
F. Right ventricle.
G. Right auricle.
H. Vena cava superior, with right phrenic
11*. Right and left lungs collapsed, and
heart’s outline.
nerve on its outer border,
turned outwards, to show the
KK*. Seventh pair of ribs.
L L. The diaphragm in section.
M. The liver in section.
N. The gall bladder with its duct joining the hepatic duct to form the
common bile duct. The hepatic artery is seen supeificial to the
common duct; the vena portae is seen beneath it. The patent
orifices of the hepatic veins are seen on the cut surface of the liver.
O. The stomach.
P. The cceliac axis dividing into the coronary, splenic and hepatic arteries.
Q. Inferior vena cava.
R. The spleen.
g g* g**. The transverse colon, between which and the lower border of
the stomach is seen the gastro-epiploic artery, formed by the splenic
and hepatic arteries.
Ascending colon in the right iliac region.
T. Convolutions of the small intestines distended with air.
COMMENTARY ON PLATE XII.
the lungs on either side of it. As the expanding lungs force the
diaphragm downwards the heart follows it, and aU the abdominal
viscera yield place to the descending thoracic contents. In strong
muscular efforts the diaphragm plays an important part, for, pre¬
viously to making forced efforts, the lungs are distended with air,
so as to swell and render fixed the thoracic walls into which so
many powerful muscles of the shoulders, the neck, back, and
abdomen, are inserted ; at the same time the muscular diaphragm
L L*, becomes tense and unbent from its arched form, thereby con¬
tracting abdominal space, which now has no compensation for this
loss of space, since the abdominal parietes are also rendered firm
and unyielding. It is at this crisis of muscular effort that the
abdominal viscera become impacted together; and, acting by their
own elasticity against the muscular force, make an exit for
themselves through the weakest parts of the abdominal walls,
and thus hernige of various kinds are produced. The most com¬
mon situations of abdominal hemise are at the inguinal regions,
towards which the intestines, T T, naturally gravitate; and at
these situations the abdominal parietes are weak and mem¬
branous.
The contents of a hernial protrusion through the abdominal
parietes, correspond in general with those divisions of the intestinal
tube, which naturally lie adjacent to the part where the rupture
has taken place. In the umbilical hernia it is either the transverse
colon s*, or some part of the small intestine occupying the
median line, or both together, with some folds of the omentum,
which will be found to form the contents of this swelling. When
the diaphragm itself sustains a rupture in its left half, the upper
portion of the descending colon, s, protrudes through the opening.
A diaphragmatic hernia has not, so far as I am aware, been seen to
occur in the right side; and this exemption from rupture of the
right half of the diaphragm may be accounted for anatomically,
by the fact that the liver, M, defends the diaphragm at this situa¬
tion. The liver occupies the whole depth of the right hypochon-
drium; and intervenes between the diaphragm L*, and the right
extremity of the transverse colon, s**.
The contents of a right inguinal hernia consist of the small
intestine, t. The contents of the right crural hernia are
formed by either the small intestine, t, or the intestinum ctecum,
s***. I have seen a few cases in which the caecum formed the right
crural hernia. Examples are recorded in which the intestine
caecum formed the contents of a right inguinal hernia. The
left inguinal and crural herniae contain most generally the small
intestine, t, of the left side.
The right lung, i*, is shorter than the left; for the liver, m, raises
the diaphragm, l, to a higher level within the thorax, on the right
side, than it does on the left. When the liver happens to be
diseased and enlarged, it encroaches still more on thoracic space;
but, doubtless, judging from the anatomical connexions of the
liver, we may conclude that when it becomes increased in volume
it wiU accommodate itself as much at the expense of abdominal
space. The liver, in its healthy state and normal proportions,
protrudes for an inch (more or less) below the margins of the
right asternal ribs. The upper or convex surface of the liver
rises beneath the diaphragm to a level corresponding with the
seventh or sixth rib, but this position wdll vary according to the
descent and ascent of the diaphragm in the respiratory movements.
The ligaments by which the liver is suspended do not prevent its
full obedience to these motions.
The left lung, i, descends to a lower level than the right; and the
left diaphragm upon which it rests is itself supported by the car¬
diac end of the stomach. When the stomach is distended, it does
not even then materially obstruct the expansion of the left lung,
or the descent of the left diaphragm, for the abdominal walls relax
and allow of the increasing volume of the stomach to accommodate
itself. The spleen, e, is occasionally subject to an extraordinary
increase of bulk; and this organ, like the enlarged liver and the
distended stomach, will, to some extent, obstruct the movements
of the diaphragm in the act of respiration, but owing to its free
attachments it admits of a change of place. The abdominal
viscera, one and aU, admit of a change of place; the peculiar forms
of those mesenteric bonds by which they are suspended, allow them
to glide freely over each other; and this circumstance, together
with the yielding nature of the abdominal parietes, allows the tho¬
racic organs to have full and easy play in the respiratory move¬
ments performed by agency of the diaphragm.
The muscles of respiration perform with ease so long as the air
has access to the lungs through the normal passage, viz., the
trachea. While the principle of the thoracic pneumatic appa¬
ratus remains underanged, the motor powers perform their func¬
tions capably. The physical or pneumatic power acts in obedience
to the vital or muscular power, while both stand in equilibrium;
but the ascendancy of the one over the other deranges the whole
thoracic machine. When the glottis closes by muscular spasm
and excludes the external air, the respiratory muscles cease to
exert a motor power upon the pulmonary cavity; their united
efibrts cannot cause a vacuum in thoracic space in opposition to
the pressure of the external air. When, in addition to the natural
opening of the glottis, a false opening is made in the side at the
point K, the air within the lung at i, and external to it in the
now open pleural cavity, wiU stand in equilibrio; the lung will
collapse as having no muscular power by which to dilate itself,
and the thoracic dilator muscles will cease to affect the capacity of
the lung, so long as by their action in expanding the thoracic
walls, the air gains access through the side to the pleural sac
external to the lung.
Whether the air be admitted into the pleural sac, by an opening
made in the side from without, or by an opening in the lung itself,
the mechanical principle of the respiratory apparatus will be
equally deranged. Pneumo-thorax will be the result of either
lesion; and by the accumulation of air in the pleura the lung will
suffer pressure. This pressure will be permanent so long as the
air has no egress from the cavity of the pleura.
The permanent distention of the thoracic cavity, caused by the
accumulation of air in the pleural sac, or by the diffusion of air
through the interlobular cellular tissue consequent on a wound of
the lung itself, wiU equaUy obstruct the breathing; and though the
situation of the accumulated air is in fact anatomicaUy different in
both cases, yet the effect produced is simUar. Interlobular pressure
and interpleural pressure result in the same thing, viz., the perma¬
nent retention of the air external to the pulmonary ceUs, which, in
the former case, are coUapsed individuaUy; and, in the latter case,
in the mass. Though the emphysematous lung is distended to a
size equal to the healthy lung in deep inspiration, yet we know
that emphysematous distention, being produced by extrabronchial
air accumulation, is, in fact, obstructive to the respiratory act.
The emphysematous lung wiU, in the same manner as the dis¬
tended pleural sac, depress the diaphragm and render the tho¬
racic muscles inoperative. The foregoing observations have been
made in reference to the effect of wounds of the thorax, the proper
treatment of which wiU be obviously suggested by our knowledge
of the state of the contained organs which have suffered lesion.
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COMMENTARY ON PLATE XIII.
THE RELATIONS OF THE PRINCIPAL BLOODVESSELS TO THE VISCERA OF THE
THORACICO-ABDOMINAL CAVITY.
The median line of the body is occupied by the centres of the four
great systems of organs which serve in the processes of circulation,
respiration, innervation, and nutrition. These organs being
fashioned in accordance with the law of symmetry, we find them
arranged in close connexion with the vertebrate centre of the
osseous fabric, which is itself symmetrical. In this symmetrical
arrangement of the main organs of the trunk of the body, a
mechanical principle is prominently apparent; for as the centre
is the least moveable and most protected region of the form, so
have these vitally important structures the full benefit of this
situation. The aortal trunk, G, of the arterial system is disposed
along the median line, as well for its own safety as for the
fitting distribution of those branches which spring symmetrically
from either side of it to supply the lateral regions of the body.
The visceral system of bloodvessels is moulded upon the organs
which they supply. As the thoracic viscera differ in form and
functional character from those of the abdomen, so we find that
the arterial branches which are supplied by the aorta to each set,
differ likewise in some degree. In the accompanying figure, which
represents the thoracic and abdominal visceral branches of the
aorta taken in their entirety, this difference in their arrangement
may be readily recognised. In the thorax, compared with the
abdomen, we find that not only do the aortic branches differ in
form according to the variety of those organs contained in either
region, but that they differ numerically according to the number
of organs situated in each. The main vessel itself, however, is
common to both regions. It is the one thoracico-abdominal vessel,
and this circumstance calls for the comparison, not only of the
several parts of the great vessel itself, but of all the branches which
spring from it, and of the various organs which lie in its vicinity
in the thorax and abdomen, and hence we are invited to the study
of these regions themselves connectedly.
In the thorax, the aorta, G G*, is whoUy concealed by the lungs
in their states both of inspiration and expiration. The first part
of the aortic arch, as it springs from the left ventricle of the heart,
is the most superficial, being almost immediately sub-sternal, and
on a level with the sternal junctions of the fourth ribs. By
applying the ear at this locality, the play of the aortic valves
may be distinctly heard. From this point the aorta, G, rises and
arches from before, backwards, to the left side of the spine, g*.
The arch of the vessel lies more deeply between the two lungs
than does its ventricular origin. The descending thoracic aorta
lies stni more deeply situated at the left side of the dorsal spine.
At this latter situation it is in immediate contact with the posterior
thick part of the left lung ; whilst on its right are placed, L, the
thoracic duct; i, the oesophagus; k, the vena azygos, and the verte¬
bral column. In Plate XV. may be seen the relation which the
superior vena cava, H, bears to the aortic arch, A.
In the span of the aortic arch will be found, H*, the left
bronchus, together with the right branch of the pulmonary artery,
and the right pulmonary veins. The pneumo-gastric and phrenic
nerves descend on either side of the arch. The left pneumo-gastric
nerve winds round beneath the arch at the point where the oblite¬
rated ductus arteriosus joins it. See Plates I. & XV.
The pulmonary artery, b, Plate I., lies close upon the fore part,
and conceals the origin, of the systemic aorta. Whenever, therefore,
the semilunar valves of either the pulmonary artery or the systemic
aorta become diseased, it must be extremely difficult to distinguish
by the sounds alone, during life, in which of the two the derange¬
ment exists. The origins of both vessels being at the fore part of the
chest, it is in this situation, of course, that the state of their valves
is to be examined. The descending part of the thoracic aorta, G*,
being at the posterior part of the chest, and lying on the vertebral
ends of the left thoracic ribs, will therefore require that we should
examine its condition in the living body at the dorsal aspect gf
the thorax. As the arch of the aorta is directed from before back¬
wards—that is, from the sternum to the spine, it follows that when
an aneurism implicates this region of the vessel, the exact situation
of the tumour mus|i be determined by antero-posterior examination;
and we should recollect, that though on the fore part of the chest
the cartilages of the second ribs, where these join the sternum,
mark the level of the aortic arch, on the back of the chest its level
is to be taken from the vertebral ends of the third or fourth ribs.
This difference is caused by the oblique descent of the ribs from
the spine to the sternum. The first and second dorsal vertebras,
with which the first and second ribs articulate, are considerably
above the level of the first and second pieces of the sternum.
In a practical point of view, the pulmonary artery possesses but
DESCRIPTION OF THE FIGURES OF PLATE XIII.
A. The thyroid body.
B. The trachea.
C C*. The first ribs.
D D*. The clavicles, cut at their middle.
E. Humeral part of the great pectoral muscle, cut.
F. The coracoid process of the scapula.
G. The arch of the aorta. G*. Descending aorta in the thorax.
H. Right bronchus. H*. Left bronchus.
I. (Esophagus.
K. Vena azygos receiving the intercostal veins.
L. Thoracic duct.
M M*. Seventh ribs.
N N. The diaphragm, in section.
O. The cardiac orifice of the stomach.
P. The liver, in section, showing the patent orifices of the hepatic veins.
Q. The coeliac axis sending off branches to the liver, stomach, and
spleen. The stomach has been removed, to show the looping
anastomosis of these vessels around the superior and inferior
borders of the stomach.
R. The inferior vena cava about to enter its notch in the posterior thick
part of the liver, to receive the hepatic veins.
S. The gall-bladder, communicating by its duct with the hepatic duct.
which is lying upon the vena portae, and by the side of the hepatic
artery.
T. The pyloric end of the stomach, joining T*, the duodenum.
U. The spleen.
V V. The pancreas.
W. The sigmoid flexure of the colon.
X. The caput coli.
Y. The mesentery supporting the numerous looping branches of the
superior mesenteric artery.
Z. Some coils of the small intestine.
2. Innominate artery.
3. Right subclavian artery.
4. Right common carotid artery.
5. Left subclavian artery.
6. Left common carotid artery.
7. Left axillary artery.
8. Coracoid attachment of the smaller pectoral muscle.
9. Subscapular muscle.
10. Coracoid head of the biceps muscle.
11. Tendon of the latissimus dorsi muscle.
12. Superior mesenteric artery, with its accompanying vein.
13. Left kidney.
COMMENTARY ON PLATE XTII.
small interest for us; and in truth the trunk of the systemic aorta
itself may be regarded in the same disheartening consideration,
forasmuch as when serious disease attacks either vessel, the “ tree
of life” may be said to be lopped at its root.
When an aneurism arises from the aortic arch it implicates those
important organs which are gathered together in contact with itself.
The aneurismal tumour may press upon and obstruct the bronchi,
HH*; the thoracic duct, z; the oesophagus, i; the superior vena
cava, H, Plate XV., or wholly obliterate either of the vagi nerves.
The aneurism of the arch of the aorta may cause sulFocation in
two ways—viz., either by pressing directly on the tracheal tube,
or by compressing and irritating the vagus nerve, whose recurrent
branch will convey the stimulus to the laryngeal muscles, and
cause spasmodic closure of the glottis. This anatomical fact also
fully accounts for the constant cough which attends some forms
of aortic aneurism. The pulmonary arteries and veins are also
liable to obstruction from the tumour. This will occur the more
certainly if the aneurism spring from the right or the inferior
side of the arch, and if the tumour should not break at an early
period, slow absorption, caused by pressure of the tumour, may
destroy even the vertebral column, and endanger the spinal
nervous centre. If the tumour spring from the left side or the
fore part of the arch, it may in time force a passage through the
anterior wall of the thorax.
The principal branches of the thoracic aorta spring from the
upper part of its arch. The innominate artery, 2, is the first to
arise from it; the left common carotid, 6, and the left subclavian
artery, 5, spring in succession. These vessels being destined for
the head and upper limbs, we find that the remaining branches of
the thoracic aorta are comparatively diminutive, and of little
surgical interest. The intercostal arteries occasionally, when
wounded, call for the aid of the surgeon; these arteries, like all
other branches of the aorta, are largest at their origin. Where
these vessels spring from g, the descending thoracic aorta,
they present of considerable caliber; but at this inaccessible
situation, they seldom or never call for surgical interference.
As the intercostal arteries pass outwards, traversing the inter-
costal spaces with their accompanjdng nerves, they diminish
in size. Each vessel divides at a distance of about two inches,
more or less, from the spine; and the upper larger branch lies
under cover of - the inferior border of the adjacent rib. When it
is required to perfonn the operation of paracentesis thoracis, this
distribution of the vessel should be borne in mind; and also, that
the farther from the spine this operation is performed, the. less in
size will the vessels be found. The intercostal artery is some¬
times wounded by the fractured end of the rib, in which case, if
the pleura be lacerated, an effusion of blood takes place within
the thorax, compresses the lung, and obstructs respiration.
The thoracic aorta descends along the left side of the spine, as
far as the last dorsal vertebra, at which situation the pillars of the
diaphragm overarch the vessel. From this place the aorta passes
obliquely in front of the five lumbar vertebrsB, and on arriving oppo¬
site the fourth, it divides into the two common iliac branches. The
aorta, for an extent included between these latter boundaries, is
named the abdominal aorta, and from its fore part arise those
branches which supply the viscera of the abdomen.
The branches which spring from the abdominal aorta to supply
the viscera of this region, are considerable, both as to their number
and size. They are, however, of comparatively little interest in
practice. To the anatomist they present many peculiarities of
distribution and form worthy of notice, as, for example, their
frequent anastomosis, their looping arrangement, and their large
size and number compared with the actual bulk of the organs
which they supply. As to this latter peculiarity, we interpret it
according to the fact that here the vessels serve other purposes
in the economy besides that of the support and repair of structure.
The vessels are large in proportion to the great quantity of fluid
matter secreted from the whole extent of the inner surface of this
glandular apparatus—^the gastro-intestinal canal, the liver, pan¬
creas, and kidneys.
As anatomists, we are enabled, from a knowledge of the relative
position of the various organs and bloodvessels of both the thorax
and abdomen, to account for certain pathological phenomena
which, as practitioners, we possess as yet but little skiU to remedy.
Thus it would appear most probable that many cases of anasarca
of the lower limbs, and of dropsy of the belly, are frequently caused
by diseased growths of the liver, p, obstructing the inferior vena
cava, E, and vena portae, rather than by what we are taught to be the
“ want of balance between secreting and absorbing surfaces.” The
like occurrence may obstruct the gall-ducts, and occasion jaundice.
Over-distention of any of those organs situated beneath the right
hypochondrium, will obstruct neighbouring organs and vessels.
Mechanical obstruction is doubtless so frequent a source of de¬
rangement, that we need not on many occasions essay a deeper
search for explaining the mystery of disease.
In the right hypochondriac region there exists a greater variety
of organs than in the left; and disease is also more frequent on the
right side. Affections of the liver will consequently implicate a
greater number of organs than affections of the spleen on the
left side, for the spleen is comparatively isolated from the more
important bloodvessels and other organs.
The external surface of the liver, p, lies in contact with the
diaphragm, n, the costal cartilages, m, and the upper and lateral
parts of the abdominal parietes; and when the fiver becomes the
seat of abscess, this, according to its situation, will point and
burst either into the thorax above, or through the side between
or beneath the false ribs, m. The hepatic abscess has been known
to discharge itself through the stomach, the duodenum, t, and the
transverse colon, facts which are readily explained on seeing the
close relationship which these parts hold to the under surface of
the ..fiver. When the fiver is inflamed, we account for the gastric
irritation, either from the inflammation ha-ving extended to the
neighbouring stomach, or by this latter organ being affected by
“ reflex action.” The hepatic cough is caused by the like pheno¬
mena disturbing the diaphragm, n, with which the fiver, p, lies in
close contact.
When large biliary concretions form in s, the gall-bladder, or
m the hepatic duct. Nature, failing in her efforts to discharge them
through the common bile-duct, into the duodenum, t, sets up in¬
flammation and ulcerative absorption, by aid of which processes
they make a passage for themselves through some adjacent part
of the intestine, either the duodenum or the transverse colon. In
these processes the gall-bladder, which contains the calculus, be¬
comes soldered by effused lymph to the neighbouring part of the
intestinal tube, into which the stone is to be discharged, and thus
its escape into the peritoneal sac is prevented. When the hepatic
abscess points externally towards m, the like process isolates the
matter from the cavities of the chest and abdomen.
In wounds of any part of the intestine, whether of x, the caecum,
w, the sigmoid flexure of the colon, or z, the small bowel, if suf¬
ficient time be allowed for Nature to establish the adhesive inflam¬
mation, she does so, and thus fortifies the peritoneal sac against
an escape of the intestinal matter into it by soldering the orifice
of the wounded intestine to the external opening. In this mode
is formed the artificial anus. The surgeon on principle aids
Nature in attaining this result.
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COMMENTARY ON PLATE XIV.
THE RELATION OF THE PRINCIPAL BLOODVESSELS OF THE THORAX AND ABDOMEN
TO THE OSSEOUS SKELETON, ETC.
HP arterial system of vessels assumes, in all cases, somewhat of
the character of the forms upon which they are distributed, or of
t e organs which they supply. This mode of distribution becomes
t e^ more apparent, according as we rise from particulars to take
a view of tJie^ whole. With the same ease that any piece of the
osseous fabric, taken separately, may be known, so may any one
art^y, taken apart from the rest, be distinguished as to the place
which It occupied, and the organs which it supplied in the economy.
Ihe vascular skeleton, whether taken as a whole or in parts,
exhibits characteristics as apparent as are those of the osseous
skeleton itself. The mam bloodvessel, ab c, of the trunk of the body,
possesses character, sui generis, just as the vertebral column itself
manifests. The main arteries of the head or limbs are as readily
distinguishable, the one from the other, as are the osseous fabrics
of the head and limbs. The visceral arteries are likewise moulded
upon the forms which they supply. But evidently the arterial
system of vessels conforms most strictly with the general design
of the osseous skeleton.
In Plate XIV., viewed as a whole, we find that as the vertebral
column stands central to the osseous skeleton, so does the aorta,
ABC, take the centre of the arterial skeleton. As the ribs jut
symmetricaUy from either side of the vertebral column, so do the
intercostal arteries foUow them from their own points of origin in
the aorta. The one side of the osseous system is not more like
the other than is the system of vessels on one side like that of the
other. And in addition to this fact of a similarity of sides in the
vascular as in the osseous skeleton, I also remark that both ex¬
tremities of the aorta divide into branches which are similar to one
another above and below, thereby conforming exactly with the upper
and lower limbs, which manifest unmistakable points of analogy.
The branches which spring from the aortic arch above are
destined to supply the head and upper limbs. They are, h, the
innominate artery, and i k, the left common carotid and subclavian
arteries. The branches which spring from the other extremity
of the aorta are disposed for the support of the pelvis and lower
limbs; they are the right and left common iliac arteries, l m.
These vessels exhibit, at both ends of the main aortic trunk, a
remarkable analogy; and as the knowledge of this fact may serve
to lighten the dry and weary detail of descriptive anatomy, at the
same time that it points directly to views of practical import, I
may be allowed briefly to remark upon it as follows:_
The vessels which spring from both ends of the aorta, as seen
in Plate XIV., are represented in what is called their normal cha¬
racter—^that is, while three vessels, h i k, spring separately from the
aortic arch above, only two vessels, l and m, arise from the aorta
below. Let the anatomist now recal to mind the “ peculiarities”
which at times appear amongst the vessels, h i k, above, and he
■will find that some of them absolutely correspond to the normal
arrangement of the vessels, l m, below. And if he will consider
the “ peculiarities” which occur to the normal order of the
vessels, l m, below, he wiU find that some of these correspond
exactly to the normal order of the vessels above. Thus, when
,i K of the left side join into a common trunk, this resembles
the innominate artery, H, of the right side, and then both these
vessels perfectly correspond with the two common iliac arteries
below. When, on the other hand, l and m, the common iliac arte¬
ries, divide, immediately after leaving the aortic trunk, into two
pairs of branches, they correspond to the abnormal condition of the
vessels, h i k, above; where h, immediately after leaving the aortic
arch, divides into two branches, like i k. With this generalization
upon the normal and abnormal facts of arrangement, exhibited
among the vessels arising from both ends of the aorta, I furnish
to the reader the idea that the vessels, h i k, above may present
of the same figure as the vessels, l m, below, and these latter may
assume the character of h i k above. Whenever, therefore, either
set of vessels becomes the subject of operation, such as having a
ligature applied to them, we must be prepared to meet the
“ varieties.”
The veins assume an arrangement similar to that of the arteries,
and the above remarks will therefore equally apply to the veins.
In the same way as the arteries, h i K, may present in the condition
of two common or brachio-cephalic trunks, and thereby simulate
the condition of the common iliac art.eries, so we find that the
normal forms of the veins above and below actually and permanently
exhibit this very type. The brachio-cephalic veins, d b, Plate
XY., exactly correspond to each other, and to the common iliac
veins, ST; and as these latter correspond precisely -with the
common iliac arteries, so may we infer that the original or typical
condition of the vessels i k, Plate XIV., is a brachio-cephalic or
common-trunk union corresponding with its brachio-cephalic vein.
When the vessels, i k, therefore present of the brachio-cephalic
form as the' vessel h, we have a perfect correspondence between
the two extremes of the aorta, both as regards the arteries arising
from it, and the veins which accompany these arteries; and this
condition of the vascular skeleton I regard as the typical uni¬
formity. The separate condition of the vessels IK, notwithstanding
the frequency of the occurrence of such, may be considered as a
special variation from the original type.
DESCRIPTION OF THE FIGURES OF PLATE XIV.
A. The arch of the aorta.
B B. The descending thoracic part of the aorta, giving offZ>5, the inter¬
costal arteries.
C. The abdominal part of the aorta.
D D. First pair of ribs.
E. The xyphoid cartilage.
G G*. The right and left kidneys.
H. The brachio-cephalic artery.
I. Left common carotid artery.
K. Left subclavian artery.
L. Right common iliac artery at its place of division.
M. Left common iliac artery, seen through the meso-rectum.
N. Inferior vena cava.
O O. The sigmoid flexure of the colon.
P. The rectum.
Q. The urinary bladder.
R. The right iliac fossa.
S S. The right and left ureters.
T. The left common iliac vein, joining the right under the right common
iliac artery to form the inferior vena cava.
U. Fifth lumbar vertebra.
V. The external iliac artery of right side.
W. The symphysis pubis.
X. An incision made over the locality of the femoral artery.
b b. The dorsal intercostal arteries.
c. The coeliac axis.
d. The superior mesenteric artery.
//. The renal arteries.
g. The inferior mesenteric artery.
h. The vas deferens bending over the epigastric artery and the os pubis,
after having passed through the internal abdominal ring.
COMMENTARY ON PLATE XIV.
The length of the aorta is variable in two or more bodies;
and so, likewise, is the length of the trunk of each of those great
branches which springs from its arch above, and of those into which
it divides below. The modes in which these variations as to
length occur, are numerous. The top of the arch of the aorta is
described as being in general on a level with the cartilages
of the second ribs, from which point it descends on the left side
of the spinal column; and after having wound gradually forwards
to the forepart of the lumbar spine at c, divides opposite to the
fourth lumbar vertebra into the right and left common iliac
arteries. The length of that portion of the aorta which is called
thoracic, is determined by the position of the pillars of the
diaphragm r, which span the vessel; and from this point to where
the aorta divides into the two common iliac arteries, the main vessel
is named abdominal. The aorta, from its arch to its point of
division on the lumbar vertebrse, gradually diminishes in caliber,
according to the number and succession of the branches derived
from it.
The varieties as to length exhibited by the aorta itself, and by
the principal branches which spring from it, occur under the fol¬
lowing mentioned conditions:—When the arch of the aorta rises
above or sinks below its ordinary position or level,—namely, the
cartilages of the second ribs, as seen in Plate XIV.,—it varies not
only its own length, but also that of the vessels i-i i k; for if the
arch of the aorta rises above this level, the vessels h i k become
shortened; and as the arch sinks below this level, these vessels
become lengthened. Even when the aortic arch holds its proper
level in the thorax, stiU. the vessels h i k may vary as to
length, according to the height to which they rise in the neck
previously to their division. When the aorta sinks below its
proper level at the same time that the vessels h i k rise consi¬
derably above that point at which they usually arch or divide’in
the neck, then of course their length becomes greatly increased.
When, on the other hand, the aortic arch rises above its usual
level, whilst the vessels n i k arch and divide at a low position
in the neck, then their length becomes very much diminished.
The length of the artery h may be increased even though the
arch of the aorta holds its proper level, and though the vessels
H I K occupy their usual position in the neck; for it is true that
the vessel h may spring from a point of the aortic arch a nearer
to the origin of this from the ventricle of the heart, whilst the
vessel I may be shortened, owing to the fact of its arising from
some part of h, the innominate vessel. All these circumstances
are so obvious, that they need no comment, were it not for the
necessity of impressing the surgeon with the fact that uncertainty
as to a successful result must always attach to his operation of
including in a ligature either of the vessels h i k, so as to ajffect
an aneurismal tumour.
Now, whilst the length of the aorta and that of the principal
branches springing from its arch may be varied according to the
above-mentioned conditions, so may the length of the aorta itself,
and of the two common iliac vessels, vary according to the place
whereat the aorta, c, bifurcates. Or, even when this point of
division is opposite the usual vertebra,—viz., the fourth lumbar,—
still the common iliac vessels may be short or long, according to the
place where they divide into external and internal iliac branches.
The aorta may bifurcate almost as high up as where the pillars
of the diaphragm overarch it, or as low down as the fifth lumbar
vertebra. The occasional existence of a sixth lumbar vertebra
also causes a variety in the length, not only of the aorta, but of
the two common iliac vessels and their branches.f
The difference between the perpendicular range of the anterior
and posterior walls of the thoracic cavity may be estimated on a
reference to Plate XIV., in which the xyphoid cartilage, e, joined
to the seventh pair of ribs, bounds its anterior wall below, while
E, the pillars of the diaphragm, bound its posterior wall. The
thoracic cavity is therefore considerably deeper in its posterior
than in its anterior wall; and this occasions a difference of an
opposite kind in the anterior and posterior walls of the abdomen;
for while the abdomen raAges perpendicularly from e to w, its
posterior range measures only from f to the ventra of the iliac
bones, r. The arching form of the diaphragm, and the lower level
which the pubic symphysis occupies compared with that of the
cristee of the iliac bones, occasion this difference in the measure of
both the thorax and abdomen.
The usual position of the kidneys, g g*, is on either side of the
lumbar spine, between the last ribs and the cristee of the iliac
bones. The kidneys lie on the fore part of the quadratus lum-
borum and pso£e muscles. They are sometimes found to have
descended as low as the iliac fossa}, r, in consequence of pressure,
occasioned by an enlarged liver on the right, or by an enlarged
spleen on the left. The length of the abdominal part of the aorta
may be estimated as being a third of the entire vessel, measured
from the top of its arch to its point of bifurcation. So many and
such large vessels arise from the abdominal part of the aorta, and
these are set so closely to each other, that it must in aU cases be
very difficult to choose a proper locality whereat to apply a ligature
on this region of the vessel. If other circumstances could fairly
justify such an operation, the anatomist believes that the circu¬
lation might be maintained through the anastomosis of the internal
mammary and intercostal arteries with the epigastric; the branches
of the superior mesenteric with those of the inferior; and the
branches of this latter with the perineal branches of the pudic.
The lumbar, the gluteal, and the circumflex ilii arteries, also
communicate around the hip-bone. The same vessels would
serve to carry on the circulation if either l, the common iliac, v,
the external iliac, or the internal iliac vessel, were the subject of
the operation by ligature.
t Whatever may be the number of variations to which the branches arising
from both extremes of the aorta are liable, all anatomists admit that the
arrangement of these vessels, as exhibited in Plate XIV., is by far the
most frequent. The surgical anatomist, therefore, when planning his
operation, takes this arrangement as the standard type. Haller asserts
this order of the vessels to be so constant, that in four hundred bodies
which he^ examined, he found only one variety —namely, that in which
the left vertebral artery arose from the aorta. Of other varieties described
by authors, he observes—Kara vero haec omnia esse si dixero cum
quadringenta nunc cadavera humana dissecuerim, fidem forte inveniam.”
(Iconum Anatom.) This variety is also stated by J. F. Meckel (Hand-
buch der Mensch Anat.), Soemmerring (De Corp. Hum Fabrica), Boyer
(Tr. d’Anat.), and Mr. Harrison (Surg. Anat. of Art.), to be the most
frequent. Tiedemann figures this variety amongst others (Tabulse
Arteriarum). Mr. Quain regards as the most frequent change which
occurs in the number of the branches of the aortic arch, “ that in which
the left carotid is derived from the innominate.” (Anatomy of the
Arteries, &c.) A case is recorded by Petsche (quoted in Haller), in which
he states the bifurcation of the aorta to have taken place at the origin of
the renal arteries: (query) are we to suppose that the renal arteries
occupied their usual position ? Cruveilhier records a case (Anat. Descript.)
in which the right common iliac was wanting, in consequence of having
divided at the aorta into the internal and external iliac branches. Whether
the knowledge of these and numerous other varieties of the arterial
system be of much practical import to the surgeon, he will determine for
himself. To the scientific anatomist, it must appear that the main object
in regard to them is to submit them to a strict analogical reasoning, so as
to demonstrate the operation of that law which has produced them. To
this end I have pointed to that analogy which exists between the vessels
arising from both extremities of the aorta. Itaque convertenda plane
est opera ad inquirendas et notandas rerum similitudines et analoga tain
integralibus quam partibus; illae enim sunt, quae naturam liniunt, et con-
stituere scientias incipiunt.” “ Natura enim non nisi parendo vincitur;
et quod in contemplatione instar causae est; id in operatione instar
regulae est.” (Novum Organum Scientiarum, Aph. xxvii-iii, lib. i.)
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COMMENTARY ON PLATE XV.
\
THE RELATION OF THE INTERNAL PARTS TO THE EXTERNAL SURFACE OF THE BODY.
An exact acquaintance with the normal character of the external
form, its natural prominences and depressions, produced by the
projecting swell of muscles and points of bone, &c., is of great
practical importance to the surgeon. These several marks de¬
scribed on the superficies he takes as certain guides to the precise
locality and relations of the more deeply situated organs. And
as, by dissection. Nature reveals to him the fact that she holds con¬
stant to these relations, so, at least, may all that department of
practice which he bases upon this anatomical certainty be accounted
as rooted in truth and governed by fixed principles. The same
organ bears the same special and general relations in all bodies,
not only of the human, but of all other species of vertebrata; and
from this evidence we conclude that the same marks on surface
indicate the exact situation of the same organs in all similar bodies.
The surface of the well-formed human body presents to our
observation certain standard characters with which we compare
all its abnormal conditions. Every region of the body exhibits
fixed character proper to its surface. The neck, the axilla, the
thorax, the abdomen, the groin, have each their special marks, by
which we know them; and the eye, well versed in the characters
proper to the healthy state of each, will soonest discover the nature
of all eifects of injury—such as dislocations, fractures, tumours of
various kinds, &c. By our acquaintance with the perfect, we
discover the imperfect; by a comparison with the geometrically
true rectangled triangle, or circle, we estimate the error of these
forms when they have become distorted; and in the same way, by
a knowledge of what is the healthy normal standard of human
form, we diagnose correctly its slightest degree of deformity,
produced by any cause whatever, whether by sudden accident, or
slowly-approaching disease.
Now, the abnormal conditions of the surface become at once
apparent to our senses; but those diseased conditions which con¬
cern the internal organs require no ordinary exercise of judgment
to discover them. The outward form masks the internal parts,
and conceals from our direct view, like the covers of a closed
volume, the marvellous history contained within. But stiU the
superficies is so moulded upon the deeper situated structures,
that we are induced to study it as a map, which discourses of aU
which it incloses in the healthy or the diseased state. Thus, the
sternum points to A, the aorta; the middle of the clavicles, to c,
the subclavian vessels; the localities 9, 10 of the coracoid pro¬
cesses indicate the place of the axillary vessels; the navel, p,
points to Q, the bifurcation of the aorta; the pubic symphysis, z.
directs to the urinary bladder, y. At the points 7, 8, may be felt
the anterior superior spinous processes of the iliac bones, between
which points and z, the iliac vessels, v, 6, pass midway to the
thigh, and give olF the epigastric vessels, 2, 3, to the abdominal
parietes. Between these points of general relations, which we
trace on the surface of the trunk of the body, the anatomist m-
cludes the entire history of the special relations of the organs within
contained. And not until he is capable of summing together
the whole picture of anatomical analysis, and of viewing this in
aU its intricate relationary combination — even through and
beneath the closed surface of living moving nature, is he prepared
to estimate the conditions of disease, or interfere for its removal.
When fluid accumulates on either side of the thoracic compart¬
ment to such an excess that an opening is required to be made
for its exit from the body, the operator, who is best acquainted
with the relations of the parts in a state of health, is enabled to
judge with most correctness in how far these parts, when in a
state of disease, have swerved from these proper relations. In
the normal state of the thoracic viscera, the left thoracic space,
G A K N, is occupied by the heart and left lung. The space
indicated within the points A N K, in the anterior region of the
thorax, is occupied by the heart, which, however, is partially
overlapped by the anterior edge of the lung, Plate XI. If the
thorax be deeply penetrated at any part of this region, the in¬
strument will wound either the lung or the heart, according to the
situation of the wound. But when fluid becomes elFused in any
considerable quantity within the pleural sac, it occupies space
between the lung and the thoracic walls; and the fluid com¬
presses the lung, or displaces the heart from the left side towards
the right. This displacement may take place to such an extent,
that the heart, instead of occupying the left thoracic angle,
A K N, assumes the position of A k* N on the right side. There¬
fore, as the fluid, whatever be its quantity, intervenes between the
thoracic walls, k k, and the compressed lung, the operation of
paracentesis thoracis should be performed at the point K, or
between k and the latissimus dorsi muscle, so as to avoid any pos¬
sibility of wounding the heart. The intercostal artery at k is
not of any considerable size.
In the normal state of the thoracic organs, the pericardial
envelope of the heart is at all times more or less uncovered by the
anterior edge of the left lung, as seen in Plate XI. When serous
or other fluid accumulates to an excess in the pericardium, so as
considerably to distend this sac, it must happen that a greater
DESCRIPTION OF THE FIGURES OF PLATE XV.
A. The systemic aorta. Owing to the body being inclined forwards, the
root of the aorta appears to approach too near the lower boundary
(N) of the thorax.
B. The left brachio-cephalic vein.
C. Left subclavian vein.
D. Right brachio-cephalic vein.
E. Left common carotid artery.
F. Brachio-cephalic artery.
G G^. The first pair of ribs.
H. Superior vena cava.
I. Left bronchus.
K K*. Fourth pair of ribs.
L. Descending thoracic aorta.
M. CEsophagus.
N. Epigastrium.
O. Left kidney.
P. Umbilicus.
Q. Abdominal aorta, at its bifurcation.
R R*. Right and left iliac fossae.
S. Left common iliac vein.
T. Inferior vena cava.
U. Psoas muscle, supporting the right spermatic vessels.
V. Left external iliac artery crossed by the left ureter.
W. Right external iliac artery crossed by the right ureter.
X. The rectum.
Y. The urinary bladder, which being fully distended, and viewed from
above, gives it the appearance of being higher than usual above
the pubic symphysis.
Z. Pubic symphysis.
2. The left internal abdominal ring complicated with the epigastric vessels,
the vas deferens, and the spermatic vessels.
3. The right internal abdominal ring in connexion with the like vessels
and duct as that of left side.
4. Superior mesenteric artery.
5. 6. Right and left external iliac veins.
7, 8. Situations of tbe anterior superior iliac spinous processes.
9, 10. Situations of the coracoid processes.
11, 12. Right and left hypochondriac regions.
COMMENTARY ON PLATE XV.
area of pericardial surface will be exposed and brought into imme¬
diate contact with the thoracic walls on the left side of the sternal
median line, to the exclusion of the left lung, which now no longer
interposes between the heart and the thorax. At this locality,
therefore, a puncture may be made through the thoracic walls'
directly into the distended pericardium, for the escape of its fluid
contents, if such proceeding were in other respects deemed prudent
and advisable.
The abdominal cavity being very frequently the seat of dropsical
effusion, when this takes place to any great extent, despite the
continued and free use of the medicinal diuretic and the hydra-
gogue cathartic, the surgeon is required to make an opening with
the instrumental hydragogue—viz., the trocar and cannula. The
proper locality whereat the puncture is to be made so as to avoid
any large bloodvessel or other important organ, is at the middle
third of the median line, between p the umbilicus, and z the
symphysis pubis. The anatomist chooses this median line as the
safest place in which to perform paracentesis abdominis, well
knowing the situation of 2, 3, the epigastric vessels, and of y, the
urinary bladder.
All kinds of fluid occupying the cavities of the body gravitate
towards the most depending part; and therefore, as in the sitting
or standing posture, the fluid of ascites falls upon the line p z, the
propriety of giving 1;he patient this position, and of choosing some
point within the line p z, for the place whereat to make the open-
ing, becomes obvious. In the female, the ovary is frequently the
seat of dropsical accumulation to such an extent as to distend the
abdomen very considerably. Ovarian dropsy is distinguished from
ascites by the particular fofm and situation of the swelling. In
ascites, the abdominal swell is symmetrical, when the body stands
or sits erect. In ovarian dropsy, the tumour is greatest on either
side of the median line, according as the affected ovary happens
to be the right or the left one.
The fluid of ascites and that of the ovarian dropsy affect the
position of the abdominal viscera variously. In ascites, the fluid
gravitates to whichever side the body inclines, and it displaces the
moveable viscera towards the opposite side. Therefore, to which¬
ever side the abdominal fluid gravitates, we may expect to find it
occupying space between the abdominal parietes and the small
intestines. The ovarian tumour is, on the contrary, comparatively
fixed to either side of the abdominal median line; and whether it
be the right or left ovary that is affected, it permanently dis¬
places the intestines on its own side; and the sac lies in contact
mth the neighbouring abdominal parietes; nor wUl the intestines
and it change position according to the line of gravitation.
Now, though the above-mentioned circumstances be anatomically
true respecting dropsical effusion within the general peritonaeal sac
and that of the ovary, there are many urgent reasons for preferring
to all other localities the line p z, as the only proper one for punc¬
turing the abdomen so as to give exit to the fluid. For though
the peritonaeal ascites does, according to the position of the patient,
gravitate to either side of the abdomen, and displace the moveable
Adscera on that side, we should recoUect that some of these are
bound fixedly to one place, and cannot be floated aside by the
gravitating fluid. The liver is fixed to the right side, 11, by its
suspensory ligaments. The spleen occupies the left side, 12. The
c*cum and the sigmoid flexure of the colon occupy, r r*, the right
and left iliac regions. The colon ranges transversely across the
abdomen, at p. The stomach lies transversely between the points,
11, 12. The kidneys, o, occupy the lumbar region. All these
organs continue to hold their proper places, to whatever extent
the dropsical effusion may take place, and notwithstanding the
various inclinations of the body in this or that direction. On
this account, therefore, we avoid performing the operation of
paracentesis abdominis at any part except the median line, pz-
and as to this place, we prefer it to aU others, for the following
cogent reasons—viz., the absence of any large artery; the absence
of any important viscus; the fact that the contained fluid gravi¬
tates in large quantity, and in immediate contact with the abdo¬
minal walls anteriorly, and interposes itself between these walls
and the small intestines, which float free, and cannot approach the
parietes of the abdomen nearer than the length which the mesen¬
teric bond allows.
If the ovarian dropsy form a considerable tumour in the abdo¬
men, it may be readily reached by the trocar and cannula pene¬
trating the line p z. And thus Ave avoid the situation of the
epigastric vessels. The puncture through the linea alba should
never be made below the point, midway between p and z, lest we
Avound the urinary bladder, Avhich, when distended, rises con¬
siderably above the pubic symphysis.
Amongst the many mechanical obstructions which, by impeding
the circulation, give rise to dropsical effusion, are the foUoAving:—
An aneurismal tumour of the aorta, a, or the innominate artery,f
p, may press upon the veins, h or d, and cause an oedematous
swelling of the corresponding side of the face and the right arm.
In the same way an aneurism of the aorta, q, by pressing upon
the inferior vena cava, t, may cause oedema of the lower limbs.
Serum may accumulate in the pericardium, OAving to an obstruc¬
tion of the cardiac veins, caused by hypertrophy of the substance
of the heart; and when from this cause the pericardium becomes
much distended with fluid, the pressure of this upon the flaccid
auricles and large venous trunks may give rise to general anasarca,
to hydrothorax or ascites, either separate or co-existing. Tuber¬
culous deposits in the lungs and scrofulous bronchial glands may
cause obstructive pressure on the pulmonary veins, followed by
effusion of either pus or serum into the pleural sac.J An abscess
or other tumour of the.liver may, by pressing on the vena portse,
cause seious effusion into the peritonasal sac; or by pressure on
the inferior vena cava, which is connected with the posterior thick
border of the liver, may cause anasarca of the lower limbs. Matter
accumulating habitually in the sigmoid flexure of the colon may
cause a hydrocele, or a varicocele, by pressing on the spermatic
veins of the left side. It is quite true that these two last-named
affections appear more frequently on the left side than on the
right; and it seems to me much more rational to attribute them
to the above-mentioned circumstance than to the fact that the left
spermatic veins open, at a disadvantageous right angle, into the
left renal vein.
t The situation of this vessel, its close relation to the pleura, the aorta,
the large venous trunks, the vagus and phrenic nerves, and the uncertainty
as to Its length, or as to whether or not a thyroid or vertebral branch
arises from it, are circumstances which render the operation of tying the
vessel in cases of aneurism very doubtful as to a successful issue The
operation (so far as I know) has hitherto failed. Anatomical relations
nearly similar to these, prevent, in like manner, an easy access to the iliac
arteries, and cause the operator much anxiety as to the issue.
t The effusion of fluid into the pleural sac (from whatever cause it may
arise) sometimes takes place to a very remarkable extent. I have had
opportunities of examining patients, in whom the heart appeared to be
completely dislocated, from the left to the right side, owing to the large
collection of serous fluid in the left pleural sac. The heart’s pulsations
could be felt distinctly under the right nipple. Paracentesis thoracis
was performed at the point indicated in Plate XV. In these cases, and
another observed at the Hotel Dieu, the heart and lung, in consequence of
the extensive adhesions which they contracted in their abnormal po¬
sition, did not immediately resume their proper situation when the fluid
was withdrawn from the chest. Nor is it to be expected that they should
ever return to their normal character and position, when the disease which
caused their displacement has been of long standing.
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COMMENTARY ON PLATE XVI.
THE SURGICAL DISSECTION OF THE SUPERFICIAL BLOODVESSELS ETC. OF THE
INGUINO-FEMORAL REGION.
Hernial protrusions are very liable to occur at the inguino¬
femoral region; and this fact has led the surgeon to study the
anatomical relations of this part with more than ordinary care and
patience. So minutely has he dissected every structure proper to
this locality, and so closely has he investigated every possible con¬
dition of it as being the seat of hemise, that the only novelty which
now remains to be sought for is that of a simplification of the
facts, already known to be far too much obscured by an unwieldy
nomenclature, and an useless detail of trifling evidence. And it
would seem that nothing can more directly tend to this simplifica¬
tion, than that of viewing the inguinal and femoral regions, not
separately, but as a relationary whole. For as both regions are
blended together by structures which are common to both, so do
the hernise which are described as being proper to either region,
occur in such close connexion as at times to render it very diflicult
to distinguish between them.
The human species is, of all others, most subject to hernise in
the groin. The erect attitude of the human form, and the fact
that many of its more powerful muscular efforts are performed
in this posture, cause its more frequent liability to the accidents
called abdominal herniae or ruptures.
The viscera of the abdomen occupy this cavity completely, and
indeed they naturally, at aU. times, subject the abdominal parictes
to a state of constant pressure, as may be proved by their escape
from the abdomen in cases of large wounds of this region. In the
erect posture of the body this pressure is increased, for the viscera
now gravitate and force downwards and forwards against the
abdominal parietes. In addition to this gravitating force, another
power impels the viscera from above downwards—namely, that of
the muscles of the trunk, and the principal agent amongst these is
the diaphragm. The lungs, again, expanding above the diaphragm,
add also to the gravitation of the abdominal contents, and these,
under the pressure thus accumulated, occasionally make an exit
for themselves at the groins, which are the weakest and most de¬
pending parts of the abdomen.
Herniae are variously named in accordance with the following
circumstances—viz., the precise locality at which they occur—
the size and form of the tumour—the time of life at which they
happen. Sexual peculiarities do not serve to distinguish herniae,
though it is true that the inguinal form, at the part n f, occurs
more commonly in the male, whilst the crural form, at the opening
E, happens more frequently in the female.
The most common forms of herniae happen at those localities
where the abdominal walls are traversed by the bloodvessels on
their way to the outstanding organs, and where, in consequence, the
walls of the abdomen have become weakened. It also happens, that
at these very situations the visceral pressure is greatest whilst the
body stands erect. These localities are, a, the umbilicus, a point
characterized as having given passage (in the foetal state) to the
umbilical vessels; d, the place where the spermatic vessels and
duct pass from the abdomen to the testicle; and immediately
beneath this, the crural arch, which gives exit to the crural vessels.
Herniae may happen at other localities, such as at the thyroid aper¬
ture, which transmits the thyroid vessels; and at the greater sacro-
sciatic 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 in¬
guinal 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 con¬
stitute the coverings of the herniae themselves.
The groin in its undissected state is marked by certain eleva¬
tions 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 obhque 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 indi¬
cates the course of the spermatic cord, n 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 XVI.,
wiU 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 invest¬
ing membrane called the superficial fascia. This fascia, o, a o,^
stretches over the lower part of the abdomen and the upper part
DESCRIPTION OF THE
A. The umbilicus.
B. The upper margin of the pubic symphysis.
C. The anterior superior spine of the left iliac bone. C*, the situation of
the corresponding part on the right side.
D. The point -where, in this subject, the cord manifested itself beneath the
fibres of the external oblique muscle. D*, a corresponding part on
the opposite side.
E. The saphenous opening in the fascia lata, receiving e, the saphenous
vein.
F. The lax and pendulous cord, which, in this case, overlies the upper-
part of the saphenous opening.
G. Lymphatic glands lying on the fascia lata in the neighbourhood of
the saphenous opening.
FIGURES OF PLATE XVI.
H. The fleshy part of the external oblique muscle.
a a a. The superficial fascia of the abdomen.
b. The same fascia forming an envelope for the spermatic cord and
scrotum.
c. Inguinal glands lyiug near Poupart’s ligament.
d. A common venous trunk, formed by branches from the thigh and
abdomen, and joining—
e e. The saphenous vein.
/. The middle cutaneous nerve, derived from the anterior crural nerve.
g. Femoral lymphatic glands.
h. Superficial external iliac vein.
i. Superficial epigastric vein.
k. External cutaneous branehes of nerves from the lumbar plexus.
I
COMMENTARY ON PLATE XVL
of the thigh. It becomes intimately attached to Poupart s liga¬
ment along the ilio-pubic line, c b ; it invests the spermatic cord, as
shown at h, and descends into the scrotum, so as to encase this
part. Where this superficial fascia overlies the saphenous open¬
ing, E, of the fascia lata, it assumes a “ cribriform” character,
owing to its being pierced by numerous l5Tnphatic 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 E, and sheathes over the saphenous opening, B, it must
follow of course that wherever the hernial protrusion takes place
in this region, whether at d, or r, or B, or adjacent parts, this
membrane forms the external subcutaneous covering of the bowel.
There is another circumstance respecting the form and attach¬
ments of the superficial fascia, which, in a pathological point of
view, is worthy of notice—viz., that owing to the fact of its en¬
veloping 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 5 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, n, emerges from the abdomen and becomes
definable through the fibres of the sheathing tendon of the external
obliq^ue muscle, h, at a point midway between the extremities Ox
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, &, as containing the
cord, and also that the place where this fold meets the ilio-pubic
line, c B, at the point d, marks the exit of the cord from the
abdomen.
The spermatic cord does not actually pierce the sheathing
tendon of the external oblique muscle at the point n, and there
does not, in fact, exist naturally such an opening as the “ external
abdominal ring,” for the cord carries Avith it a production of the
tendon of the external oblique muscle, and this has been named
by surgical anatomists the “ intercolumnar .fascia,”')’ the “ spermatic
fascia.” The fibres of this spermatic fascia are seen at d b, 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.
The close relations which the cord, d b, 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 b, it ap¬
proaches 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 Avith a moderate degree of judg¬
ment, based upon the habit of referring the anatomy to the sur¬
face, such error may always be avoided. This important subject
shall be more fuUy 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, ^, the external
circumflex ilii vein, A, and another venous branch, 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. SmaU 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 stran¬
gulated hernia; but they are, for the most part, unimportant
in size. Some branches of nerves, such as, A, 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.
Numerous lymphatic glands occupy the inguino-femoral region;
these can be felt, lying subcutaneous, even in the undissected state
of the parts. These glands form two principal groups, one of
which, c, lies along the middle of the inguinal fold, c b ; the other,
G lies scattered in the neighbourhood of the saphenous opening.
The former group receive the lymphatic vessels of the generative
organs; and the glands of which it is composed are those which
suppurate in syphilitic or other affections of these parts.
The general relations which the larger vessels of the inguino¬
femoral region bear to each other and to the superficies, may be
referred to in Plate XVI., Avith practical advantage. The
umbilicus. A, indicates pretty generally the level at which the
aorta bifurcates on the forepart of the lumbar vertebras. In the
erect, and even in the recumbent posture, the aorta may (especially
in emaciated subjects) be felt pulsating under the pressure of the
hand; for the vertebras bear forAvard the vessel to a level nearly
equal with, c c, the anterior superior spinous processes of the iliac
bones. If a gunshot were to pass through the abdomen, trans¬
versely, from these points, and through b, it would penetrate the
aorta at its bifurcation. The line A b coincides with the linea
alba. The obfique lines, a d, A d*, indicate the course of the
iliac vessels. The point n marks the situation where the spermatic
vessels enter the abdomen; and also where the epigastric artery
is given off from the external iliac. The most convenient line of
incision that can be made for reaching the situation of either of
the iliac arteries, is that which ranges from c, the iliac spine, to
D, the point Avhere the spermatic cord enters the abdomen. The
direct line draAvn between d and G marks the course of the
femoral artery, and this ranges along the outer border, e, of the
saphenous opening.
t 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 apo¬
neurotic 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
are 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 stein
requirements of surgical skill, but they serve to degrade it from the rank
and roll of the sciences. Whilst operating for the reduction of inguma
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 pro¬
priety of naming it “ tunica vaginalis communis,” “ tunique fibreuse u
cordon spermatique,” “fascia cremasterica,” or “ tunica aponeuiotica
HAtiaan
COMMENTARY ON PLATE NVII.
THE SURGICAL DISSECTION OF THE FIRST, SECOND, THIRD, AND FOURTH LAYERS OF THE
INGUINAL REGION IN CONNEXION WITH THOSE OF THE THIGH.
The common integument or first layer of the inguino-femoral
region being removed, we expose the superficial fascia constituting
the second layer. The connexion of this fascia with Poupart’s
ligament along the line c n, together with the facts, that corre¬
sponding with this line the fascia is devoid of adipous substance,
and the integument thin and delicate, whilst above over the
abdomen, and below over the upper part of the thigh, the meshes
of the fascia are generally loaded with a considerable quantity of
adipous tissue, Avill account for the permanency and distinctness
of the fold of the groin. As this fold corresponds with Poupart’s
ligament, it is taken as a guide to distinguish between the inguinal
and femoral forms of hemise.
The general relations of the superficial fascia are well described
by Camper in the following sentence: “ Musculus obliquus igitur
externus abdominis, qua parte carneus est, membrana quadam
propria, quali omnes musculi, tegitur, quse sensim in aponeurosin
mutata, ac cum tendineis hujus musculi partibus unita, externe ac
anteriore parte abdomen tegit; finem vero nuUibi habere per-
spicuum est, ad pubem enim miscet cellulosa membrana, cum
ligamento penis in viris ac clitoridis in feminis, involucrum dat
musculo cremasteri, ac aponeuroseos speciem musculis anterioribus
femoris, qua glandulae inguinales, ac cruris vasa majora obtegun-
tur.” (leones Hemiarum.)
Owing to the varied thickness of the adipous tissue contained in
the superficial fascia at several regions of the same body, and
at some corresponding regions of different individuals, it will be
evident that the depth of the incision required to divide it, so as to
expose subjacent structures, must vary accordingly. Whete the
superficial fascia, after encasing the cord, descends into the scro¬
tum, it is also devoid of the fatty tissue.
By the removal of the superficial fascia and glands we expose
the aponeurosis of the external oblique muscle, A a. Fig. 1, (con¬
stituting the third layer of the groin,) and also the fascia of the
thigh, H L. These strong fibrous structures will be observed to
hold still in situ the other parts, and to be the chief agents in
determining the normal form of this region.
The inguino-femoral region, as being the seat of hernial protru¬
sions, may in this stage of the dissection be conveniently described
as a’space formed of two triangles—the one inguinal, the other
femoral, placed base to base. The inguinal triangle may be drawn
between the points, b c d, Fig. 1, while the femoral triangle may
be marked by the points, c D N. The conjoined bases of these
triangles correspond to Poupart’s ligament along the line, c D.
The inguinal varieties of hernise occur immediately above the line,
c D, while the femoral varieties of hernise take place below this
line. The hernias of the inguinal triangle are, therefore, dis¬
tinguishable from those of the femoral triangle by a reference to
the fine, c d, or Poupart’s ligament.
The aponeurosis of the external oblique muscle occupies the
whole of that space which I have marked as the inguinal triangle,
BCD, Fig. 1. The fleshy fibres of the muscle, a, after forming
the lateral AvaU of the abdomen, descend to the level of c, the iliac
spinous process, and here give off the inguinal part of their broad
tendon, a. The fibres of this part of the tendon descend obliquely
downwards and forwards to become inserted at the median line of
the abdomen into the linea alba, b d, as also into the symphysis
and crista of the os pubis. The lower band of the fibres of this
tendinous sheath—viz., that which is stretched between c, the
iliac spine, and D, the crista pubis, is named Poupart’s ligament;
and this is strongly connected with H, the iliac portion of the
fascia lata of the thigh.
Poupart’s ligament is not stretched tensely in a right line, like
the string of a bow, between the points, c and D. With regard
to these points it is lax, and curves down towards the thigh like
the arc of a circle. The degree of tension which it manifests
when the thigh is in the extended position is chiefly owing to
its connexion with the fascia lata. If in this position of the
limb we sever the connexion between the ligament and fascia,
the former becornes relaxed in the same degree as it does when we
flex the thigh upon the abdomen. The utmost degree of relaxa¬
tion which can be given to Poupart’s ligament is effected by
flexing the thigh towards the abdomen, at the same time that we
support the body forwards. This fact has its practical application
in connexion with the reduction of herniae.
Immediately above the middle of Poupart’s ligament, at the
point E, Fig. 1, we observe the commencement of a separation
taking place among the fibres of the aponeurosis. These divide
into two bands, which, gradually widening from each other as
they proceed inwards, become inserted, the upper one into the
symphysis pubis, the lower into the spine and pectineal ridge of
DESCRIPTION OF THE FIGURES OF PLATE XVII.
Figure 1.
A. Tlie fleshy part of the external oblique muscle ; a, its tendon covering
the rectus muscle.
B. The umbilicus.
C. The anterior superior spinous process of the ilium.
D The spinous process of the os pubis.
e' The point where in this instance the fibres of the aponeurotic tendon
of the external oblique muscle begin to separate and form the
pillars of the external ring.
E G See Figure 2. i • •
H The fascia lata-its iliac portion. The letter indicates the situation
of the common femoral artery; h, the falciform edge of the
saphenous opening. • w
I The sartorius muscle covered by a process of the fascia lata.
K The spermatic fascia derived from the external oblique tendon.
L. ‘ The pubic part of the fascia lata forming the inner and posterior
boundary, of the saphenous opening.
M. The saphenous vein.
M A tvibiitarv vein coming from the fore part of the thigh.
Figure 2.
A. The muscular part of the external oblique ; a, its tendon.
B. The umbilicus.
C. The anterior superior iliac spine.
D. The spine of the os pubis.
E. The cremasteric fibres, within the external ring, surrounding the cord;
c, the cremasteric fibres looping over the cord outside the ring.
F. The muscular part of the internal oblique giving off, e, the cremaster ;
its tendon sheathing the rectus muscle.
G. The linea alba; /, g, the linea semilunaris.
H. The iliac part of the fascia lata; h, the upper cornu of its falciform
process.
I. The femoral vein.
K. The femoral artery.
L. The anterior crural nerve.
M. The sartorius muscle.
N. The sheath of the femoral vessels; n, its upper part.
O. The saphena vein.
P. The pubic part of the fascia lata.
COMMENTARY ON PLATE XVII.
this bone. The lower band identifies itself with Poupart’s liga¬
ment. The interval which is thus formed by the separation of
these fibres assumes the appearance of an acute triangle, the apex
of which is at E, and the base at d. But the outer end of this
interval is rounded off by certain fibres which cross those of the
bands at varying angles. At this place, the aponeurosis, thus
constituted of fibres disposed crossways, is elongated into a canal,
forming an envelope for the cord, k. This elongation is named
the “ external spermatic fascia,” and is continued over the cord as
far as the testicle. In the female, a similar canal encloses the
round ligament of the uterus. From the above-mentioned facts,
it will appear that the so-called “ external abdcminal ring” does
not exist as an aperture with defined margins formed in the tendon
of the external oblique muscle. It is only when we divide the
spermatic fascia upon the cord at K, that we form the external
ring, and then it must be regarded as an artificial opening, as at
D, Fig. 2.
The part of the groin where the spermatic fascia is first derived
from the aponeurosis, so as to envelope the cord, varies in several
individuals; and thereupon depends, in great measure, the strength
or weakness of the groin. In some cases, the cord becomes pen¬
dulous as far outwards as the point E, Fig. 1, which corresponds to
the internal ring, thereby offering a direct passage for the hernial
protrusion. In other instances, the two bands of the aponeurosis,
known as the “ pillars of the ring,” together -with the transverse
fibres, or “ intercolumnar fascia,” firmly embrace and support the
cord as far inwards as the point K, and by the oblique direction
thus given to the cord in traversing the inguinal parietes, these
parts are fortified against the occurrence of hernia. In Fig. 1,
the cord, ic, will be observed to drop over the lower band of fibres,
(“ external pillar of the ring,”) and to have D, the crista pubis,
on its inner side. In Fig. 2, the upper band of fibres (“ internal
pillar of the ring”) may be seen proceeding to its insertion into
the symphysis pubis. When a hernial tumour protrudes at the
situation k, it is invested, in the same manner as the cord, by the
spermatic fascia, and holds in respect to the fibrous bands or
pillars the same relations also as this part.
After removing the tendon of the external oblique muscle, A a.
Fig. 1, together with its spermatic elongation, E, we expose
the internal oblique, F E, Fig. 2, and the cremaster, constituting
the fourth inguinal layer. The fleshy part of this muscle, F e,
occupies a much greater extent of the inguinal region than does
that of the external oblique. Whilst the fleshy fibres of the latter
terminate on a level with c, the iliac spine, those of the internal
oblique are continued down as far as the external abdominal
ring, E D A, and even protrude through this place in the form of a
cremaster. The muscular fibres of the internal oblique terminate
internally at the linea semilunaris, g; while Poupart’s ligament,
the spinous process and crest of the ilium, give origin to
them externally. At the linea semilunaris, the tendon of the
internal oblique is described as dividing into two layers, which
passing, one before and the other behind the rectus abdominis,
thus enclose this muscle in a sheath, after which they are
inserted into the linea alba, G. The direction of the fibres of the
inguinal portion of the muscle, F E, is obliquely downwards and
forwards, and here they are firmly overlaid by the aponeurosis of
the external oblique.
The cremaster muscle manifests itself as being a part of the
internal oblique, viewing this in its totality. Cloquet (R^cherches
anatomiques sur les Hernies de I’Abdomen) first demonstrated
the correctness of this idea.
The oblique and serial arrangement of the muscular fibres of
the internal oblique, F, Fig. 2, is seen to be continued upon the
spermatic cord by the fibres of the cremaster, e e. These fibres,
like those of the lower border of the internal oblique, arise from
the middle of Poupart’s ligament, and after descending over the
cord as far as the testicle in the form of a series of inverted loops, r,
again ascend to join the tendon of the internal oblique, by which
they become inserted into the crest and pectineal ridge of the os
pubis. The peculiar looping arrangement exhibited by the
cremasteric fibres indicates the fact that the testicle, during its
descent from the loins to the scrotum, carried with it a mus¬
cular covering, at the expense of the internal oblique muscle.
The cremaster, therefore, is to be interpreted as a production of
the internal oblique, just as the spermatic fascia is an elongation
of the external oblique. The hernia, which follows the course of
the spermatic vessels, must therefore necessarily become invested
by cremasteric fibres.
The fascia lata, n. Fig. 1, being strongly connected and continuous
with Poupart’s ligament along its inferior border, the boundary
line, which Poupart’s ligament is described as drawing between the
abdomen and thigh, must be considered as merely an artificial one.
In the upper region of the thigh the fascia lata is divided into
two parts—viz., H, the iliac part, and L, the pubic. The iliac part,
H, which is external, and occupying a higher plane than the
pubic part, is attached to Poupart’s ligament along its whole
extent, from c to D, Fig. 1; that is, from the anterior iliac spinous
process to the crista pubis. From this latter point over the
upper and inner part of the thigh, the iliac division of the fascia
appears to terminate in an edge of crescentic shape, h; but this
appearance is only given to it by our separating the superficial
fascia with which it is, in the natural state of the parts, blended.
The pubic part of the fascia, l. Fig. 1, which is much thinner than
the iliac part, covers the pectineus muscle, and is attached to the
crest and pectineal ridge of the os pubis, occupying a plane, there¬
fore, below the iliac part, and in this way passes outwards beneath
the sheath of the femoral vessels, k i. Fig. 2. These two divisions
of the fascia lata, although separated above, are united and con¬
tinuous on the same plane below. An interval is thus formed
between them for the space of about two inches below the inner
third of Poupart’s ligament; and this interval is known as the
“ saphenous opening,” l A, Fig. 1. Through this opening, the
saphena vein, o. Fig. 2, enters the femoral vein, i.
From the foregoing remarks it will appear that no such aperture
as that which is named “saphenous,” and described as being
shaped in the manner of l A, Fig. 1, with its “ upper and lower
cornua,” and its “ falciform process,” or edge. A, exists naturally.
Nor need we be surprised, therefore, that so accurate an observer
as Soemmering (de Corporis Ilumani Fabrica) appears to have
taken no notice of it.
Whilst the pubic part of the fascia lata passes beneath the
sheath of the femoral vessels, k i. Fig. 2, the iliac part, ii A, blends
by its falciform margm with the superficial fascia, and also with
N n, the sheath of the femoral vessels. The so-caUed saphenous
opening, therefore, is naturally masked by the superficial fascia;
and this membrane being here perforated for the passage of the
saphena vein, and its tributary branches, as also the efferent
vessels of the lymphatic glands, is termed “ cribriform.”
The femoral vessels, k i, contained in their proper sheath, lie
immediately beneath the iliac part of the fascia lata, in that
angle which is expressed by Poupart’s ligament, along the line
c D above; by the sartorius muscle in the line c m externally;
and by a line drawn from d to N, corresponding to the pectineus
muscle internally. The femoral vein, i, lies close to the outer
margin of the saphenous opening. The artery, k, lies close to
the outer side of the vein; and external to the artery is seen, l,
the anterior crural nerve, sending off its superficial and deep
branches.
When a femoral hernia protrudes at the saphenous space l A,
Fig. 1, the dense falciform process. A, embraces its outer side, while
the pubic portion of the fascia, l, lies beneath it. The cord, k, is
placed on the inner side of the hernia; the ci’ibriform fascia covers
it; and the upper end of the saphena vein, m, passes beneath
its lower border. The upper cornu. A, Fig. 2, of the falciform
process would seem, by its situation, to be one of the parts
which constrict a crural hernia. An inguinal hernia, which
descends the cord, k. Fig. 1, provided it passes no further than
the point indicated at K, and a crural hernia turning upwards
from the saphenous interval over the cord at k, are very likely to
present some difficulty in distinctive diagnosis.
1*
V-'^'<:i'
mWM
. —^---^ ^t*,.'■ V .-
B
H A. N. ifaiihan lith. limters
COMMENTARY ON PLATE XVIII.
THE SURGICAL DISSECTION OF THE FIFTH, SIXTH, SEVENTH, AND EIGHTH LAYERS OF THE INGUINAL
REGION, AND THEIR CONNEXION WITH THOSE OF THE THIGH.
When we remove the internal oblique and cremaster muscles, we
expose the transverse muscle, which may be regarded as the fifth
inguinal layer^ e, Fig. 1. This muscle is similar in shape and
dimensions to the internal oblique. The connexions of both are
also similar, inasmuch as they arise from the inner edge of the
crista ilii, and from the outer half of, v, Poupart’s ligament. The
fleshy fibres of these two muscles vary but little in direction, and
terminate at the same place—^viz., the linea semilunaris, which
marks the outer border of the rectus muscle. But whilst the
fleshy parts of these three abdominal muscles, D b f, form successive
strata in the groin, their aponeurotic tendons present the following
peculiarities of arrangement in respect to the rectus muscle. The
tendon of the external oblique, d, passes altogether in front of the
rectus; that of the internal oblique is split opposite the linea
semilunaris into two layers, which enclose the rectus between
them as they pass to be inserted into the linea alba. But midway
between the navel and pubes, at the point marked g, both layers
of the tendon are found to pass in front of the rectus. The
tendon of the transverse muscle passes behind the rectus; but
opposite the point G, it joins both layers of the internal oblique
tendon, and with this passes in front of the rectus. The fibrous
structure thus constituted by the union of the tendons of the
internal oblique and transverse muscles, e /, is named the “ con¬
joined tendon.”
The conjoined tendon, /, Figs. 1 and 2, appears as a continuation
of the linea semilunaris, for this latter is in itself a result of the union
of the tendons of the abdominal muscles at the external border
of the rectus. As the conjoined tendon curves so far outwards
to its insertion into the pectineal ridge of the pubic bone, as to
occupy a situation immediately behind the external ring, it
thereby fortifies this part against the occurrence of a direct
protrusion of the bowel. But the breadth, as weU as the density,
of this tendon varies in several individuals, and these will
accordingly be more or less liable to the occurrence of hernia.
The arched inferior border of the transverse muscle, f, Fig. 1,
expresses by its abrupt termination that some part is wanting to
it; and this appearance, together with the fact that the fibres of
this part of the muscle blend with those of the internal oblique
and cremaster, and cannot be separated except by severing the
connexion, at once suggests the idea that the cremaster is a
derivation from both these muscles.
Assuming this to be the case, therefore, it follows that when
the dissector removes the cremaster from the space L A, he himself
causes this vacancy in the muscular parietes of the groin to
occur, and at the same time gives unnatural definition to the
lower border of the transverse and oblique muscles. In a
dissection so conducted, the cord is made to assume the variable
positions which anatomists report it to have in respect to the
neighbouring muscles. But when we view nature as she is,
and not as fashioned by the scalpel, we never fail to find an easy
explanation of her form.
In the foetus, prior to the descent of the testicle, the cremaster
muscle does not exist. (Cloquet, op cit.) From this we infer, that
those parts of the muscles, e f. Fig. 1, which at a subsequent period
are converted into a cremaster, entirely occupy the space l A. In
the adult body, where one of the testicles has been arrested in
the inguinal canal, the muscles, E f, do not present a defined
arched margin, above the vacant space L A, but are continued
(as in the foetus) as low down as the external abdominal ring.
In the adult, where the testicle has descended to the scrotum, the
cremaster exists, and is serially continuous with the muscles, E F,
covering the space L A; the meaning of which is, that the cre¬
masteric parts of the muscles, e f, cover this space. The name
cremaster therefore must not cancel the fact that the fibres so named
are parts of the muscles, e f. Again, in the female devoid of a
cremaster, the muscles, E f, present of their full quantities, having
sustained no diminution of their bulk by the formation of a
cremaster. But when an external inguinal hernia occurs in the
female body, the bowel during its descent carries before it a
cremasteric covering at the expense of the muscles B F, just in
the same way as the testicle does in the foetus. (Cloquet.)
From the above-mentioned facts, viewed comparatively, it seems
DESCRIPTION OF THE
Figure 1.
A. The anterior superior iliac spine.
B. The umbilicus.
C. The spine of the pubis.
D. The external oblique muscle; d, its tendon.
E. The internal oblique muscle; e, its tendon.
F. The transverse muscle; f, its tendon, forming, withe, the conjoined
tendon.
G. The rectus muscle enclosed in its sheath.
H. The fascia spermatica interna covering the cord; A, its funnel-shaped
extremity.
I. K, L, M. See Fig. 2.
N. The femoral artery; w, its profunda branch.
O. The femoral vein.
P. The saphena vein.
Q. The sartorius muscle.
R. The sheath of the femoral vessels.
S. The falciform margin of the saphenous opening.
T. The anterior crural nerve.
U. The pubic portion of tBe fascia lata.
V. The iliac portion attached to Poupart’s ligament.
W. The lower part of the iliacus muscle.
FIGURES OF PLATE XVIII.
Figure 2.
A. The anterior superior iliac spine.
B. The umbilicus.
C. The spine of the pubis.
D. The external oblique muscle ; d, its tendon; d*, the external ring.
E. The internal oblique muscle.
F. The transverse muscle; /, its tendon; forming, with e, the conjoined
tendon.
G. The rectus muscle laid bare.
H h. The fascia spermatica interna laid open above and below d*, the ex¬
ternal ring.
I. The peritonaeum closing the internal ring.
K. The fascia transversalis; A, its pubic part.
L. The epigastric artery and veins.
M. The spermatic artery, veins, and vas deferens bending round the epi¬
gastric artery at the internal ring; tn, the same vessels below the
external ring.
N. The femoral artery ; n, its profunda branch.
O. The femoral vein, joined by—
P. The saphena vein.
Q. The sartorius muscle.
R. The sheath of the femoral vessels.
S S. The falciform margin of the saphenous opening.
T. The anterior crural nerve.
U. The pubic part of the fascia lata.
V. The iliac part of the fascia lata.
W. The lower part of the iliacus muscle.
COMMENTARY ON PLATE XVIII.
that the following inferences may he leghimately drawn1st, that
the space l h does not naturally exist devoid of a muscular cover¬
ing; for, in fact, the cremaster overlies this situation; 2nd, that
the name cremaster is one given to the lower fibres of the internal
oblique and transverse muscles which cover this space; and 3rd,
that to separate the cremasteric elongation of these muscles, and
then describe them as presenting a defined arched margin, an inch
or two above Poupart’s ligament, is an act as arbitrary on the
part of the dissector as if he were to subdivide these muscles
still more, and, while regarding the subdivisions as different
structures, to give them names of different signification. When
once we consent to regard the cremaster as constituted of the
fibres originally proper to the muscles, e f, we then are led to
the discovery of the true relations of the cord in respect to these
muscles.
On removing the transverse muscle, we expose the inguinal part
of the transversalis fascia— the sixth inguinal layer^ L /i. Fig. 1 k
Fig. 2. This fascia or membrane affords a general lining to the
abdominal Avails, in some parts of which it presents of a denser and
stronger texture than in others. It is stretched over the abdomen
between the muscles and the peritonaeum. The fascia iliaca, the
fascia pelvica, and the fivscia transversalis, are only regional divisions
of the one general membrane. On viewing this fascia in its totality,
I find it to exhibit many features in common Avith those other fibrous
structures which envelope serous cavities. The transversalis
fascia supports externally the peritonaium, in the same way as the
dura mater supports the arachnoid membrane, or as the pleural
fascia supports the serous pleura. While the serous membranes
form completely shut sacs, the fibrous membranes Avhich lie
external to those sacs are pierced by the vessels Avhich course ,
between them and the serous membranes, and afford sheaths or i
envelopes for these vessels in their passage from the interior
to the external parts. The sheath, ii A, Figs. 1 and 2, which
surrounds the spermatic vessels, and the sheath, R, Fig. 2,
Avhich envelopes the crural vessels, are elongations of the fascia
transversalis.
In the groin, the transversalis fascia, k Fig. 2, presents, in
general, so dense a texture as to offer considerable resistance to
visceral pressure. Here it is stretched between the transverse
muscle, E, Fig. 2, and the peritonaeum, i. It adheres to the
external surface of the peritonaeum, and to the internal surface of
the transverse muscle, by means of an intervening cellular tissue.
It is connected below to Poupart’s ligament, along the line of
which it joins the fascia iliaca. It lines the lower posterior aspect
of the rectus muscle, where this is devoid of its sheath; and it is
incorporated Avith /, the conjoined tendon, thereby fendng the
external abdominal ring. Immediately above the middle of
Poupart’s ligament, this membrane, at the point marked A, Fig. 1,
is pouched into a canal-shaped elongation, Avhich invests the
spermatic vessels as far as the testicle in the scrotum; and to this
elongation is given the names “ fascia spermatica interna
(Cooper), “fascia infundibuliform” (Cloquet). The same part,
Avhen it encloses an external oblique hernia, is named “fascia
propria.” The neck or inlet of this funnel-shaped canal is oval,
and named the “ internal abdominal ring.” As this ring looks
towards the interior of the abdomen, and forms the entrance of
the funnel-shaped canal, it cannot of course be seen from before
until we slit open this canal. Compare the parts marked h h in
Figs. 1 and 2.
The inguinal and iliac portions of the fascia transversalis join
along the line of Poupart’s ligament, A c. The iliac vessels, in
their passage to the thigh, encounter the fascia at the middle third
of the crural arch formed by the ligament, and take an investment
(the sheath, r) from the fascia. The fore part of this sheath is
mentioned as formed by the fascia transversalis—the back part by
the fascia iliaca; but these distinctions are merely nominal, and
it is therefore unnecessary to dAvell upon them. The sheath of
the femoral vessels is also funnel-shaped, and suriounds them on
all sides. Its broad entrance lies beneath the middle of Poupart’s
ligament. Several septa are met with in its interior. These
serve to separate the femoral vessels from each other. The
femoral vein, o. Fig. 1, is separated from the falciform margin,
s 5 , of the saphenous opening by one of these septa. Between
this septum and the falx an interval occurs, and through it the
crural hernia usually descends. These parts will be more par¬
ticularly noticed when considering the anatomy of crural hernia.
Beneath the fascia transversalis is found the sub-serous cellular
membrane, which serves as a connecting medium between the
fascia and the peritonaeum. This cellular membrane may be
considered as the seventh inguinal layer. It is described by Scarpa
(suir Ernie) as forming an investment for the spermatic vessels
inside the sheath, where it is copious, especially in old inguinal
hernia. It is also sometimes mixed with fatty tissue. In it is
found embedded the infantile cord—the remains of the upper part
of the peritonaeal tunica vaginalis^—a structure which will be con¬
sidered in connexion with congenital hernias.
By removing the subserous cellular tissue, we lay bare the
peritonaeum, which forms the eighth layer oj^ the inguinal region.
Upon it the epigastric and spermatic vessels are seen to rest.
These vessels course betAveen the fascia transversalis and the
peritonfEum. The internal ring Avhich is formed in the fascia, k A,
may be now seen to be closed by the peritonaeum, i. The inguinal
canal, therefore, does not, in the normal state of these parts,
communicate Avith the general serous cavity; and here it must
be evident that before the bowel, which is situated immediately
behind the peritonasAim, i, can be received into the canal, h A, it
must either rupture that membrane, or elongate it in the form
of a sac.
The exact position which the epigastric, l. Fig. 2, and spermatic
A^essels, M, bear in respect to the internal ring, is a point of chief
importance in the surgical anatomy of the groin; for the various
forms of hernia; Avhich protrude through this part have an
intimate relation to these vessels. The epigastric artery, in
general, arises from the external iliac, close above the middle of
Poupart’s ligament, and ascends the inguinal Avail in an oblique
course towards the navel. It applies itself to the inner border of
the internal ring, and here it is crossed on its outer side by
the spermatic vessels, as these are about to enter the inguinal
canal.
The inguinal canal is the natural channel through which the
spermatic vessels traverse the groin on their way to the testicle in
the scrotum. In the remarks Avhich have been already made respect¬
ing the several layers of structures found in the groin, I endea¬
voured to realize the idea of an inguinal canal as consisting of
elongations of these layers invaginated the one within the other,
the outermost layer being the integument of the groin elongated
into the scrotal skin, AA-hilst the innennost layer consisted of the
transversalis fascia elongated into the fascia spennatica interna, or
sheath. The peidtoneeum, Avhich forms the eighth layer of the
groin, Avas seen to be draAAOi across the internal ring of this canal
above in such a Avay as to close it completely, whilst aU the other
layers, seven in number, were described as being continued over the
spermatic vessels in the form of funnel-shaped investments, as far
doAvn as the testicle.
With the ideas of an inguinal canal thus naturally constituted,
I need not hesitate to assert that the form, the extent, and the
boundaries of the inguinal canal, as given by the descriptive
anatomist, are purely conventional, and do not exist until after
dissection; for which reason, and also because the form and
condition of these parts so described and dissected do not appear
absolutely to correspond in any two indmduals, I omit to mention
the scale of measurements drawn up by some eminent surgeons,
Avith the object of determining the precise relative position of the
several parts of the inguinal region.
The existence of an inguinal canal consisting, as I have
described it, of funnel-shaped elongations from the several
inguinal layers continued over the cord as far as the testicle,
renders the adult male especially liable to hernial protrusions at
this part. The obbque direction of the canal is, in some measure,
a safeguard against these accidents; but this obliquity is not of
the same degree in all bodies, and hence some are naturally more
prone to hernia; than others.
COMMENTAEY ON PLATE XIX.
THE DISSECTION OF THE OBLIQUE OR EXTERNAL AND THE DIRECT OR INTERNAL
INGUINAL HERNIA.
The order in ■whicli the herniary bowel takes its investments from
the eight layers of the inguinal region, is precisely the reverse of
that order in which these layers present in the dissection from
before backwards. The innermost layer of the inguinal region
is the peritonasum, and from this membrane the intestine, when
about to protrude, derives its first covering. This covering con¬
stitutes the hernial sac. Almost all varieties of inguinal herniae
are said to be enveloped in a sac, or elongation of the peritonaeum.
This is accounted as the general rule. The exceptions to the
rule are mentioned as occurring in the following modes: 1st,
the cajcum and sigmoid flexure of the colon, which are devoid
of mesenteries, and only partially covered by the peritonaeum,
may slip down behind this membrane, and become hernial; 2nd,
the inguinal part of the peritonaeum may suffer rupture, and
aUow the intestine to protrude through the opening. When
a hernia occurs under either of these circumstances, it will be
found deprived of a sac.
All the bloodvessels and nerves of the abdomen lie external to
the peritoneum. Those vessels which traverse the abdomen on
their way to the external organs course oiitside the peritoneum,
and at the places where they enter the abdominal parietes, the
membrane is reflected from them. This disposition of the ^ peri¬
toneum in respect to the spermatic and iliac vessels is exhibited
in Fig. 1. _ , .
The part of the peritoneum which lines the inguinal parietes
does not (in the normal state of the adult body) exhibit any
aperture corresponding to that named the internal ring. The
membrane is in this place, as elsewhere, continuous throughout,
being extended over the ring, as also over other localities, where
subjacent structures may be in part wanting. It is in these
places, where the membrane happens to be unsupported, that
herni^ are most liable to occur. And it must be added, that
the natural form of the internal surface of the groin is such as to
guide the viscera under pressure directly against those parts w ic
are the weakest.
The inner surface of the groin is divided into two pouches or
foss®, by an intervening crescentic fold of the peritonaeum, w ic
irresponds with the situation of the epigastric vesseR. This fold
formed by the epigastric vessels and the umbilical ligament,
Rich, being tenser and shorter than the peritoneum, thereby
ause this membrane to project. The outer fossa represents
triangular space, the apex of which is below, at P; the base
eing formed by the fibres of the transverse muscle above; the
nner side by the epigastric artery; and the outer side by Poupart’s
Lgament. The apex of this inverted triangle is opposite the
ntemal ring. The inner fossa is bounded by the epigastric
trtery externally; by the margin of the rectus muscle internally;
md by the os pubis and inner end of Poupart’s hgainent
nferiorly. The inner fossa is opposite the external abdoimnal
•ing, and is known as the triangle of Hesselbach.
The two peritonfeal fossae being named external and internal, in
reference to the situation of the epigastric vessels, we find that
the two varieties of inguinal herniae which occur in these ossae
are named external and internal also, in reference to the same part.
The external inguinal hernia, so caUed from its commencing
in the outer peritonaeal fossa, on the outer side of the epigastric
artery, takes a covering from the peritoneum of this place, and
pushes fonvard into the internal abdomina,! ring at the point
marked P Fig. 1. In this place, the incipient hernia or bubo¬
nocele, covered by its sac, lies on the fore part of the spermatic
vessels, and becomes invested by those same coverings which
constitute the inguinal canal, through which these vessels pass.
In this stage of the hernia, its situation in respect to the
epigastric artery is truly external, and in respect to t e
spermatic vessels, anterior, while the protruded intestine itself
is separated from actual contact vrith either of these vessels by
its proper sac. The bubonocele, projecting through the internal
ring at the situation marked P, (Fig. 2,) midway between a, the
anterior iliac spine, and i, the pubic spine, continues to increase
in size; but as its further progress from behind directly forwards
becomes arrested by the tense resisting aponeurosis of the
external oblique muscle, h, it changes its course obliqudy
inwards along the canal, traversing this canal with the spermatic
vessels, which still lie behind it, and, lastly, makes its exit at the
description of the figures of plate XIX.
Figure 1.
. That part of the ilium which abuts against the sacrum.
The spine of the ischium.
!. The tuberosity of the ischium.
). The symphysis pubis.
5. Situation of the anterior superior ihac spine.
S'. Crest of the ilium.
a. PsolTiTagnts muscle supporting the spermatic vessels.
[. Transversalis muscle.
K. Termination of the sheath of the l ectus ^ ^ transversalis
L' L* L^ The iliac, transverse and peliic porno
fascia
versalis fascia, L .
L\':;"r:mex«,naU„gmna. he™, fonaed before the
Q. A» oceurs between the umbiUcal liganten.
and the epigastnc ^’'t^direct inguinal hernia occurs when, as in
** rrr —oUes the space „a.ed dte in-
ternal fossa—the triangle of Hesselbach.
S. Lower part of the right spermatic cord.
T The bulb of the urethra.
u. External iliac vein covered by the per,h.ntenn..
V. External iliac artery covered by the peritonseum.
W. Internal iliac artery.
X. Common iliac artery.
Figure 2. _ The External Inguinal Hernia.
A. Anterior iliac spinous process.
B. The umbilicus. ^ 3
C. Fleshy part of the external oblique muscle; c, its tendon.
D. Fleshy part of the internal oblique muscle; d, its tendon.
E Transversalis muscle; e, the conjoined tendon.
F f. The funnel-shaped sheath of the spermatic vessels covering the ex-
ternal hernia; upon it are seen the cremasteric fibres.
The pe,h.n».l cLring or sac of the external he™ia w..h.„ the
sheath.
H. The external abdominal ring.
I. The crista pubis.
K h. The saphenous opening.
L. The saphena vein.
M. The femoral vein.
N. The femoral artery; n, its profunda branch.
O. The anterior crural nerve. ,,.,11,
P. The epigastric vessels overlaid by the neck of the henna.
Q Q. The sheath of the femoral vessels.
R. The sartorius muscle.
S. The iliacus muscle.
Figure 3.— The Internal Inguinal Hernia.
The letters indicate the same parts as in Figure 2.
COMMENTARY ON PLATE XIX.
external ring, H. The obliquity of this course, pursued by the
hernia, from the internal to the external ring, has gained for it
the name of ol)li(ju6 hernia. In this stage of the hernial protru¬
sion, the only part of it which may be truly named external is the
neck of its sac, f, for the elongated body, G, of the hernia lies now
actuaUy in front of the epigastric arterjq p, and this vessel is sepa¬
rated from the anterior wall of the canal, H A, by an interval equal
to the bulk of the hernia. While the hernia occupies the canal,
F H, without projecting through the external ring, H, it is named
“ incomplete.” When it has passed the external ring, H, so as to
fonn a tumour of the size and in the situation of/ it is named
“ complete.” When, lastly, the hernia has extended itself so far
as to occupy the whole length of the cord, and reach the scrotum,
it is termed “ scrotal hernia.” These names, it will be seen, are
given only to characterise the several stages of the one kind of
hernia_^viz., that which commences to form at a situation external
to the epigastric artery, and, after following the course of the
spermatic A'^essels through the inguinal canal, at length terminates
in the scrotum.
The external inguinal hernia having entered the canal, p,
(Fig. 1,) at a situation immediately in front of the spermatic
vessels, continues, in the several stages of its descent, to hold the
same relation to these vessels through the whole length of the canal,
even as far as the testicle in the scrotum. This hernia, however,
when of long standing and large size, is known to separate the
spermatic vessels from each other in such a way, that some are
found to lie on its fore part—others to its outer side. However
great may be the size of this hernia, even when it becomes scrotal,
stiU the testicle is invariably found below it. This fact is accounted
for by the circumstance, that the lower end of the spermatic
envelopes is attached so firmly to the coats of the testicle as to
prevent the hernia from either distending and elongating them to
a level below this organ, or from entering the cavity of the tunica
vaginalis.
The external form of inguinal hernia is, comparatively speaking,
but rarely seen in the female. When it does occur in this sex,
its position, investments, and course through the inguinal canal,
where it accompanies the round ligament of the uterus, are the
same as in the male. When the hernia escapes through the external
abdominal ring of the female groin, it is found to lodge in the
labium pudendi. In the male body, the testicle and spermatic cord,
which have carried before them investments derived from all the
layers of the inguinal region, have, as it were, already marked out
the track to be followed by the hernia, and prepared for it its several
coverings. The muscular parietes of the male inguinal region,
from which the loose cremaster muscle has been derived, have by
this circumstance become weakened, and hence the more frequent
occurrence of external inguinal hernia in the male. But in the
female, where no such process has taken place, and where a
cremaster does not exist at the expense of the internal oblique and
transverse muscles, the inguinal parietes remain more compact,
and are less liable to suffer distention in the course of the uterine
ligament.
The internal inguinal hernia takes its peritonaeal covering (the
sac) from the inner fossa, Q E, Fig. 1, internal to the epigastric
artery, and forces, directly forwards through the external abdo¬
minal ring, carrying investments from each of such structures as
it meets with in this locality of the groin. As the external ring,
H, Fig. 3, is opposite the inner peritonaeal fossa, q e. Fig. 1, this
hernia, which protrudes thus immediately from behind forwards,
is also named direct. In this way these two varieties of hernia.
(the external. Fig. 2, and the internal. Fig. 3,) though com¬
mencing in different situations, p and e. Fig. 1, within the
abdomen, arrive at the same place—-viz., the external ring, ii.
Figs. 2, 3. The coverings of the internal hernia. Fig. 3, though
not derived exactly from the same locality as those which invest
the cord and the external variety, are, nevertheless, but different
parts of the same structures; these are, 1st, the peritonasum, g,
which forms its sac; 2nd, the pubic part of the fascia transversalis;
3rd, the conjoined tendon itself, or (according as the hernia may
occur further from the mesial line) the cremaster, which, in com¬
mon with the internal oblique and transverse muscles, terminates
in this tendon; 4th, the external spermatic fascia, derived from
the margins of the external ring; 5th, the superficial fascia and
integuments.
The coverings of the internal inguinal hernia are (as to number)
variously described by authors. Thus with respect to the conjoined
tendon, the hernia is said, in some instances, to take an investment
of this structure; in others, to pass through a cleft in its fibres; in
others, to escape by its outer margin. Again, the cremaster
muscle is stated by some to cover this hernia; by others, to be
rarely met with, as forming one of its coverings; and by others,
never. Lastly, it is doubted by some whether this hernia is even
covered by a protrusion of the fascia transversalis in all instances.*
The variety in the number of investments of the internal inguinal
hernia (especially as regards the presence or absence of the con¬
joined tendon and cremaster) appears to me to be dependent, Ist^
upon the position whereat this hernia occurs; 2nd, upon the state
of the parts through Avhich it passes; and 3rd, upon the manner in
which the dissection happens to be conducted.
The precise relations which the internal hernia holds in respect
to the epigastric and spermatic vessels are also mainly dependent (as
in the external variety) upon the situation where it traverses the
groin. The epigastric artery courses outside the neck of its sac,
sometimes in close connexion with this part—at other times, at
some distance from it, according as the neck may happen to be
wide and near the vessel, or nai-row, and removed from it nearer
to the median line. At the external ring, h, (Fig. 3,) the sac of
this hernia, protnides on the inner side of the spermatic
vessels, /; and the size of the hernia distending the ring, removes
these vessels at a considerable interval from, i, the crista pubis.
At the ring, h, (Fig. 3,) the investments, ^/, of the direct hernia
are not always distinct from those of the oblique hernia, g /,
(Fig. 2); for whilst in both varieties the intestine and the
spermatic vessels are separated from actual contact by the sac, yet
it is true that the direct hernia, as well as the oblique, may occupy
the inguinal canal. It is in relation to the epigastric artery alone
that the direct hernia differs essentially from the oblique variety;
for I find that both may be enclosed in the same structures as invest
the spermatic vessels.
The external ring of the male groin is larger than that
of the female; and this circumstance, with others of a like
nature, may account for the fact, that the female is very rarely
the subject of the direct hernia. In the male, the direct hernia is
found to occur much less frequently than the oblique, and this we
might, h priory expect, from the anatomical disposition of the
parts. But it is true, nevertheless, that the part Avhere the
direct hernia occurs is not defended so completely in some male
bodies as it is in others. The conjoined tendon, which is described
as shielding the external ring, is in some cases very weak, and in
others so narrow, as to offer but little support to this part of the
groin.
* Mr. Lawrence (Treatise on Ruptures) remarks, “ How often it may
be invested by a protrusion of the fascia transversalis, I cannot hitherto
determine.” Mr. Stanley has presented to St. Bartholomew’s Hospital
several specimens of this hernia invested by the fascia. Hesselbach
speaks of the fascia as being always present. Cloquet mentions it as
being present always, except in such cases as where, by being ruptured,
the sac protrudes through it. Langenbeck states that the fascia is con¬
stantly protruded as a covering to this hernia: “ Quia hernia inguinalis
interna non in canalis abdominalis aperturam internam transit, tunicam
vaginalem communem intrare nequit; parietem autem canalis abdominalis
internum aponeuroticum, in quo fovea inguinalis interna, et qui ex ad-
verso annulo abdominali est, ante se per annulum trudit.” (Comment, ad
illust. Herniarum, &c.) Perhaps the readiest and surest explanation
which can be given to these differences of opinion may be had from the
following remark:—“Culter enim semper has partes extricat, quae in-
volucro adeo inhaerent, ut pro lubitu musculum (membranam) efformare
queas unde magnam illam inter anatomicos discrepantiam ortam conjicio.”
(Camper. leones Herniarum.)
COMMENTARY ON PLATE XX.
THE DISTINCTIVE DIAGNOSIS BETWEEN EXTERNAL AND INTERNAL INGUINAL HERNIA, THE TAXIS,
THE SEAT OF STRICTURE, AND THE OPERATION.
A COMPARISON of the relative position of these two varieties of
hernias is in ordinary cases the chief means by which we can
determine their distinctive diagnosis; but oftentimes they are
found to exhibit such an interchange of characters, that the
name direct or oblique can no longer serve to distinguish between
them. The nearer the one approaches the usual place of the
other, the more likely are they to be mistaken the one for the other.
An internal hernia may enter the inguinal canal, and become
oblique; while an external hernia, though occupying the canal,
may become direct. It is only when these hernias occur at the
situations commonly described, and where they manifest their
broadest contrast, that the following diagnostic signs can be
observed.
The external bubonocele, h, Fig. 3, G, Fig. 4, when recently
formed, may be detected at a situation midway between the iliac
and pubic spinous processes, where it has entered the internal ring.
When the hernia extends itself from this part, its course will be
obliquely inwards, corresponding with the direction of the inguinal
canal. While it stUl occupies the canal without passing through
the external ring, it is rendered obscure by the restraint of the
external oblique tendon; but yet a degree of fulness may be felt
in this situation. When the hernia has passed the external ring,
T, Fig. 2, it dilates considerably, and assumes the form of an
oblong swelling, h, Fig. 2, behind which the spermatic vessels
are situated. When it has become scrotal, the cord will be found
stiU on its posterior aspect, while the testicle itself occupies a
situation directly below the sweUing.
The internal hernia, h. Fig. 4, also traverses the external ring, t,
where it assumes a globular shape, and sometimes projects so far
inwards, over the pubes, c, as to conceal the crista of this bone
As the direction of this hernia is immediately from behind forwards,
the inguinal canal near the internal ring is found empty, unswoUen.
The cord, Q, lies external to and somewhat over the fore part of
this hernia; and the testicle does not occupy a situation exactly
beneath the fundus of the sac, (as it does in the external herma,)
but is found to be placed either at its fore part or its outer side.
This dilference as to the relative position of the cord and testicle
in both these forms of hernise, is accounted for under the supposi¬
tion that whilst the external variety descends inside the sheaths
of the inguinal canal, the internal variety does not.^ But this
statement cannot apply to all cases of internal herma, for this
also occasionally enters the canal.
Both forms of inguinal hernia may exist at the same time on
the same side: the external, G, Fig. 4, being a bubonocele, still
occupying the inguinal canal; while the internal, H, protrudes
through the external ring, T, in the usual way. In this form o
hernia—a compound of the oblique and dmect—while the parts
remain stiU covered by the integuments, it must be difficult to
tell its nature, or to distinguish any mark by which to diagnose t e
case from one of the external variety, H, Fig. 2, which, on entering
the canal at the internal ring, protrudes at the external rmg. n
both cases, the sweUing produced in the groin must be exactly ot
the same size and shape. The epigastric artery in the case where
the two herniie co-exist lies between them, holding m its usua
position mth respect to each when occurring separately—that is,
on the outer side of the internal hernia, h, and on the inner side
of the external one, g; and the external hernia, G, not having
descended the canal as far as the external ring, t, allows the
DESCRIPTION OF THE FIGURES OF PLATE XX.
Figure 1.
A. Anterior superior spine of the ilium; a, indicates the situation of the
middle of Poupart’s ligament.
B. Symphysis pubis.
C. Rectus abdominis muscle covered by the fascia transversalis.
D. The peritonmum lining the groin.
E. The situation of the conjoined tendon resisting the further progress o
the external hernia gravitating inwards.
F. A dotted line indicating the original situation of the epigastric artery
in the external hernia. • j i,
G. The new position assumed by the epigastric artery borne inwards y
the weight of the old external hernia.
H. The original situation of the neck of the sac ef the external hernia.
I. The new situation assumed by the neck of the sac of an old extona
hernia which has gravitated inwards Rom its original place at H.
K. The external iliac vein covered by the peritonaeum.
l! The external iliac artery covered by the peritonaeum and crossed by
the spermatic vessels. .
M. The psoas muscle supporting the spermatic vessels and the genito-
crural nerve.
N. The iliacus muscle.
O. The transversalis fascia lining the transverse muscle.
Figure 2.—An Anterior View oe Figure 1.
A. Anterior superior iliac spinous process.
B. The navel.
C. The situation of the crista pubis.
D. The external oblique muscle; d, its tendon.
E. Internal oblique muscle; e, its tendon, covering the rectus muscle.
F. Lower part of the transverse muscle; /, the conjoined tendon.
G The transversalis fascia investing the upper part of the hermal sac, g,
the original situation of the epigastric artery internal to this hernia;
q* the new situation of the artery pushed inwards.
H. The hernial sac, invested by, A, the elongation of the fascia transversalis,
or funnel-shaped sheath.
I. The femoral artery.
K. The femoral vein.
L. The sartorius muscle.
M. Iliac part of the fascia lata joining Poupart’s ligament.
N. Pubic part of the fascia lata.
O. Saphena vein.
p Falciform margin of the saphenous opening.
Q. See Fig. 4.
R. Sheath of the femoral vessels.
S. Anterior crural nerve.
T. The external ring.
Figure 3.
All the letters except the following indicate the same parts as in Fig. 1.
F. The epigastric artery passing between the two hernial sacs.
G. The umbilical ligament.
H. The neck of the sac of the external hernia.
I. The neck of the sac of the internal hernia.
Figure 4.— An Anterior View oe Figure 3.
All the letters, with the exception of the following, refer to the same parts
as in Fig. 2.
G. The funnel-shaped elongation of the fascia transversalis leceiving g,
the sac of the external bubonocele.
H. The sac of the internal inguinal hernia invested by h, the transveisa i
f£tSCl£l» • • * 1
Q. The spermatic vessels lying on the outer side of H, the direct inguina
hernia.
COMMENTARY ON PLATE XX.
internal hernia, h, to assume its usual position Avith respect to
the cord, Q.*
Returning, however, to the more frequent conditions of in uinal
hernia—viz., those in which either the direct or the oblique
variety occurs alone—it should be remembered that a hernia
originally oblique, h. Figs. 1 and 3, may, when of long standing,
and having attained a large size, destroy, by its gravitation, the
obliquity of the inguinal canal to such a degree as to bring the
internal, h. Fig. 1, opposite to the external ring, as at i, and
thereby exhibit all the appearance of a hernia originally direct, i.
Fig. 3. In such a case, the epigastric artery, f, which lies on
the outer side of the neck of a truly direct hernia, i. Fig. 3, Avill
be found to course on the inner side, G, of the neck of this false-
seeming direct hernia, i. Fig. 1.
In the trial made for replacing the protruded bowel by the
taxis^ two circumstances should be remembered in order to
facilitate this object: 1st, the abdominal parietes should be
relaxed by supporting the trunk forwards, and at the same time
flexing the thigh on the trunk; 2nd, as every complete hernial
protrusion becomes distended more or less beyond the seat of
stricture—wherever this may happen to be—its reduction by the
taxis should be attempted, with gradual, gentle, equable pressure,
so that the sac may be first emptied of its fluid. That part of the
hernia which protruded last should be replaced first. The
direction in which the hernia protrudes must always determine
the direction in which it is to be reduced. If it be the external
or oblique variety, the viscus is to be pushed upwards, outwards,
and backwards; if it be the internal or direct variety, it is to be
reduced by pressure, made upwards and backAvards. Pressure
made in this latter direction Avill serve for the reduction of that
hernia which, from being originally external and oblique, has
assumed the usual position of the internal or direct variety.
The seat of the stricture in an external inguinal hernia is found
to be situated either at the internal ring, corresponding to the
neck of the sac, or at the external ring. Between these two
points, which “ bound the canal,” and which are to be regarded
merely as passive agents in causing stricture of the j)rotruding
boAvel, the lower parts of the transversalis and internal obhque
muscles embrace the herniary sac, and are known at times to be
the cause of its active strangulation or spasm.
The seat of stricture in an internal hernia may be either at the
neck of its sac, i. Fig. 3, or at the external ring, t. Fig 4; and
according to the locality where this hernia enters the inguinal wall,
the nature of its stricture Avill vary. If the hernia pass through a
cleft in the conjoined tendon, /, Fig. 4, this structure Avill con¬
strict its neck aU around. If it pass on the outer margin of this
tendon, then the neck of the sac, bending inwards in order to gain
the external ring, aauU be constricted against the sharp resisting
edge of the tendon. Again, if the hernia enter the inguinal AvaU
close to the epigastric artery, it will find its way into the inguinal
canal, become invested by the structures forming this part, and
here it may suffer active constriction from the muscular fibres of
the transverse and internal oblique or their cremasteric parts.
The external ring may be considered as always causing some degree
of pressure on the hernia which passes through it.
In both kinds of inguinal herniie, the neck of the sac is described
as being occasionally the seat of stricture, and it certainly is so*
but never from a cause originating in itself pe,^ se, or independently
of adjacent structures. The form of the sac of a hernia is influ¬
enced by the parts through which it passes, or which it pushes
and elongates before itself. Its neck, h. Fig. 3, is narrow at the
internal ring of the fascia transversalis, because this ring is itself
narrowed; it is again narrowed at the external ring, t. Fig. 2 from
the same cause. The neck of the sac of a direct heria, i Fig. 3
being formed in the space of the separated fibres of the conjoined
tendon, or the pubic part of the transversalis fascia, while the sac
Itself passes through the resisting tendinous external ring, is eqiial
to the capacities of these outlets. But if these constricting outlets
did not exist, the neck of the sac Avould be also wanting. When,
however, the neck of the sac has existed in the embrace of these
constricting parts for a considerable period—when it suffers in¬
flammation and undergoes chronic thickening—then, even though
we liberate the stricture of the internal ring or the external, the
neck of the sac Avill be found to maintain its narrow diameter, and
to have become itself a real seat of stricture. It is in cases of this
latter kind of stricture that experience has demonstrated the neces¬
sity of opening the sac (a proceeding otherwise not only needless,
but objectionable) and dmding its constricted neck.
The fact that the stricture may be seated in the neck of the sac
independent of the internal ring, and also that the duplicature of
the contained bowel may be adherent to the neck or other part of
the interior, or that firm bands of false membrane may exist so as
to constrict the bowel within the sac, are circumstances which re¬
quire that this should be opened, and the state of its contained
parts examined, prior to the replacement of the bowel in the ab¬
domen. If the bowel were adherent to the neck of the sac, Ave
might, when trjdng to reduce it by the taxis, produce visceral in¬
vagination ; or while the stricture is in the neck of the sac, if we
were to return this and its contents en masse (the “ reduction en
bloc”) into the abdomen, it is obvious that the bowel would be still
in a state of strangulation, though free of the internal ring or other
opening in the inguinal wall.
The operation for the division of the stricture by the knife is
conducted in the foUoAving way: an incision is to be made
through the integuments, adipous membrane, and superficial
fascia, of a length and depth sufficient to expose the tendon of
the external oblique muscle for an inch or so above the external
ring; and the hernia for the same extent beloAv the ring. The length
of the incision Avill require to be varied according to circumstances,
but its direction should be oblique Avith that of the hernia itself,
and also over the centre of its longitudinal axis, so as to avoid
injuring the spermatic vessels. If the constriction of the hernia
be caused by the external ring, a director is to be inserted beneath
this part, and a few of its fibres divided. But Avhen the stricture
is produced by either of the muscles which lie beneath the apo¬
neurosis of the exteiTial oblique, it will be necessary to divide this
part in order to expose and incise them.
When the thickened and indurated neck of the sac is felt to be
the cause of the strangulation, or when the bowel cannot be
replaced, in consequence of adhesions which it may have contracted
Avith some part of the sac, it then becomes necessary to open this
envelope. And now the position of the epigastric artery is to be
remembered, so as to avoid wounding it in the incision about to
be made through the constricted neck of the sac. The arteiy
being situated on the inner side of the nech of the sac of an oblique
hernia, requires the incision to be made outwards from the external
side of the neck; whereas in the direct hernia, the artery being
on its outer side, the incision should be conducted inwards from
the inner side of the neck. But as the external or oblique hernia
may by its weight, in process of time, gravitate so far inAvards as
to assume the position and appearance of a hernia originally direct
and internal, and as by this change of place the oblique hernia,
becoming direct as to position, does not at the same time become
internal in respect to the epigastric artery,—for this vessel, f.
Fig. 1, has been boine inwards to the place, g, Avhere it still lies,
internal to the neck of the sac,—and since, moreover, it is very
difiicult to diagnose a case of this kind with positive certainty, it
is therefore recommended to incise the stricture at the neck of the
sac in a line carried directly upwards. (Sir Astley Cooper.) It
Avill be seen, however, on referring to the figures of PI. XIN.-XX.
that an incision carried obliquely upwards towards the umbilicus
Avould be much more likely to avoid the epigastric artery through
aU its varying relations.
•+T. K aaV?^ tkis double hernia (external and internal) have been met
Avith by Wilmer, Arnaud, Sandifort, Richter, and others. A plurality of
e same variety of hernia may also occur on the same side. A complete
and incomplete external inguinal hernia existing in the one grCin, is re¬
corded by Mr. Aston Key in his edition of Sir Astley Cooper’s work on
ernia. Sir Astley Cooper states his having met with three internal
inguinal hernim in each inguinal region. (Ing. et Congenit. Hernim.)
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COMMENTAKY ON PLATE XXL
DEMONSTRATIONS OF THE NATURE OF CONGENITAL AND INFANTILE INGUINAL HERNUE,
AND OF HYDROCELE.
Figure 1.— The descent of the testicle from the loins to the scrotum.
—The foetal abdomen and scrotum form one general cavity, and
are composed of parts which are structurally identical. The
cutaneous, fascial, muscular, and membranous layers of the abdo¬
minal parietes are continued into those of the scrotum. At the
fifth month of foetal life, the testicle, 3, is situated in the loins
beneath the kidney, 2. The testicle is then numbered amongst
the abdominal viscera, and, like these, it is developed external to
the peritonseal membrane, which forms an envelope for it. At the
back and sides of the testicle, where the peritonaeum is reflected
from it, a small membranous fold or mesentery (mesorchium,
Seiler) is formed, and between the layers of this the nerves^and
vessels enter the organ, the nerves being derived from the
neighbouring sympathetic ganglia (aortic plexus), while the
arteries and veins spring directly from the main abdominal blood¬
vessels. It being predetermined that the testicle, 3, should migrate
from the loins to the scrotum, 6 a, 7, at a period included between
the sixth and ninth month, certain structural changes are at this
time already effected for its sure and easy passage. By the time
that the testis, 5, is about to enter the internal inguinal ring, 6 a,
(seventh or eighth month,) a process or pouch of the peritomeal
membrane (processus vaginalis) has already descended through
this aperture into the scrotum, and the testicle follows it.
The descent of the testis is effected by a very slow and gradual
process of change. (Tout va par degres dans la nature, et rien
par sauts.—.Bonnet.) But how, or by what distinct and active
structural agent, this descent is effected, or whether there does
exist, in fact, any such agent as that which anatomists name
“ gubernaculum testis,” are questions which appear to me by no
means settled.*
The general lining membrane of the foetal a,bdomen is composed
of two layers—an outer one of fibrous, and an inner one of serous
structure. Of these two layers, the abdominal viscera form for
themselves a double envelope.f The testis in the loins has a cover¬
ing from both membranes, and is still found to be enclosed by
both, even when it has descended to the scrotum. The two cover¬
ings of fibro-serous structure which surrounded the testis in the
loins become respectively the tunica albuginea and tunica vagi¬
nalis when the gland occupies the scrotal cavity.
Figure 2.— The testicle in the scrotum. —When the testicle, 5,
descends into the scrotum, 7, which happens in general at the time
of birth, the abdomino-scrotal fibro-serous membrane, 6 a, 6 cZ, is
stiU continuous at the internal ring, 6 h. From this point down¬
wards, to a level with the upper border of the testicle, the canal of
communication between the scrotal cavity and the abdomen be¬
comes elongated and somewhat constricted. At this part, the
canal itself consists, like the abdominal membrane above and the
scrotal membrane below, of a fibrous and serous layer, the latter
enclosed within the former. The serous lining of this canal is
destined to be obliterated, while the outer fibrous membrane is
designed to remain in its primitive condition. When the serous
* Dr Carpenter (Principles of Human Physiology) remarks, that “the
luse of this descent is not very clear. It can scarcely be due merely, as
jme have supposed, to the contraction of the gubernaculum, since that
oes not contain any hbrous structure until after the lowermg of the testis
as commenced.” Dr. Sharpey (Quain’s Anatoiny, 5th edition) obsei^es,
iat “ the office of the gubernaculum is yet imperfectly understood. The
ninions of these two distinguished physiologists will doubtless be regaided
s an impartial estimate of the results of the researches prosecuted m
eference to these questions by Haller, Camper, Hunter, Arnaud, Lobstein,
Ieckel,Paletta,Wrisberg, Vicq d’Azyr, Brugnone, Tumiati, Seilei, Giraidi,
looper, Bell, Weber, Carus, Cloquet, Curling, and others. From my own
Bservations, I am led to believe that no such muscular structure as a
-ubernaculum exists, and therefore that the descent of the testis is the
:ffect of another cause. Leaving these matters,however to considei ation
if the physiologist, it is sufficient for the surgeon to know that the testis
canal contracts and degenerates to the form of a simple cord, it
leaves the fibrous canal still continuous above with the fibrous
membrane (transversalis fascia) of the abdomen, and below with
the fibrous envelope (tunica albuginea) of the testis; and at the
adult period, this fibrous canal is known as the internal sper¬
matic sheath, or infundibuliform fascia enclosing the remains of
the serous canal, together with the spermatic vessels, &c.
Figure 3.— The serous tunica vaginalis is separated from the
peritonoeum. —When the testicle, 7, has descended to the scrotum,
the serous tube or lining of the inguinal canal and cord, 6 6 c,
closes and degenerates into a simple cord, (infantile spermatic
cord,) and thereby the peritomeal sac, 6 a, becomes distinct from
the serous tunica vaginalis, 6 d. But the fibrous tube, or outer
envelope of the inguinal canal, remains still pervious, and continues
in this condition throughout life. In the adult, we recognise this
fibrous tube as the infundibuliform fascia of the cord, or as form¬
ing the fascia propria of an external inguinal hernia. The an¬
terior part of the fibrous spermatic tube descends from the fascia
transversalis; the posterior part is continuous with the fascia
iliaca. In relation to the testicle, the posterior part will be seen
to be reflected over the body of the gland as the tunica albuginea,
while the anterior part blends with the cellular tissue of the front
wall of the scrotum. The tunica vaginalis, 6 c?, is now traceable
as a distinct sac,J closed on all sides, and reflected from the fore
part of the testicle, above and below, to the posterior aspect of the
front wall of the scrotum.
Figure 4._ The abdomino-scrotal serous lining remains continuous
at the internal ring., and a congenital hydrocele is formed. —When the
serous spermatic tube, 6 &, 6 c, remains pervious and continuous
above with the peritonaeum., 6 a, and below with the serous tunica
vaginalis, 6 d, the serous fluid of the abdomen will naturally gra¬
vitate to the most depending part—viz., the tunica vaginalis; and
thus a hydrocele is formed. This kind of hydrocele is named
congenital, owing to the circumstance that the natural process of
obliteration, by which the peritonaeum becomes separated from the
tunica vaginalis, has been, from some cause, arrested. § As long as
the canal of communication, 6 6 c, between the tunica vaginalis,
6 d, and the peritonaeum, 6 a, remains pervious, which it may be
throughout life, this form of hydrocele is, of course, liable to occur.
It may be diagnosed from diseased enlargements of the testicle, by
its transparency, its fluctuation, and its smooth, uniform fulness
and shape, besides its being of less weight than a diseased testis
of the same size would be. It may be distinguished from the
common form of hydrocele of the isolated tunica vaginalis by the
fact, that pressure made on the scrotum will cause the fluid to
pass freely into the general cavity of the peritonaeum. As the
fluid distends the tunica vaginalis, 6 c, 6 (i, in front of the testis,
this organ will of course lie towards the back of the scrotum, and
therefore, if it be found necessary to evacuate the fluid, the punc¬
ture may be made with most safety in front of the scrotum. If
ascites should form in an adult in whom the tunica vaginalis still
in its transition derives certain coverings from the parietes of the groin,
and that a communication is thereby established between the scrotal and
abdominal cavities.
t Langenbeck describes the peritonaeum as consisting of two layers;
one external and fibrous, another internal and serous. By the first, he
means, I presume, that membrane of which the transversalis and iliac
fasciae are parts. (See Comment, de Periton. Structura, &c.)
X Mr. Owen states that the Chimpanzee alone, amongst brute animals,
has the tunica vaginalis as a distinct sac.
§ The serous spermatic tube remains open in all quadrupeds; but their
natural prone position renders them secure against hydrocele or hernial
protrusion. It is interesting to notice how in man, and the most anthropo¬
morphous animals, where the erect position would, subject these to the
frequent accident of hydrocele or hernia, nature causes the serous sper-
matic tube to close.
COMMENTARY ON PLATE XXL
commuBicates with the peritonseal sac, the fluid which accumulates
in the latter membrane will also distend the former, and all the
collected fluid may be evacuated by tapping the scrotum. When
a hydrocele is found to be congenital, it must be at once obvious
that to inject irritating fluids into the tunica vaginalis (the radical
cure) is inadmissible. In an adult, free from all structural dis¬
ease, and in whom a congenital hydrocele is occasioned by the
gravitation of the ordinary serous secretion of the peritonaeum, a
cure may be effected by causing the obliteration of the serous
spermatic canal by the pressure of a truss. When a congenital
hydrocele happens in an infant in whom the testicle, 5, Fig. 1, is
arrested in the inguinal canal,* if pressure be made on this passage
with a view of causing its closure, the testicle will be prevented
from descending.
Figure 5._ The serous spermatic canal closes imperfectly^ so as
to become sacculated, and thus a hydrocele of the cord is formed.—
After the testicle, 7, has descended to the scrotum, the sides of
the serous tube, or lining of the inguinal canal and cord, 6 h, 6 c,
may become adherent at intervals; and the intervening sacs of
serous membrane continuing to secrete their proper fluid, wiU
occasion a hydrocele of the cord. This form of hydrocele will
differ according to the varieties in the manner of closure; and these
may take place in the following modes1st, if the serous tube
close only at the internal ring, 6 a, while the lower part of it,
6 6 c, remains pervious, and communicating with the tunica
vaginalis, 6 i, a hydrocele wiUbe formed of a corresponding shape;
2nd, if the tube close at the upper part of the testicle, 6 c, thus
isolating the tunica vaginalis, 6 d, while the upper part, 6 h, remains
pervious, and the internal ring, 6 a, open, and communicating
with the peritonaeal sac, a hydrocele of the cord wiU happen
distinct from the tunica vaginalis; or this latter may be, at the
same time, distended with fluid, if the disposition of the subject
be favourable to the formation of dropsy; 3rd, the serous tube
may close at the internal ring, form sacculi along the cord, and
close again at the top- of the testicle, thus separating the tunica
vaginalis from the abdomen, and thereby several isolated hydroceles
may be formed. If in this condition of the parts we puncture
one of the sacs for the evacuation of its contents, the others, owing
to their separation, will remain distended.
Figure 6.— Hydrocele of the isolated tunica vaginalis. —When
the serous spermatic tube, 6 J, 6 c, becomes obliterated, according
to the normal rule, after the descent of the testicle, 7, the tunica
vaginalis, 6 d, is then a distinct serous sac. If a hydrocele form
in this sac, it may be distinguished from the congenital variety
by its remaining undiminished in bulk when the subject assumes
the horizontal position, or when pressure is made on the tumour,
for its contents cannot now be forced into the abdomen. The
testicle, 7, holds the same position in this as it does in the con¬
genital hydrocele.f The radical cure may be performed here
without endangering the peritonaeal sac. Congenital hydrocele is
of a cylindrical shape; and this is mentioned as distinguishing it
from isolated hydrocele of the tunica vaginalis, which is pyriform;
but this mark will fail when the cord is at the same time dis¬
tended, as it may be, in the latter form of the complaint.
Figure 7. —The serous spermatic tube remaining pervious, a con¬
genital hernia is formed. —When the testicle, 7, has descended to
the scrotum, if the communication between the peritonaeum, 6 a,
and the tunica vaginalis, 6 c, be not obliterated, a fold of the
intestine, 13, will follow the testicle, and occupy the cavity of the
tunica vaginalis, 6 d. In this form of hernia (hernia tunicae
vaginalis, Cooper), the intestine is in front of, and in immediate
contact with, the testicle. The intestine may descend lower than
the testicle, and envelop this organ so completely as to render its
position very obscure to the touch. This form of hernia is named
congenital, since it occurs in the same condition of the parts as is
found in congenital hydrocele—viz., the inguinal ring remaining
unclosed. It may occur at any period of life, so long as the
original congenital defect remains. It may be distinguished from
hydrocele by its want of transparency and fluctuation. The
impulse which is communicated to the hand applied to the scrotum
of a person atfected with scrotal hernia, when he is made to cough,
is also felt in the case of congenital hydrocele. But in hydrocele
of the separate tunica vaginalis, such impulse is not perceived.
Congenital hernia and hydrocele may co-exist; and, in this case,
the diagnostic signs which are proper to each, when occurring
separately, will be so mingled as to render the precise nature of
the case obscure.
Figure 8.— Infantile hernia. —When the serous spermatic tube
becomes merely closed, or obliterated at the inguinal ring, 6 b, the
lower part of it, 6 c, is pervious, and communicating with the
tunica vaginalis, 6 d. In consequence of the closure of the tube
at the inguinal ring, if a hernia now occur, it cannot enter the
tunica vaginalis, and come into actual contact with the testicle.
The hernia, 13, therefore, when about to force the peritona3um, 6 a,
near the closed ring, 6 b, takes a distinct sac or investment from
this membrane. This hernial sac, 6 e, Avill vary as to its position
in regard to the tunica vaginalis, 6 d, according to the place
whereat it dilates the peritonseum at the ring. The peculiarity
of this hernia, as distinguished from the congenital form, is owing
to the scrotum containing two sacs,—the tunica vaginalis and the
proper sac of the hernia; whereas, in the congenital variety, the
tunica vaginalis itself becomes the hernial sac by a direct recep¬
tion of the naked intestine. If in infantile hernia a hydrocele
should form in the tunica vaginalis, the fluid iviU also distend the
pervious serous spermatic tube, 6 c, as far up as the closed
internal ring, 6 b, and wiU thus invest and obscure the descending
herniary sac, 13. This form of hernia is named infantile {Hey),
owing to the congenital defect in that process, whereby the serous
tube lining the cord is normally obliterated. Such a form of
hernia may occur at the adult age for the first time, but it is stiU
the consequence of original default.
Figure 9.— Oblique inguinal hernia in the adult. —This variety
of hernia occurs not in consequence of any congenital defect, except
inasmuch as the natural weakness of the inguinal wall opposite
the internal ring may be attributed to this cause. The serous
spermatic tube has been normally obliterated for its whole length
between the internal ring and the tunica vaginalis; but the fibrous
tube, or spermatic fascia, is open at the internal ring where it
joins the transversalis fascia, and remains pervious as far down as
the testicle. The intestine, 13, forces and distends the upper end
of the closed serous tube; and as this is now wholly obliterated,
the herniary sac, 6 c, derived anew from the inguinal peritonaeum,
enters the fibrous tube, or sheath of the cord, and descends it as
far as the tunica vaginalis, 6 d, but does not enter this sac, as it
is already closed. When we compare this hernia. Fig. 9, with
the infantile variety. Fig. 8, we find that they agree in so far as
the intestinal sac is distinct from the tunica vaginalis; whereas the
difference between them is caused by the fact of the serous cord re¬
maining in part pervious in the infantile hernia; and on comparing
Fig. 9 with the congenital variety. Fig. 7, we see that the intestine
has acquired a new sac in the former, whereas, in the latter, the
intestine has entered the tunica vaginalis. The variable position of
the testicle in Figs. 7, 8, and 9, is owing to the variety in the ana¬
tomical circumstances under which these hernias have happened.
* In many quadrupeds (the Rodentia and Monotremes) the testes
remain within the abdomen. In the Elephant, the testes always occupy
their original position beneath the kidneys, in the loins. Human adults
are occasionally found to be “ testicondethe testes being situated below
the kidneys, or at some part between this position and the internal inguinal
ring. Sometimes only one of the testes descends to the scrotum.
t When a hydrocele is interposed between the eye and a strong light,
the testis appears as an opaque body at the back of the tunica vaginalis.
But this position of the organ is, from several causes, liable to vary. The
testis may have become morbidly adherent to the front wall of the serous
sac, in which case the hydrocele will distend the sac laterally. Or the
testis may be so transposed in the scrotum, that, whilst the gland occupies
its front part, the distended tunica vaginalis is turned behind. The tunica
vaginalis, like the serous spermatic tube, may, in consequence of inflam¬
matory fibrinous effusion, become sacculated-multilocular, in which case,
if a hydrocele form, the position of the testis will vary accordingly.—See
Sir Astley Cooper’s work, (“ Anatomy and Diseases of the Testis;”)
Morton’s “ Surgical AnatomyMr. Curling’s “ Treatise on Diseases of
the Testisand also his article “ Testicle,” in the Cyclopaedia of Anatomy
and Physiology.
COMMENTARY ON PLATE XXIl.
demonstrations of the origin and progress of inguinal
HERNIA IN GENERAL.
^ Figure 1.—When the serous spermatic tube is obliterated for
Its whole length between the internal ring, 1, and the top of the
testicle, 13, a hernia, in order to enter the inguinal canal, 1, 4,
must either rupture the peritoneum at the point 1, or dilate this
membrane before it in the form of a sac.* If the peritoneum at
t e point 1 be ruptured by the intestine, this latter will enter
the fibrous spermatic tube, 2, 3, and will pass along this tube
devoid of the serous sac. If, on the other hand, the intestine
dilates the serous membrane at the point, 1, where it stretches
aCToss the internal ring, it will, on entering the fibrous tube,
(mfundibuhform fascia,) be found invested by a sac of the peri¬
toneum, which it dilates and pouches before itself As the
epigastric artery, 9, bends in general along the internal border of
the ring of the fibrous tube, 2, 2, the neck of the hernial sac which
enters the ring at a point external to the artery must be external
to it, and remain so despite 'all further changes in the form,
position, and dimensions of the hernia. And as this hernia enters
the ring at a point anterior to the spermatic vessels, its neck must
be anterior to them. Again, if the bowel be invested by a serous
sac, formed of the peritonaeum at the point 1, the neck of such sac
must intervene between the protruding bowel and the epigastric
and spermatic vessels. But if the intestine enter the ring of the
fibrous tube, 2, 2, by having ruptured the peritoneum at the
point 1, then the naked intestine will lie in immediate contact
with these vessels.
Figure 2—When the serous spermatic tube, 11, remains
pervious between the internal ring, 1, (where it communicates
with the general peritonaeal membrane,) and the top of the testicle,
(where it opens into the tunica vaginalis,) the bowel enters this tube
directly, without a rupture of the peritonaeum at the point 1.
This tube, therefore, becomes one of the investments of the bowel.
It is the serous sac, not formed by the protruding bowel, but one
already open to receive the bowel. This is the condition necessary
to the formation of congenital hernia. This hernia must be one of
the external oblique variety, because it enters the open abdominal
end of the infantile serous spermatic tube, which is always external
to the epigastric artery. Its position in regard to the spermatic
vessels is the same as that noticed in Figure 1. But, as the serous
tube through which the congenital hernia descends, still com¬
municates with the tunica vaginalis, so wiU this form of hernia
enter this tunic, and thereby become different to all other hernias,
forasmuch as it will lie in immediate contact with the testicle.f
Figure 3.—The infantile serous spermatic tube, 11, sometimes
remains pervious in the neighbourhood of the internal ring, 1, and
a narrow tapering process of the tube (the canal of Nuck) descends
within the fibrous tube, 2, 3, and lies in front of the spermatic
vessels and epigastric artery. Before this tube reaches the testicle,
it degenerates into a mere filament, and thus the tunica vaginalis
has become separated from it as a distinct sac. When the bowel
enters the open abdominal end of the serous tube, this latter
becomes the hernial sac. It is not possible to distinguish by any
special character a hernia of this nature, when already formed,
from one which occurs in the condition of parts proper to Fig. 1,
or that which is described in the note to Figure 2; for when
the intestine dilates the tube, 11, into the form of a sac, this latter
assumes the exact shape of the sac, as noticed in Figure 1. The
hernia in question cannot enter the tunica vaginalis. Its position
in regard to the epigastric and spermatic vessels is the same as
that mentioned above.
Figure 4.—If the serous spermatic tube, 11, be obliterated or
closed at the internal ring, 1, thus cutting off communication with
the general peritoneal membrane; and if, at the same time, it
remain pervious from this point above to the tunica vaginalis
below, then the herniary bowel, when about to protrude at the
point 1, must force and dilate the peritoneum, in order to form
its sac anew, as stated of Figure 1. Such a hernia does not enter
either the serous tube or the tunica vaginalis; but progresses from
the point 1, in a distinct sac. In this case, there will be found two
sacs—one enclosing the bowel; and another, consisting of the
serous spermatic tube, still continuous with the tunica vaginalis.
This original state of the parts may, however, suffer modification
in two modes: 1st, If the bowel rupture the peritonaeum at the
point 1, it will enter the serous tube 11, and descend through this
into the cavity of the tunica vaginalis, as in the congenital variety.
2nd, If the bowel rupture the peiitonaeum near the point 1,
and does not enter the serous tube 11, nor the tunica vaginalis,
then the bowel will be found devoid of a proper serous sac, while
the serous tube and tunica vaginalis stiU exist in communication.
In either case, the hernia will hold the same relative position in
regard to the epigastric artery and spermatic vessels, as stated of
Figure 1.
Figure 5. —Sudden rupture of the peritonaeum at the closed
internal serous ring, 1, though certainly not impossible, may yet
be stated as the exception to the rule in the formation of an
external inguinal hernia. The aphorism, “natura non facit saltus,”
is here applicable. When the peritonaeum suffers dilatation at
the internal ring, 1, it advances gradatim and pari passu with the
progress of the protruding bowel, and assumes the form, character,
position, and dimensions of the inverted curved phases, marked
11, 11, tiU, from having at first been a very shallow pouch, lying
external to the epigastric artery, 9, it advances through the
inguinal canal to the external ring, 4, and ultimately traverses
this aperture, taking the course of the fibrous tube, 3, down to
the testicle in the scrotum.
Figure 6. —When the bowel dilates the peritonasum opposite
the internal ring, and carries a production of this membrane
before it as its sac, then the hernia will occupy the inguinal canal,
and become invested by all those structures which form the
canal. These structures are severally infundibuliform processes,
so fashioned by the original descent of the testicle; and, there¬
fore, as the bowel follows the track of the testicle, it becomes,
of course, invested by the selfsame parts in the selfsame manner.
Thus, as the infundibuliform fascia, 2, 3, contains the hernia and
spermatic vessels, so does the cremaster muscle, extending from
the lower margins of the internal oblique and transversalis, invest
them also in an infundibuliform manner. J
* Mr. Lawrence (op. cit.) remarks, “ When we consider the texture of
the peritonaeum, and the mode of its connexion to the abdominal parietes,
we cannot fancy the possibility of tearing the membrane by any attitude
or motion.” Cloquet and Scarpa have also expressed themselves to the
effect, that the peritonaeum suffers a gradual distention before the pro¬
truding bowel.
t A hernia may be truly congenital, and yet the intestine may not enter
the tunica vaginalis. Thus, if the serous spermatic tube close only at
the top of the testicle, the bowel which traverses the open internal inguinal
ring and pervious tube will not enter the tunica vaginalis.
J Much difference of opinion prevails as to the true relation which the
cord (and consequently the oblique hernia) bears to the lower margins of
the oblique and transverse muscles, and their cremasteric prolongation.
Mr. Guthrie (Inguinal and Femoral Hernia) has shown that the fibres of
the transversalis, as well as those of the internal oblique, are penetrated
by the cord. Albinus, Haller, Cloquet, Camper, and Scarpa, record
opinions from which it may be gathered that this disposition of the parts
is (with some exceptions) general. Sir Astley Cooper describes the lower
edge of the transversalis as curved all round the internal ring and cord.
From my own observations, coupled with these, I am inclined to the belief
that, instead of viewing these facts as isolated and meaningless particulars,
we should now fuse them into the one idea expressed by the philosophic
Carus, and adopted by Cloquet, that the cremaster is a production of the
abdominal muscles, formed mechanically by the testicle, which in its
descent dilates, penetrates, and elongates their fibres.
COMMENTARY
ON PLATE XXII.
,,_w.en..—“r
)rotrudes the peritonaeum ^ 3 3 it imitates, m
lescen* the inguinal cana and The difference
nost respects, the origma in which they
jetween both descents attaches a
accome covered by the serous ‘ the
through the internal ring r»g this membrane i whereas
rbrei —this ;art 01 t- P^—/r
as occurring m Figs. 1 and 3, 5 ^ . i^ggg the
Fiannn 8.-When .ftLards pouch
internal ring, as seen a , g ^ inguinal canal, we shall
the peritomeum at this P^^and miter^t
then have the foim f ^ '^_^/^thin the cord, 13, and corn-
serous sacs ’"" t'O . the other, 11, containing
municating with th . ^ inversion into the upper ex-
the “fg^“«.hrre infLtile serous canal, 13, receives
rw sac, 11. The in^nal c-" ^2 ^“^e
multicapsular, as m Fig. 8, rom var ^ ^ ^ q£ hernial
Wng a distinct he ”^tLe intermptedly
formation the ongma^ these sacs may
obliterated, as in Plate sJU, -^Jg- to their number,
persist to adult age, and have a hemid " totheir
whatever this may be Ihrfty.the ^e
may persist, and after having receweo t
howel may " " srmlyCve be» obliterated by
^e^a may prot^de at the
point 1 , and this may serous
iXtideThe. ' Thepossihihty of these occurrences is self-evident,
even if they were never as yet experienced-f ^
FioiraE 9.—The epigastric artery, 9, being covered by
fascia transversalis, can lend no support to the mtemal ring, , ,
iTto the tube prolonged from it. The herniary bowel may
iLTore, dilate 2 peritonainm immediately on the inner side of
the artery, and enter the inguinal canal. In this way the hemi ,
U although situated internal to the epigastric artery, assumes »
oblique course through the canal, and thus closely simulates the
xtral variety of 4inal hernia, Fig. 7. If the hernia ente
the canal, as represented in Fig. 9, it becomes invested by he
same structures, and assumes the same position m respect to
suermatic vessels, as the external hernia. ^
Fioueh lO.-The hernial sac, 11, which entered the nng of the
fibrous tube 2, 2, at a point immediately internal to the epigastric
X 9 mayifrimhavingheenatfirstoblique, asinFig. 9 assume
a d Jet position. In this case, the ring of the fibrous tube, 2,2, wi
be much widened; but the artery and spermatic vessels will remain
in their normal position, being in no wise affected by the gram-
tating hernia. If the conjoined tendon, 6, he so weak as not to
resist the gravitating force of the hernia, the tendon will become
bent upon itself. If the umbilical cord, 10, be side by side with
the epigastric artery at the time that the herma enters the month
of the fibrous tube, then, of course, the cord will be found
, Tf the cord lie towards the pubes, apart from fhe vessel
external. ^ tube between the cord, 10, and
the hernia “ay e iptemal hernia to assume the
artery, 9.t « >y“I’ . f the original serous spermatic
TlfFlr^’ S— te the epigastric a^ry, 9, cminot
tube, 11, Pig. he e to this vessel.
be entered by the he p„t rupture
Fmunn H'-Ev^ ^ ptoduced anew from this
the *t^, hernia enter the inguinal canal or not.
membmne, whrth ^ jhrous membrane
But this IS not th ^ -t, Tf the hernia enter the inguinal
which forms the fascia propn^^^ epigastric artery,
wall ring of the fibrous tube, 2 , 2 ,
Fig. 9, it 11, Fig. 11,
already prepared to re artery, 9, and
ftThe*'’2 TCmlin tr tTelr isull position, while the bowel
the tube, 2, 2, investment from the transversahs
5 Y^Thrt part of the conjoined tendon which stands
fascia, 5, P in its proper place, and
separates it from the fold of the fascia which invests the hernial sac.
Thist tie only form in which an internal hernia can be said to
absolutely d Jnct from the inguinal canal and spermatic vesse s
This hernia, when passing the external ring, 4, has the spermatic
"'fiotee 12.—The external hernia, from having been ongmaUy
obW may assume the position of a hernia ongmally internal
l!a 2ct. The change of place exhibited by this form of hernia
"t imply a Ch4e Aher in its original investments or m
its position lith respect to the epigastric artey and spermatic
vessels. The change is merely caused by the weig * “ “
tion of the hernial mass, which bends the epigastnc artepi, 9 ,
from its first position on the inner margin of
till it assumes the place 9. In consequence of this the intern
ring of the fascia transversalis, 2, 2, is considerably widened
as it is also in Fig. 10. It is the inner margin of the fibrous
ring which has suffered the pressure; and thus the hernia now
projects directly from behind forwards, through, 4, the external
ring. The conjoined tendon, 6 , when weak, becomes bent upon
itself. The change of place performed by the gravitating hernm
may disturb the order and relative position of the spermatic
vessels; but these, as well as the hernia, stiU «<'<=“P3'
canal, and are invested by the spermatic fascia, 3 3. When
internal hernia. Fig. 9, enters the inguinal canal, it also my
descend the cord as far as the testicle, and assume in respect to
this gland the same position as the external hernia.§
Figubes 13, 14, 15.-The form and position of the inguinal
canal varies according to the sex and age of the individual. n
early life. Fig. 14, the internal ring is situated nearly oyosite
the external ring, 4. As the pelvis widens graduaUy in tie
advance to adult age. Fig. 13, the canal becomes oblique as to
position. This obliquity is caused by a change of place, peifonnc
rather by the internal than the externalring.H The greater width
of the female pelvis than of the male, renders the canal more
oblique in the former; and this, combined with the circumstance
that the female inguinal canal. Fig. 15, merely transmits toe round
ligament, 14, accounts anatomically for the fact, that this sex is
less liable to the occurrence of rupture in this situation.
+ Aocording to Mr. Lawrence and M. Cloquet, most of the serous
Bvlts found around hernial tumours are ancient sacs obliterated at e
liech, and adhering to the new swelling (opera cit.)
t M Cloquet states that the umbilical cord is always found on the
inner side of the external hernia. Its position vanes in respect to the
internal hernia, (op. cit. prop. 52.)
^ As the external hernia, Fig. 12, may displace the epigastric artery
inwaids so may the internal hernia, Fig. 9, displace die artery outwards.
Mr Lawrence, Sir Astley Cooper, Scarpa, Hesselbach, and Langen
Silt smte. however, that the internal hernia does not disturb the artery
from its usual position three-fourths of an inch from the external
M. Velpeau (NouveauxElemens de med. Operat.) states the length of
the inguinal canal in a well-formed adult, measured from the ^nteruMto
the external ring, to be H or 2 inches, and 3 inches including the rings ,
but that in some individuals the rings are placed nearly opposit^ whilst
in young subjects the two rings nearly always eorrespoy. When n
company with these facts, we recollect how much the parts are liable to
be distmhed in ruptures, it must be evident that their relative posi ion
cannot be exactly ascertained by measurement, from any given point what¬
ever. The iudgment alone must fix the general average.
COMMENTAliY ON PLATE XXlll.
THE DISSECTION OF FEMORAL HERNIA, AND THE SEAT OF STRICTURE.
Whilst all forms of inguinal hernia escape from the abdomen at
places situated immediately above Poupart’s ligament, the femoral
hernia, G, Fig. 1, is found to pass from the abdomen immediately
below this structure, A i, and between it and the horizontal branch
of the pubic bone. The inguinal canal and external abdominal
ring are parts concerned in the passage of inguinal hernise, whether
oblique or direct, external or internal; whilst the femoral canal and
saphenous opening are the parts through which the femoral hernia
passes. Both these orders of parts, and of the hernise connected
with them respectively, are, however, in reality situated so closely
to each other in the inguino-femoral region, that, in order to
understand either, we should examine both at the same time
comparatively.
The structure which is named Poupart’s ligament in connexion
with inguinal herniie, is named the femoral or crural arch
(Gimbernat) in relation to femoral hernia. The simple line,
therefore, described by this ligament explains the narrow interval
which separates both varieties of the complaint. So small is the
line of separation described between these herni* by the ligament,
that this (so to express the idea) stands in the character of an
arch, which, at the same time, supports an aqueduct (the inguinal
canal) and spans a road (the femoral sheath.) The femoral arch,
A I, Fig. 1, extends between the anterior superior iliac spinous
process and the pubic spine. It connects the aponeurosis of the
external oblique muscle, d rf. Fig. 4, with e, the fascia lata.
Immediately above and below its pubic extremity appear the
external ring and the saphenous opening. On cutting through
the falciform process, f. Fig. 3, we find Gimbernat’s ligament, R,
a structure well known in connexion Avith femoral hernia. Gim¬
bernat’s ligament consists of tendinous fibres which connect the
inner end of the femoral arch with the pectineal ridge of the os
pubis. The shape of the ligament is acutely triangular, corre¬
sponding to the form of the space which it occupies. Its apex is
internal, and close to the pubic spine; its base is external, sharp
and concave, and in apposition with the sheath of the femoral
vessels. It measures an inch, more or less; in width, and it is broader
in the male than in the female-a fact which is said to account for
the greater frequency of femoral hernia in the latter sex than in the
former, (Monro.) Its strength and density also vary in different
individuals. It is covered anteriorly by, p. Fig. 3, the upper cornu
of the falciform process; and behind, it is in connexion with, k,
the conjoined tendon. This tendon is inserted with the ligament
into the pectineal ridge. The falciform process also blends with
the ligament; and thus it is that the femoral hernia, when
constricted by either of these three structures, may AveU be
supposed to suffer pressure from the three togethei.
A second or deep femoral arch is occasionally met with. This
structure consists of tendinous fibres, lying deeper than, but
parallel with, those of the superficial arch. The deep arch spans
the femoral sheath more closely than the superficial arch, and
occupies the interval left between the latter and the sheath of the
vessels. When the deep arch exists, its inner end blends with
the conjoined tendon and Gimbernat’s ligament, and with these
may also constrict the femoral hernia.
The sheath, e/, of the femoral vessels, e f. Fig. 1, passes^ from
beneath the middle of the femoral arch. In this situation, the
iliac part of the fascia lata, f g. Fig. 4, covers the sheath. Its
inner side is bounded by Gimbernat’s ligament, R, Fig. 3, an ^ F,
the falciform edge of the saphenous opening. On its outer side
are situated the anterior crural nerve, and the femoral parts
of the psoas and iliacus muscles. Of the three compartments
into which the sheath is divided by two septa in its interior, the
external one, E, Fig. 1, is occupied by the femoral artery; the
middle one, H, by the femoral vein; whilst the inner one, G, gives
passage to the femoral lymphatic vessels; and occasionally, also,
a lymphatic body is found in it. The inner compartment, G, is
the femoral canal, and through it the femoral hernia descends
from the abdomen to the upper and forepart of the thigh. As
the canal is the innermost of the three spaces inclosed by the
sheath, it is that which lies in the immediate neighbourhood ot
the saphenous opening, Gimbernat’s ligament, and the conjoine
tendon, and between these structures and the femoral vein.
The sheath of the femoral vessels, like that of the spermatic
cord, is infundibuliform. Both are broader at their abdominal
DESCRIPTION OF THE FIGURES OF PLATE XXIII.
Figure 1.
Anterior superior iliac spine.
•Iliacus muscle, cut.
Anterior crural nerve, cut.
■ llZr7^£rjel:cM in its compartment of the femoral sheath.
Femoral vein in its compartment,/, of the femoial sheat .
The fascia propria of the hernia; g, the containec sac.
. Gimhernat’s ligament.
Round ligament of the uterus.
Figure 2.
Anterior superior iliac spine.
. Simphysis pubis.
Rectus abdominis muscle.
I. Peritonmum.
1. Conjoined tendon.
oToSoClh, obtu««„ ar^r, when given offftom U.e epigastric.
I. Neck of the sac of the crural hernia.
Round ligament of the uterus.
L External iliac vein.
parvus urusce. resting on the psoas ™agn„,.
i. Iliacus muscle.
). Transversalis fascia.
Figure 3.
A. Anterior superior iliac spine.
B. The crural hernia.
C. Round ligament of the uterus.
D. External oblique muscle; d, Fig. 4, its aponeurosis.
E. Sapbaena vein.
F. Falciform process of the saphenous opening.
G. Femoral artery in its sheath.
H. Femoral vein in its sheath.
I. Sartorius muscle. . . j j
K. Internal oblique muscle; k, conjoined tendon.
L L. Transversalis fascia.
M. Epigastric artery.
N. Peritonaeum.
O. Anterior crural nerve.
P. The hernia vrithin the crural canal.
Q Q. Femoral sheath.
R. Gimbernat’s ligament.
Figure 4.
The other letters refer to the same parts as seen in Fig. 3.
G. Glands in the neighbourhood of Pouparfs
H. Glands in the neighbourhood of the saphenous opening.
I. The sartorius muscle seen through its fascia.
COMMENTARY ON PLATE XXIII.
ends than elsewhere. The femoral sheath being broader above
than below, whilst the vessels are of an uniform diameter, presents,
as it were, a surplus space to receive a hernia into its upper end.
This space is the femoral or crural canal. Its abdominal entrance
is the femoral or crural ring.
The femoral ring, h. Fig. 2, is, in the natural state of the parts,
closed over by the peritonteum, in the same manner as this
membrane shuts the internal inguinal ring. There is, however,
corresponding to each ring, a depression in the peritonasal covering;
and here it is that the bowel first forces the membrane and forms
of this part its sac.
On removing the peritonasum from the inguinal wall on the
inner side of the iliac vessels, k l, we find the horizontal branch
of the os pubis, and the parts connected with it above and below,
to be still covered by what is called the subserous tissue. The
femoral ring is not as yet discernible on the inner side of the iliac
vein, k; for the subserous tissue being stretched across this
aperture masks it. The portion of the tissue which closes the
ring is named the crural septum, (Cloquet.) When we remwe
this part, we open the femoral ring leading to the corresponding
canal. The ring is the point of union between the fibrous
membrane of the canal and the general fibrous membrane which
lines the abdominal walls external to the peritonfeum. This
account of the continuity between the canal and abdominal fibrous
membrane equally applies to the connexion existing between the
general sheath of the vessels and the abdominal membrane. The
difference exists in the fact, that the two outer compartments of
the sheath are occupied by the vessels, whilst the inner one is
vacant. The neck or inlet of the hernial sac, H, Fig. 2, exactly
represents the natural form of the crural ring, as formed in the
fibrous membrane external to, or (as seen in this view) beneath
the peritonjeum.
The femoral ring, h, is girt round on all sides by a dense
fibrous circle, the upper arc being formed by the two femoral
arches; the outer arc is represented by the septum of the femoral
sheath, which separates the femoral vein from the canal; the
inner arc is formed by the united dense fibrous bands of the
conjoined tendon and Gimbernat’s ligament; and the inferior arc
is formed by the pelvic fascia where this passes over the pubic
bone to unite with the under part of the femoral canal and sheath.
The ring thus bound by dense resisting fibrous structure, is
rendered sharp on its pubic and upper sides by the salient edges
of the conjoined tendon and Gimbernat’s ligament, &c. From
the femoral ring the canal extends down the thigh for an inch
and a-half or two inches in a tapering form, supported by the
pectineus muscle, and covered by the iliac part of the fascia lata.
It lies side by side with the saphenous opening, but does not
communicate with this place. On a level with the lower cornu
of the saphenous opening, the walls of the canal become closely
applied to the femoral vessels, and here it may be said to
terminate.
The bloodvessels which pass in the neighbourhood of the femoral
canal are, 1st, the femoral vein, f. Fig. 1, which enclosed in its
proper sheath lies parallel with and close to the outer side of the
passage. 2nd, Within the inguinal canal above are the spermatic
vessels, resting on the upper surface of the femoral arch, which
alone separates them from the upper part or entrance of the femoral
canal. 3rd, The epigastric artery, f. Fig. 2, which passes close to
the outer and upper border of, H, the femoral ring. This vessel oc-
casionaUy gives off the obturator artery, which, when thus derived,
will be found to pass towards the obturator foramen, in close con¬
nexion with the ring; that is either descending by its outer border,
G*, between this point and the iliac vein, k; or arching the ring, G,
so as to pass down close to its inner or pubic border. In some in¬
stances, the vessel crosses the ring; a vein generally accompanies
the artery. These peculiarities in the origin and course of the ob¬
turator artery, especially that of passing on the pubic side of the
ring, behind Gimbernat’s ligament and the conjoined tendon, e h,
are fortunately very rare.
As the course to be taken by the bowel, when a femoral hernia
is being formed, is through the crural ring and canal, the struc¬
tures which have just now been enumerated as bounding this pas¬
sage, will, of course, hold the like relation to the hernia. The
manner in which a femoral hernia is formed, and the way in which
it becomes invested in its descent, may be briefly stated thus:
The bowel first dilates the peritonaeum opposite the femoral ring,
H, Fig. 2, and pushes this membrane before it into the canal.
This covering is the hernial sac. The crural septum has, at the
same time, entered the canal as a second investment of the bowel.
The hernia is now enclosed by the sheath, G, Fig. 1, of the canal
itself t Its further progress through the saphenous opening, b f.
Fig. 3, must be made either by rupturing the weak inner wall of
the canal, or by dilating this part; in one or other of these modes, the
herniary sac emerges from the canal through the saphenous open¬
ing. In general, it dilates the side of the canal, and this becomes
the fascia propria, B G. If it have ruptured the canal, the hernial
sac appears devoid of this covering. In either case, the hernia,
increasing in size, turns up over the margin of F, the falciform
process,! and ultimately rests upon the iliac fascia lata, below
the pubic third of Poupart’s ligament. Sometimes the hernia
rests upon this ligament, and simulates, to all outward appearance,
an oblique inguinal hernia. In this course, the femoral hernia
win have its three parts—neck, body, and fundus—forming nearly
right angles with each other: its neck§ descends the crural canal,
its body is directed to the pubis through the saphenous opening,
and its fundus is turned upwards to the femoral arch.
The crural hernia is much more liable to sufier constriction than
the inguinal hernia. The peculiar sinuous course which the former
takes from its point of origin, at the crural ring, to its place on
Poupart’s ligament, and the unyielding fibrous structures which
form the canal through which it passes, fully account for the more
frequent occurrence of this casualty. The neck of the sac may,
indeed, be supposed always to suffer more or less constriction at
the crural ring. The part which occupies the canal is also very
much compressed; and again, where the hernia 'turns over the
falciform process, this structure likewise must cause considerable
compression on the bowel in the sac. || This hernia suffers stricture
of the passive kind always; for the dense fibrous bands in its neigh¬
bourhood compress it rather by withstanding the force of the her¬
niary mass than by reacting upon it. There are no muscular
fibres crossing the course of this hernia; neither are the parts
which constrict it likely to change their original position, however
long it may exist. In the inguinal hernia, the weight of the mass
may in process of time widen the canal by gravitating; but the
crural hernia, resting on the pubic bone, cannot be supposed to
dilate the crural ring, however greatly the protrusion may in¬
crease in size and weight.
t The sheath of the canal, together with the crural septum, constitutes
the fascia propria” of the hernia (Sir Astley Cooper), Mr. Lawrence
denies the existence of the crural septum.
X The upper cornu of the saphenous opening,” the falciform process”
(Burns), and the femoral ligament” (Hey), are names applied to the same
part. With what difficulty and perplexity does this impenetrable fog of
surgical nomenclature beset the progress of the learner!
§ The neck of the sac at the femoral ring lies very deep, in the undis¬
sected state of the parts (Lawrence).
II Sir A. Cooper (Crural Hernia) is of opinion that the stricture is gene¬
rally in the neck of the sheath. Mr. Lawrence remarks, “ My own ob¬
servations of the subject have led me to refer the cause of stricture to the
thin posterior border (Gimbernat’s ligament) of the crural arch, at the
part where it is connected to the falciform process.” (Op. cit.) This
statement agrees also with the experience of Hey, (Practical Obs.)
COMMENTARY ON PLATE XXIV.
DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF FEMORAL HERNIA—ITS DIAGNOSIS, THE TAXIS,
AND THE OPERATION.
Figure 1_The point, 3, from which an external inguinal
hernia first progresses, and the part, 5, within which the femoral
hernia begins to he formed, are very close to each other. The
inguinal hernia, 3, arising above, 5, the crural arch, descends the
canal, 3, 3, under cover of the aponeurosis of the external oblique
muscle, obliquely downwards and inwards till it gains the external
abdominal ring formed in the aponeurosis, and thence descends
to the scrotum. The femoral hernia, commencing on a level with,
5, the femoral arch, descends the femoral canal, under cover of
the fascia lata, and appears on the upper and forepart of the thigh
at the saphenous opening, 6, 7, formed in the fascia lata; and
thence, instead of descending to the scrotum, like the inguinal
hernia, turns, on the contrary, up over the falciform process, 6, till
its fundus rests near, 5, the very place beneath which it originated.
Such are the peculiarities in the courses of these two hernia; and
they are readily accounted for by the anatomical relations of the
parts concerned.
Figure 2.—There exists a very evident analogy between the
canals through which both herniie pass. The infundibuliform fascia,
3, 3, of the spermatic vessels is like the infundibuliform sheath, 9, 9,
of the femoral vessels. Both sheaths are productions of the general
fibrous membrane of the abdomen. They originate from nearly
the same locality. The ring of the femoral canal, 12, is situated
immediately below, but to the inner side of the internal inguinal
ring, 3. The epigastric artery, 1, marks the width of the interval
which separates the two rings. Poupart’s ligament, 5, being the
line of union between the oblique aponeurosis of the abdominal
muscle and the fascia lata, merely overarches the femoral sheath,
and does not separate it absolutely from the spermatic sheath.
Figure 3.—The peritonaeum, 2, 3, closes the femoral canal, 12,
at the femoral ring, in the same^way as this membrane closes the
inguinal canal at the internal inguinal ring, 3, Fig. 2. The epi
gastric artery ahvays holds an intermediate position between both
rings. The spermatic vessels in the inguinal tube, 3, 3, Fig. 2,
are represented by the round ligament in the female inguinal
canal. Fig. 3. When the bowel is about to protrude at either of
the rings, it first dilates the peritonaeum, which covers these
openings.
Figure 4.— The place of election for the formation of any
hernia is that which is structurally the weakest. As the space
which the femoral arch spans external to the vessels is fully occu¬
pied by the psoas and iliacus muscles, and, moreover, as the ab¬
dominal fibrous membrane and its prolongation, the femoral
sheath, closely embrace the vessels on their outer anterior and pos¬
terior sides, whilst on their inner side the membrane and sheath
are removed at a considerable interval from the vessels, it is
through this interval (the canal) that the hernia may more readdy
pass.'" The peritoneum, 2, and crural septum, 13, form at this
place the only barrier against the protrusion of the bowel into the
canal.
Figure 5.—The hernia cannot freely enter the compartmen ,
10, occupied by the artery, neither can it enter the place 11, occu¬
pied as it is by the vein. It cannot readily pass through the inguinal
wall at a point internal to, 9, the crural sheath, for here it is op¬
posed by, 4, the conjoined tendon, and by, 8, Gimbernat’s ligament.
Neither wiU the hernia force a way at a point external to the femoral
vessels in preference to that of the crural canal, which is already
prepared to admit it.f The bowel, therefore, enters' the femoral
canal, 9, and herein it lies covered by its peritomeal sac, derived
from that part of the membrane which once masked the crural ring.
The septum crurale itself, having been dilated before the sac, of course
invests it also. The femoral canal forms now the third covering
of the bowel. If in this stage of the hernia it should suffer
constriction, Gimbernat’s ligament, 8, is the cause of it. An
incipient femoral hernia of the size of 2, 12, cannot, in the
undissected state of the parts, be detected by manual operation;
for, being bound down by the dense fibrous structures which gird
the canal, it forms no apparent tumour in the groin.
Figure 6.— The hernia, 2, 12, increasing gradually in size,
becomes tightly impacted in the crural canal, and being unable to
dilate this tube uniformly to a size corresponding with its own
volume, it at length bends towards the saphenous opening, 6, 7,
this being the more easy point of egress. Still, the neck of the
sac, 2, remains constricted at the ring, whilst the part which
occupies the canal is also very much narrowed. The fundus
of the sac, 9*, 12, alone expands, as being free of the canal; and
covering this part of the hernia may be seen the fascia propria, 9 .
This fascia is a production of the inner wall of the canal; and if
we trace its sides, we shall find its lower part to be continuous with
the femoral sheath, whilst its upper part is stiU continuous with
the fascia transversalis. When the hernia ruptures the saphenous
side of the canal, the fascia propria is, of course, absent.
Figure 7.—The anatomical circumstances which serve for the
diagnosis of a femoral from an inguinal hernia maybe best explained
by vieAving in contrast the respective positions assumed by both
complaints. The direct hernia, 13, traverses the inguinal waU from
behind, at a situation corresponding with the external ring; and
from this latter point it descends the scrotum. An oblique external
inguinal hernia enters the internal ring, 3, which exists further
apart from the general median line, and, in order to gain the
external ring, has to take an oblique course from without inwards
through the inguinal canal. A femoral hernia enters the crural
ring, 2, immediately below, but on the inner side of, the internal
inguinal ring, and descends the femoral canal, 12, vertically to
where it emerges through, 6, 7, the saphenous opening. The direct
inguinal hernia, 13, owing to its form and position, can scarcely
ever be mistaken for a femoral hernia. But in consequence of the
close relationship between the internal inguinal ring, 3, and the
femoral ring, 2, through which their respective herniie pass, some
difficulty in distinguishing between these complaints may occur.
An incipient femoral hernia, occupying the crural canal between
the points 2, 12, presents no apparent tumour in the undissected
state of the parts; and a bubonocele, or incipient inguinal hernia,
occupying the inguinal canal, 3, 3, where it is braced down by the
external oblique aponeurosis, will thereby be also obscured in
some degree. But, in most instances, the bubonocele distends the
inguinal canal somewhat; and the impulse which on coughing is
felt at a place above the femoral arch, wiU serve to indicate,
by negative evidence, that it is not a femoral hernia. ^
Figure 8.—When the inguinal and femoral hernise are fully
produced, they best explain their distinctive nature. The inguinal
hernia, 13, descends the scrotum whilst the femoral hernia, 9*,
turns over the falciform process, 6, and rests upon the fascia lata
and femoral arch. Though in this position the fundus of a femoral
hernia lies in the neighbourhood of the inguinal canal, 3, yet the
sw ellin g can scarcely be mistaken for an inguinal rupture, since, m
+ The mode in which the femoral sheath, continued from the abdominal
^ u-anp Tipcomes simply applied to the sides of the vessels, rendeis it
Tomse not impossible for a hernia to protrude into the sheath at any
its abdominal entrance. Mr. Stanley and M. Cloquet have
jserved a femoral hernia external to the vessels. Hesselbach has also
et with this variety. A hernia of this nature has come under my own
observation Cloquet has seen the hernia descend the sheath once in front
of the vessels, and once behind them. These varieties, however, must be
very rare. The external form has never been met with by Hey, Cooper,
or Scarpa; whilst no less than six instances of it have come under the
notice of Mr. Macilwain, (on Hernia, p. 293.)
COMMENTARY ON PLATE XXIV.
addition to its being superficial to the aponeurosis which covers
the inguinal canal, and also to the femoral arch, it may be with¬
drawn readily from this place, and its body, 12, traced to where it
sinks into the saphenous opening, 6, 7, on the upper part of the
thigh. An inguinal hernia manifests its proper character more
and more plainly as it advances from its point of origin to its
termination in the scrotum. A femoral hernia, on the contrary,
masks its proper nature, as well at its point of origin as at its
termination. But when a femoral hernia stands midway between
these two points—viz., in the saphenous opening, 6, 7, it best
exhibits its special character; for here it exists below the
femoral arch, and considerably apart from the external abdominal
ring.
Figure 9.—The neck of the sac of a femoral hernia, 2, lies
always close to, 3, the epigastric artery. When the obturator
artery is derived from the epigastric, if the former pass internal
to the neck behind, 8, Gimbernat’s ligament, it can scarcely
escape being wounded when this structure is being severed by the
operator’s knife. If, on the other hand, the obturator artery descend
external to the neck of the sac, the vessel AviU. be comparatively
remote from danger while the ligament is being divided. In addition
to the fact that the cause of stricture is always on the pubic side, 8,
of the neck of the sac, 12, thereby requiring the incision to cor¬
respond A^ththis situation only, other circumstances, such as the con¬
stant presence of the femoral vein, 11, and the epigastric artery, 1,
determine the avoidance of ever incising the canal on its outer
or upper side. And if the obturator artery,* by rare occurrence,
happen to loop round the inner side of the neck of the sac, sup¬
posing this to be the seat of stricture, what amount of anatomical
knowledge, at the call of the most dexterous operator, can render
the vessel safe from danger?
The taxis, in a case of crural hernia, should be conducted in
accordance with anatomical principles. The fascia lata, Poupart’s
ligament, and the abdominal aponeurosis, are to be relaxed by
bending the thigh inwards to the hypogastrium. By this measure,
the falciform process, 6, is also relaxed; but I doubt whether the
situation occupied by Gimbernat’s ligament allows this part to be
influenced by any position of the limb or abdomen. The hernia
is then to be drawn from its place above Poupart’s ligament, (if
it have advanced so far,) and when brought opposite the saphenous
opening, gentle pressure made outwards, upwards, and backwards,
so as to slip it beneath the margin of the falciform process, will best
serve for its reduction. When this cannot be effected by the taxis,
and the stricture still remains, the cutting operation is required.
The precise seat of the stricture cannot be known except during
the operation. But it is to be presumed that the sac and con¬
tained intestine sufier constriction throughout the whole length
of the canal.f Previously to the commencement of the operation,
the urinary bladder should be emptied; for this organ, in its
distended state, rises above the level of the pubic bone, and may
thus be endangered by the incision through the stricture—
especially if Gimbernat’s ligament be the structure which
causes it.
An incision commencing a little Avay above Poupart’s ligament,
is to be carried vertically over the hernia parallel with, but to the
inner side of its median line. This incision divides the skin and
subcutaneous adipose membrane, which latter varies considerably
in quantity in several individuals. One or two small arteries (super¬
ficial pubic, &c.) may be divided, and some Ijnnphatic bodies ex¬
posed. On cautiously turning aside the incised adipose membrane
contained between the two layers of the superficial fascia, the fascia
propria, 9, Figs. 10, 11, of the hernia is exposed. This envelope,
besides varying in thickness in two or more cases, may be absent
altogether. The fascia closely invests the sac, 12; but sometimes
a layer of fatty substance interposes between the two coverings,
and resembles the omentum so much, that the operator may be
led to doubt whether or not the sac has been already opened.
The fascia is to be cautiously slit open on a director; and now the
sac comes in view. The hernia having been draAvn outwards, so
as to separate it from the inner wall of the crural canal, a director |
is next to be passed along the interval thus left, the groove of the
instrument being turned to the pubic side. The position of the
director is now between the neck of the sac and the inner wall of
the canal. The extent to which the director passes up in the
canal will vary according to the suspected level of the stricture.
A probe-pointed bistoury is now to be slid along the director, and
with its edge turned upwards and inwards, according to the seat
of stricture, the following mentioned parts are to be divided— auz.,
the falciform process, 6; the inner wall of the canal, Avhich is con¬
tinuous with the fascia propria, 9; Gimbernat’s ligament, 8; and
the conjoined tendon, 4; where this is inserted with the ligament
into the pectineal ridge. By this mode of incision, which seems
to be all-sutficient for the liberation of the stricture external to
the neck of the sac, we avoid Poupart’s ligament; and thereby the
spermatic cord, 3, and epigastric artery, 1, are not endangered.
The crural canal being thus laid open on its inner side, and the
constricting fibrous bands being severed, the sac may now be
gently manipulated, so as to restore it and its contents to the
cavity of the abdomen; but if any impediment to the reduction
still remain, the cause, in all probability, arises either from the
neck of the sac having become strongly adherent to the crural
ring, or from the bowel being bound by bands of false membrane
to the sac. In either case, it will be necessary to open the sac,
and examine its contents. The neck of the sac is then to be
exposed by an incision carried through the integument across
the upper end of the first incision, and parallel with Poupart’s
ligament. The neck is then to be divided on its inner side, and
the exposed intestine may now be restored to the abdomen.
M. Velpeau (Medecine Operatoire), in reference to the relative
frequency of cases in which the obturator artery is derived from the
epigastric, remarks, “ L’examen que j’ai pu en faire sur plusieurs milliers
de cadavies, ne me permet pas de dire qu’elle se rencontre un fois sur trois,
ni sur cinq, ni meme sur dix, mais bien seulement sur quinze a vingt.”
Monro (Obs. on Crural Hernia) states this condition of the obturator
artery to be as 1 in 20-30. Mr. Quain (Anatomy of the Arteries) gives,
as the result of his observations, the proportion to be as 1 in 3^ and in
this estimate he agrees to a great extent with the observations of Cloquet
and Hesselbach. Numerical tables have also been drawn up to show the
relative frequency in which the obturator descends on the outer and inner
borders of the crural ring and neck of the sac. Sir A. Cooper never met
with an example where the vessel passed on the inner side of the sac and
from this alone it may be inferred that such a position of the vessel is’very
rare. It is generally admitted that the obturator artery, when derived from
the epigastric, passes down much more frequently between the iliac vein
and outer border of the ring. The researches of anatomists (Monro and
others) m reference to this point have given rise to the question, “ What
determines the position of the obturator artery with respect to the femoral
ring?” It appears to me to be one of those questions which do not admit
of a precise answer by any mode of mathematical computation; and even
if it did, where then is the practical inference ?
t “ The seat of the stricture is not the same in all cases, though, in by
far the greater number of instances, the constriction is relieved by the
division upwards and inwards of the falciform process of the fascia lata,
and the lunated edge of Gimbernat’s ligament, where they join with each
other. In some instances, it will be the fibres of the deep crescentic
(femoral) arch; in others, again, the neck of the sac itself, and produced
by a thickening and contraction of the subserous and peritonseal membranes
where they lie within the circumference of the crural ring.” — Morton
(Surgical Anatomy of the Groin, p. 148).
t The finger is the safest director; for at the same time that it guides
the knife it feels the stricture and protects the bowel. As all the
structures which are liable to become the seat of stricture—viz., the
falciform process, Gimbernat’s ligament, and the conjoined tendon, lie in
very close apposition, a very short incision made upwards and inwards is
all that is required.
A' *
Ik'
S##t
SS!§>iJf3^ft{fe?W!'Jr.'lJa-,. -.f
sS’e-
yi?P
WM'lr
W'"^ V
IHi
W it
COMMENTAEY ON PLATE XXV.
THE SURGICAL DISSECTION OF THE PRINCIPAL BLOODVESSELS AND NERVES OF THE ILIAC
AND FEMORAL REGIONS.
Through the groin, as through the axiUa, the principal bloodvessels
and nerves are transmitted to the corresponding limb. The main
artery of the lower limb frequently becomes the subject of a
surgical operation. The vessel is usually described as divisible
into parts, according to the regions which it traverses. But, as in
examining any one of those parts irrespective of the others, many
facts of chief surgical importance are thereby obscured and over¬
looked, I propose to consider the vessel as a whole^ continuous
from the aorta to where it enters the popliteal space. The general
course and position of the main artery may be described as
follows :—The abdominal aorta. A, bifurcates on the body of the
fourth lumbar vertebra. The level of the aortic bifurcation
corresponds with the situation of the navel in front, and the crista
ilii laterally. The aorta is in this situation borne so far forwards
by the lumbar spine as to occupy an almost central position in
the cavity of the abdomen. If the abdomen were pierced by two
lines, one extending from a little to the left side of the navel,
horizontally backwards to the fourth lumbar vertebra, and the
other from immediately over the middle of one crista ilii, trans¬
versely to a corresponding point in the opposite side, these lines
would intersect at the aortic bifurcation. The two arteries, G G,
into which the aorta divides symmetrically at the median line,
diverge from one another in their descent towards the two groins.
As both vessels correspond in form and relative position, the
description of one will serve for the other.
While the thigh is abducted and rotated outwards, if a line
be dra-\vn from the navel to a point, d, of the inguinal fold, mid¬
way between b, the anterior iliac spine, and c, the symphysis pubis,
and continued thence to the inner condyle of the femur, it would
indicate the general course of the artery, G i w. In this course,
the vessel may be regarded as a main trunk, giving off at intervals
large branches for the supply of the pelvic organs, the abdominal
parietes, and the thigh. From the point where the vessel leaves
the aorta. A, down to the inguinal fold, d, it lies within the abdo¬
men, and here, therefore, all operations affecting the vessel are
attended with more difficulty and danger than elsewhere, in its
course.
The artery of the lower limb, arising at the bifurcation of the
aorta on the fourth lumbar vertebra, descends obliquely outwards
to the sacro-iliac junction, and here it gives off its first branch, G,
(internal iliac,) to the pelvic organs. The main vessel is named
common iliac^ at the interval between its origin from the aorta and
the point where it gives off the internal iliac branch. This
interval is very variable as to its length, but it is stated to be
usually two inches. The artery, i, continuing to diverge in its
first direction from its fellow of the opposite side, descends along
the margin of the true pelvis as far as Poupart’s ligament, d.
where it gives off its next principal branches,—viz., the epigastric
and circumflex iliac. At the interval between the internal iliac
and epigastric branches, the main artery, i, is named external iliac;
and the surgical length of this part is also liable to vary, in con¬
sequence of the epigastric or circumflex iliac branches arising
higher up or lower doAvn than usual. The main vessel, after
passing beneath the middle of Poupart’s ligament, D, next gives off
the profundus branch, N, to supply the thigh. This branch gene¬
rally arises at a point an inch and half or two inches below the fold
of the groin; and between it and the epigastric above, the mam
artery is named common femoral. From the point where the
profundus branch arises, down to the popliteal space, the vessel
remains as an undivided trunk, being destined to supply the leg
and foot. In this course, the artery is accompanied by the vein,
H K 0, which, according to the region in which it lies, assumes
different names, corresponding to those applied to the artery.
Both vessels may now be viewed in relation to each other, and
to the several structures which lie in connexion with them.
The two vessels above Poupart’s ligament lie behind the intes¬
tines, and are closely invested by the serous membrane. The origin
of the vena cava, f, lies close to the right sid€^ of the bifurcation of
the aorta, a; and here both vessels are supported by the lumbar
spine. Each of the two arteries, g g, into which the aorta divides,
has its accompanying vein, h, on its inner side, but the common
iliac part of the right artery is seen to lie upon the upper portions
of both the veins, as these joining beneath it form the commence¬
ment of the vena cava. The external iliac part, i, of each
artery has its vein, k, on its inner side. At the point, G, where
the artery gives off its internal iliac branch, the ureter, y, crosses
it, and thence descends to the bladder. The internal iliac branch
subdivides in general so soon after its origin, that it may be
regarded as for the most part an unsafe proceeding to place a
ligature upon it.
The iliac vessels, A G i, in approaching Poupart’s ligament along
the border of the true pelvis, are supported by the psoas muscle, and
invested and bound to their place by the peritonasum, and a thin
process of the iliac fascia. Some lymphatic glands are here found
to lie over the course of the vessels. The spermatic artery and vein,
together with thegenito-crural nerve, descend along the outer border
of the niac artery. When arrived at Poupart’s ligament, the iliac
vessels, i k, become complicated by their own branches, and also
by the spermatic vessels, as these are about to pass from the abdo¬
men through the internal inguinal ring. While passing beneath
the middle of Poupart’s ligament, D, the iliac artery, i, having its
vein, K, close to its inner side, rests upon the inner border of the psoas
muscle, and in this place it may be effectually compressed against
the os pubis. The anterior crural nerve, p, which in the iliac region
DESCRIPTION OF PLATE XXV.
A. The aorta at its point of bifurcation.
B. The anterior superior iliac spine.
C. The symphysis pubis.
D. Poupart’s ligament, immediately above which are seen the circumflex
ilii and epigastric arteries, with the vas deferens and spermatic
vessels.
EE*. The right and left iliac muscles covered by the peritonaeum, the
external cutaneous nerve is seen through the membrane.
F. The vena cava. -
GG*. The common iliac arteries giving oflF the internal iliac branches on
the sacro-iliac symphyses; gg, the right and left ureters.
HH*. The right and left common iliac veins.
IT*. The right and left external iliac arteries, each is crossed by the cir¬
cumflex ilii vein.
KK. The right and left external iliac veins. •
L. The urinary bladder covered by the peritonaeum.
M. The rectum intestinum.
N. The profundus branch of the femoral artery.
O. The femoral vein; o, the saphena vein.
P. The anterior crural nerve.
Q. The sartorius muscle, cut.
S. The pectiuaeus muscle.
T. The adductor longus muscle.
U. The gracilis muscle.
V. The tendinous sheath given off from the long adductor muscle,
crossing the vessels, and becoming adherent to the vastus
internus muscle.
W. The femoral artery. The letter is on the part where the vessel
becomes first covered by the sartorius muscle.
COMMENTARY ON PLATE XXV.
lies concealed by the psoas muscle, and separated by this from the
vessels, now comes into view, lying on the outer side of the artery.
When the vessels have passed from beneath Poupart’s ligament,
the serous membrane no longer covers them, but the fibrous mem¬
brane is seen to invest them in the form of a sheath, divided into
two compartments, one of which (internal) receives the vein, the
other the artery. The iliac vessels, in passing to 'the thigh,
assume the name femoral.
The femoral vessels, ONw, in the upper third of the thigh
traverse a triangular space, the base of which is formed by Pou-
part s ligament, n, whilst the sides and apex are formed by the
sartorius, q, and adductor longus muscles, T, approaching each
other. In the undissected state of the part, the structures which
bound this space can in general be easily recognised. A central
depression extends from the middle of its base, d, to its apex, v, and
marks the course of the vessels. Near the middle of Poupart’s
ligament, the vessels are comparatively superficial, and here the
artery may be felt pulsating; but lower down, as they approach the
apex of the triangle, the vessels become gradually deeper, till the
sartorius muscle inclining from its origin obliquely inwards to the
centre of the thigh, w, at length overlaps them. The inner border
of the sartorius muscle at the lower part of the upper third of the
thigh, w, guides to the position of the artery. Whilst traversing
the femoral triangle, the vessels enclosed in their proper sheath are
covered by the fascia lata, adipose membrane, and integument. In
Ais place they lie imbedded in loose cellular and adipose tissue.
The femoral vein, o, is on the same plane 4ith the artery near
oupart s ligament; but from this place downwards through the
thigh, the vein gradually winds from the inner to the back part of
the artery; and when both vessels pass under cover of the sartorius
they enter a strong fibrous sheath, v, derived from the tendons of
the adductor muscles upon which they lie. The artery approaches
the shaft of the femur near its middle; and in this place itmay be
readily compressed against the bone by the hand. The anterior
crural nerve, p, dividing on the outer side of the artery, sends
some of Its branches coursing over the femoral sheath; and one of
tbese-the long saphenous nerve-enters the sheath and follows the
artery as far as the opening in the great adductor tendon. The
femoj^l artery, before it passes through this openiug into the
wrt b»»ch. The profundus
bmnch, n spmgs from the outer side of the femoral artery usually
at a distace of from one to two inehes (seldom more) below
oupart s ligament, and soon subdivides.* The femoral artery
in a few mstances has been found double. ^
any tlrof “"r ««• “
Z Z ! Wlifod space
But the situation most ehgible for performing Lch an OMra-
XSlt ir”' anatomical and
pathological If an aneurism affect the popUteal part of the
vesse, or 1 , froni whatever cause arising, it be found expedient to
t e the femora above this part, the place best suited for L opera-
on IS a wiere the artery, w, first passes under cover of the
« muscle-t For, considering that the vessel Z off 1
^portan branch destined to supply any part of the thigh or Z
ween the profundus branch and those into which tt divid«
below the popliteal space, the arrest to circulation will be the Z
m amount atwhiche™ part of the vessel between these wo poZ
the ligature be applied. But since the vessel in the I r
W can be reached with greater facifity teZn eCZ
be Z™' f moreover, a ligature applied to it here will
riielZfZ ZZ Prt>ftndus Lnch above an!
seat of disease below, to produce the desired result, the cZ
of the oj^erator is determined accordingly. Tlie steps of the
operation performed at the situation w, where tlie arteiy is
about to pass beneath the sartorius, are these: an incision of
sufficient length—from two to three inches—is to be made over
the course of the vessel, so as to divide the skin and adipose
membrane, and expose the fascia lata, through which the inner
edge of the sartorius muscle becomes now readily discernible.
A vein (anterior saphena) may be found to cross in this situa¬
tion, but the saphena vein proper is not met with, as this lies
nearer the inner side of the thigh. The fascia having been next
divided, the edge of the sartorius is to be turned aside, and now
the pulsation of the artery in its sheath will indicate its exact
position. The sheath is next to be opened, for an extent sufficient
only to carry the point of the ligature-needle safely around the
artery, care being taken not to injure the femoral vein, which lies
close behind it, and also to exclude any nerve which may lie in
contact with the vessel.
If an aneurism affect the common femoral portion of the artery,
the external iliac part would require to be tied, because, between the
seat of the tumour and the epigastric and circumflex ilii branches
above, there would not be sufficient space to allow the ligature to rest
undisturbed; and even if the aneurism arose from the femoral below
the profundus branch in the upper third of the thigh, or if, after
amputation of the thigh, a secondary haemorrhage took place from
the femoral and the profunda arteries, a ligature would with more
safety be applied to the external iliac part than to the common
femoral, because of this latter, even when of its clear normal
length, presenting so small an interval between the epigastric and
profundus branches. In addition to this, it must be noticed, that
occasionally the profundus itself, or some one of its branches,' (ex¬
ternal and internal circumflex, &c.), arises as high up as Poupart’s
ligament, close to the origin of the epigastric and circumflex iliac.J
^ The external iliac part of the artery, g i, when requiring to be
tied, may be reached in the following way: an incision, commenc¬
ing above the anterior iliac spine, b, is to be carried inwards
paraUel to, and above, Poupart’s ligament, d, as far as the outer
margin of the internal abdominal ring. This incision is the one best
calculated for avoiding the epigastric artery, and for not disturbiim
the peritomeum more than is necessary. The skin and the three
abdominal muscles having been successively incised, the fibrous
transversahs fascia is next to be carefully divided, so as to expose
Ae peritomeum. This membrane is then to be gently raised
_ y e fingers, from off the ihacus and psoas muscles as far
inwards as the margin of the true pelvis where the artexy lies.
On raising the peritoneum the spermatic vessels wiU be found
adhering to it The fliac artery itself is liable to be displaced by
adhering to the serous membrane, when this is being detached
om the inner side of the psoas muscle.§ The artery having been
divested of Its smus covering as far up as a point midway between
IG, the epigastric and internal iliac branches, the ligature is to be
rZZ /‘r Z “ Z these t,™
side of the artery, the point of the instrument should first be inserted
bet^n them, and passed from within outwards, in ord« „ Zd
Wi^unding the vem. If an aneurism affeet the upper end o^Z
external diac artery, it is proposed to tie the common iliac but
‘be poZuZnZmZsZ o" ZZ
authority gfe" ‘ tnarrny^f ^
t This is the situation chosen bv S^L r" Arteries,” &c.
circulation through the femoral aftP arresting by ligature the
The reasons stated in the text are thos^ ' V popliteal aneurism,
perform the operation in thL placet ^
of the thigh) where Mr. Huntt first mn
I The main artery (Plate XXV
femoral regions with the object tt show' iliac and
ODject of showing the relation which its parts
§ The student in r, ^ arterial anastomosis.
find that thetac artertdo^" T”" P«
the time that he has lifted th°° ™ situation, urn
I have once seen dtp'^'t
operation on the living body at ff surgeon, whilst perform
mg body, at fault owing to the same cause.
COMMENTAEY ON PLATE XXVI
THE RELATIVE ANATOMY OF THE MALE PELVIC ORGANS.
As the abdomen and pelvis form one general cavity, the organs
COTtained in both regions are thereby intimately related. The
viscera of the abdomen completely till this region, and transmit
to the pelvic organs all the impressions made upon them by
the diaphragm and abdominal walls. The expansion of the
lungs, the descent of the diaphragm, and the contraction of the
abdominal muscles, cause the abdominal viscera to descend and
compress the pelvic organs; and at the same time the muscles
occupying the pelvic outlet, becoming relaxed or contracted, allow
the perinseum to be protruded or sustained voluntarily according
to the requirements. Thus it is that the force originated in the
muscular parietes of the thorax and abdomen is, while opposed
by the counterforce of the perinaeal muscles, brought so to bear
upon the pelvic organs as to become the principal means whereby
the contents of these are evacuated. The abdominal muscles are,
during this act, the antagonists of the diaphragm, while the
muscles which guard the pelvic outlet become at the time the
antagonists of both. As the pelvic organs appear therefore to
be little more than passive recipients of their contents, the
voluntary processes of defecation and micturition may with more
correctness be said to be performed rather for them than by them.
The relations which they bear to the abdomen and its viscera,
and their dependence upon these relations for the due performance
of the processes in which they serve, are sufficiently explained by
pathological facts. The same system of muscles comprising those
of the thorax, abdomen and perineum, performs consentaneously
the acts of respiration, vomiting, defecation and micturition.
When the spinal cord suffers injury above the origin of the phrenic
nerve, immediate death supervenes, owing to a cessation of the
respiratory act. Considering, however, the effect of such an
injury upon the pelvic organs alone, these may be regarded as
being absolutely excluded from the pale of voluntary influence in
consequence of the paralysis of the diaphragm, the abdominal and
perinasal muscles. The expulsory power over the bladder and
rectum being due to the opposing actions of these muscles above
and below, if the cord be injured in the neck below the origin of
the phrenic nerve, the inferior muscles becoming paralysed, the
antagonism of muscular forces is thereby interrupted, and the
pelvic organs are, under such circumstances, equally withdrawn
from the sphere of volition. The antagonism of the abdominal
muscles to the diaphragm being necessary, in order that the
pelvic viscera may be acted upon, if the cord be injured in the
lower dorsal region, so as to paralyse the abdominal walls and
the perinfeal muscles, the downward pressure of the diaphragm
alone could not evacuate the pelvic organs voluntarily, for the
abdominal muscles are now incapable of deflecting the line of
force backwards and downwards through the pelvic axis; and
the perinaeal muscles being also unable to act in agreement, the
contents of the viscera pass involuntarily. Again, as the muscular
apparatus which occupies the pelvic outlet acts antagonistic to the
abdomen and thorax, when by an injury to the cord in the sacral
spine the perinaeal apparatus alone becomes paralysed, its relaxa¬
tion allows the thoracic and abdominal force to evacuate the pelvic
organs involuntarily. It would appear, therefore, that the term
“ paralysis” of the bladder or rectum, when following spinal
injuries, &c., &c., means, or should mean, only a paralytic state
of the abdomino-pelvic muscular apparatus, entirely or in part.
For, in fact, neither the bladder nor rectum ever acts voluntarily
per se any more than the stomach does, and therefore the name
“ detrusor” urinse, as applied to the muscular coat investing the
bladder, is as much a misnomer (if it be meant that the act of
voiding the organ at will be dependent upon it) as would be
the name “ detrusor” applied to the muscular coat of the stomach,
under the meaning that this were the agent in the spasmodic
effort of vomiting.
The urinary bladder, g. Fig. 2, (in the adult body,) occupies
the true pelvic region when the organ is collapsed, or only partly
distended. It is situated behind the pubic symphysis and in front
of the rectum, c,—the latter lies between it and the sacrum, a.
In early infancy, when the pelvis is comparatively small, the
bladder is situated in the hypogastric region, with its summit
pointing towards the umbilicus; as the bladder varies in shape,
according to whether it be empty or full, its relations to neigh¬
bouring parts, especially to those in connexion with its summit,
vary also considerably. When empty, the back and upper surface
of the bladder collapse against its forepart, and in this state the
organ lies flattened against the pubic S 3 miphysis. Whether the
bladder be distended or not, the small intestines lie in contact with
its upper surface, and compress it in the manner of a soft elastic
cushion. When distended largely, its summit is raised above the
pubic symphysis, the small intestines having yielded place to it,
and in this state it can be felt by the hand laid upon the hypo-
gastrium.
The* shape of the bladder varies in different individuals. In
some it is rounded, in others pyriform, in others peaked towards its
summit. Its capacity varies also considerably at different ages and
in different sexes. When distended, its long axis will be found to
coincide with a line passing from a point midway between the
navel and pubes to the point of the coccyx, the obliquity of this
direction being greatest when the body is in the erect posture, for the
DESCRIPTION OF THE FIGURES IN PLATE XXVI.
Figure 1.
A. The anterior superior iliac spine.
B. The anterior inferior iliac spine.
C. The acetabulum ; c, the ligamentum teres.
D. The tuber ischii.
E. The spine of the ischium.
F. The pubic horizontal ramus.
G. The summit of the bladder covered by the peritonseum.
H. The femoral artery.
I. The femoral vein.
K. The anterior crural nerve.
L. The thyroid ligament.
M. The spermatic cord.
N. The corpus cavernosum penis;its artery.
O. The urethra; the bulbus urethrm.
P. The sphincter ani muscle.
Q. The coccyx.
R. The sacro-sciatic ligament.
S. The pudic artery and nerve.
T. The sacral nerves.
U. The pyriformis muscle, cut.
V. The gluteal artery.
W. The small gluteus muscle.
Figuke 2.
A. The part of the sacrum which joins the ilium.
B. The external iliac artery, cut across.
C. The upper part of the rectum.
D. The ascending pubic ramus.
E. The spine of the ischium, cut.
F. The horizontal pubic ramus, cut.
G. The summit of the bladder covered by the peritonseum; its side,
not covered by the membrane.
HH. The recto-vesical peritonseal pouch.
I. The vas deferens.
K. The ureter.
L. The vesicula seminalis.
M. N, 0, P, Q, R, S, T, U, refer to the same parts as in Fig. 1.
COMMENTARY ON PLATE XXVL
intestines now gravitate upon it. When the body is recumbent,
the bladder recedes somewhat from the pubes, and as the intes¬
tines do not now press upon it from above, it allows of being
distended to a much greater degree without causing uneasiness,
and a desire to void its contents.
The manner in which the bladder is connected to neighbouring
parts is such as to admit of its full distension. Its summit, back,
and upper sides are free and covered by the elastic peritonasum,
whilst its front, lower sides, and base are adherent to adjacent
parts, and divested of the serous membrane. On tracing the
peritonaeum from the front wall of the abdomen to its point of
reflexion over the summit of the bladder, we find the membrane
to be in this part so loosely adherent, that the bladder when much
distended, raises the peritonaeum above the level of the upper
margin of the pubic symphysis. In this state the organ may be
punctured immediately above the pubic symphysis without
endangering the serous sac. When the bladder is collapsed, the
peritonaeum follows its summit below the level of the pubes, and
in this position of the organ such an operation would be inad¬
missible, if indeed the necessity for it can now be conceived.
By removing the os innominatum, a d. Fig. 1, together with
the internal obturator, and levator ani muscles, which arise from
its inner side, we obtain a lateral view. Fig. 2 , of the pelvic
viscera, and of the vessels &c. connected with them. Those parts
of the bladder, g, and the rectum, c, which are invested by the
peritonasum, are also now fully displayed. On tracing this mem¬
brane from before backwards, over the summit of the bladder, g,
we find it descending deeply upon the posterior surface of the
organ, before it becomes reflected so as to ascend over the fore¬
part of the rectum. This duplicature of the serous membrane, h h,
is named the recto-vesical pouch, and it is required to ascertain
with all the exactness possible the level to which it descends, so as
to avoid it in the operation of puncturing the bladder through the
rectum. The serous pouch descends lower in some bodies than in
others 5 but in all there exists a space, of greater or less dimensions,
between it and the prostate, v, whereat the base of the bladder
is in direct apposition with the rectum, w, the serous membrane
not intervening.
When the peritoneum is traced from one iliac fossa to the
other, we find it sinking deeply into the hollow of the pelvis
behind the bladder, so as to form the sides of the recto-vesical
pouch; but when traced over the summit of the bladder,
this organ is seen to have the membrane reflected upon it,
almost immediately below the pelvic brim. At the situations
where the peritoneum becomes reflected in front, laterally, and
behind, upon the sides of the bladder, the membrane is thrown
into folds, which are named “ false ligaments.” The pelvic fascia,
in being reflected to the bladder from the front and sides of the
pelvis, at a lower level than that of the peritonaium, for ms the “ true
ligaments.” In addition to these ligaments, which serve to keep the
base and front of the bladder fixed in the pelvis, other structures,
such as the ureters, k, the vasa deferentia, i, the hypogastric cords,’
the urachus, and the bloodvessels, embrace the organ in various
directions, and act as bridles, to hmit its expansion more or less
in all directions, but least so towards its summit, which is always
comparatively free.
The neck and outlet of the bladder, v, are situated at the ante¬
rior part of Its base, and point towards the subpubic space. The
prostate gland, v, surrounds its neck, and occupies a position
behind and below the pubic arch, n, and in front of the rectum w
The gland, v, being of a rounded form and dense structure, can be
felt in this situation by the finger, passed upwards through the
bowel. The prostate is suspended from the back of the pubic arch
by the anterior true ligament of the bladder, and at its forepart,
where the membranous portion of the urethra commences, this
passes through the deep perinseal fascia, x. The anterior fibres
of the levator ani muscle embrace the prostate on both its sides.
Behind the base of the prostate, the ureter, k, is seen to enter
the coats of the bladder obliquely, whilst the vas deferens, i,
joined by the vesicula seminalis, l, penetrates the substance of
the prostate, v, at its lower and back part, which lies in apposition
with the rectum.
The rectum, wc, at its middle and upper parts, occupies the
hollow of the sacrum, A q, and is behind the bladder. The lower
third of the rectum, w, not being covered by the peritonaeum, is
that part on which the various surgical operations are performed.
At its upper three-fifths, the rectum describes a curve correspond¬
ing to that of the sacrum; and if the bladder be full, its convex back
part presses the bowel against the bone, causing its curve to be
greater than if the bladder were empty and collapsed. This fact
requires to be borne in mind, for, in order to introduce a bougie,
or to allow a large injection to pass with freedom into the bowel,
the bladder should be first evacuated. The coccygeal bones, q,
continuing in the curve of the sacrum, bear the rectum, w, for¬
wards against the base of the bladder, and give to this part a
degree of obliquity upwards and backwards, in respect to the
perineeum and anus. From the point where the prostate, v, lies in
contact with the rectum, w, this latter curves downwards, and
shghtly backwards, to the anus, p. The prostate is situated at a
distance of about an inch and half or two inches from the anus_
the distance varying according to whether the bladder and bowel
be distended or not.*
The arteries of the bladder are derived from the branches of the
internal iliac, s. The rectum receives its arteries from the inferior
mesenteric and pudic. The veins which course upwards from the
rectum are large and numerous, and devoid of valves. When
these veins become varicose, owing to a stagnation of their circula¬
tion, produced from whatever cause, the bowel is liable to be
affected with hiemorrhoids or to assume a hiemorrhagic ten-
passes from the pelvis by the great sciatic foramen, below the
pyriformis muscle, and in company with the sciatic artery. The
pudic artery and vein wind around the spine, e, of the ischium,
where they are joined by the pudic nerve, derived from, t, the
sacral plexus. The artery, in company with the nerve and ’vein
re-enters the pelvis by the smaU sciatic foramen, and gets under
cover of a dense fibrous membrane (obturator fascia), between
which and the obturator muscle, it courses obliquely downwards
and forwards to the forepart of the perimeum. At the place where
t e vessel re-enters the pelvis, it lies removed at an interval of an
inch and a half from the perineum, but becomes more superficial
as It approaches the subpubic space, n. The levator ani muscle
separates the pudic vessels and nerves from the sides of the rectum
an bladder. The principal branches given off from the pudic
aateiy of either side, are ( 1 st), the inferior hemorrhoidal, to supply
the lower end of the rectum; ( 2 nd), the transverse and superficial
perineal; (3rd), the artery of the bulb; (4th), that which enters
the corpus cavemosum of the penis, k; and ( 5 th), the dorsal
artery of the penis.f The branches given off from the pudic
nerve correspond in number and place to those of the artery.
Having now considered the relations of the pelvic organs in a
lateral view, we are better prepared to understand these relations
when seen at their perinaeal aspect.
The distance between any two given parts is found to vary in different
cases. In subjects of an advanced age,” Mr. Stanley remarks, « a deep
permaeum, as it is termed, is frequently met with. This may be occasioned
either by an unusual quantity of fat in the perinmum, or by an enlarged
prostate, or by the dilatation of that part of the rectum which is contiguous
to the prostate and bladder. Under either of these circumstances the
piostate and bladder become situated higher in the pelvis than naturally
and consequently at a greater distance from the perin£eum.”-0« the
Lateral Operation of Lithotomy.
i*® branches, occasionally und
goes marked deviations from the ordinary course. In Mr. Quain’s wo
tU ° Arteries,”) a case is represented in which the artt
tV. 1 f pudic as far back as the tuber ischii, and cross
e me o incision made in the lateral operation of lithotomy. In anotl
baw 1"' accessory pudic”), which, passing between t
tbA 1 A 1 i! “d the levator ani muscle, crosses in contact wi
tne left lobe of the prostate.
>m.
-’I
pM&BM0^
ImW
SMfi
2^. ir. Hanhart lith. Frinters
COMMENTARY ON PLATE XXVII.
THE SUEGICAL DISSECTION OF THE SUPERFICIAL STEUCTIIEES OF THE MALE PERINiEDM.
The median line of the body is marked as the situation where
the opposite halves unite and constitute a perfect symmetrical
figure. Every structure—superficial as well as deep—^which
occupies the median line is either single, by the union of halves,
or dual, by the cleavage and partition of halves. The two sides
of the body being absolutely similar, the median line at which they
unite is therefore common to both. Union along the median line
is an occlusion taking place by the junction of sides; and every
hiatus or opening, whether normal or abnormal, which happens at
this line, signifies an omission in the process of central union.
The sexual peculiarities are the results of the operation of this law,
and aU forms which are anomalous to either sex, may be inter¬
preted as gradations in the same process of development; a few of
these latter occasionally come under the notice of the surgeon.
The region which extends from the umbilicus to the point of
the coccyx is marked upon the cutaneous surface by a central raphe
dividing the hypogastrium, the penis, the scrotum, and the peri-
naeum respectively into equal and similar sides. The umbilicus is
a cicatrix formed after the metamorphosis of a median foetal struc¬
ture—the placental cord, &c. In the normal form, the meatus
urinarius and the anus coincide with the line of the median raphe,
and signify omissions at stated intervals along the line of central
union. When between these intervals the process of union happens
likewise to be arrested, malformations are the result; and of these
the following are examples:—Extrusion of the bladder at the hypo¬
gastrium is caused by a congenital hiatus at the lower part of the
linea alba, which is in the median line; Epispadias, which is an
urethral opening on the dorsum of the penis; and Hypospadias,
which is a similar opening on its under surface, are of the same
nature—namely, omissions in median union. Hermaphrodism may
be interpreted simply as a structural defect, compared to the normal
form of the male, and as a structural excess compared to that of
the female. Spina bifida is a congenital malformation or hiatus in
union along the median line of the sacrum or loins. As the pro¬
cess of union along the median line may err by a defect or omis¬
sion, so may it, on the other hand, err by an excess in fulfilment,
as, for example, when the urethra, the vagina, or the anus are
found to be imperforate. As the median line of union thus seems
to influence the form of the hypogastrium, the genitals, and the
perinacum, the dissection of these parts has been conducted ac¬
cordingly.
By removing the skin and subjacent adipose membrane from the
hypogastrium, we expose the superficial fascia. This membrane,
E E E*, Fig. 1, is, in the middle line, adherent to B, the linea alba,
and thereby contributes to form the central depression which
extends from the navel to the pubes. The adipose tissue, which
in some subjects accumulates on either side of the linea alba,
renders this depression more marked in them. At the folds of the
groin the fascia is found adherent to Poupart s ligament, and this
also accounts for the depressions in both these localities. Fiom
the central linea alba to which the fascia adheres, outwards on
either side to the folds of both groins, the membrane forms two
distinct sacs, which droop down in front, so as to invest the
testicles, e**, and penis in a manner similar to that of the skm
covering these parts. As the two sacs of the superficial fascia
join each other at the line b, coinciding with the linea alba, they
form by that union the suspensory ligament of the penis, which is
a structure precisely median.
The superficial fascia having invested the testicles each in a
distinct sac, the adjacent sides of both these sacs, by joining toge¬
ther, form the median septum scroti, e, Fig. 2. In the perinteum.
Fig. 4, the fascia, a, may be traced from the back of the scrotum
to the anus. In this region the .membrane is found to adhere
laterally to the rami of the ischium and pubes; whilst along the
median perinseal line the two sacs of which the membrane is com¬
posed unite, as in the scrotum, and form an imperfect septum. In
front of the anus, beneath the sphincter ani, the fascia degenerates
into cellular membrane, one layer of which is spread over the
adipose tissue in the ischio-rectal space, whilst its deeper and
stronger layer unites with the deep perinteal fascia, and by this
connexion separates the urethral from the anal spaces. The super¬
ficial fascia of the hypogastrium, the scrotum, and the perinseum
forming a continuous membrane, and being adherent to the several
parts above-noticed, may be regarded as a general double sac,
which isolates the inguino-perinaeal region from the femoral and anal
regions, and hence it happens that when the urethra becomes rup¬
tured, the urine which is extravasated in the perinaeum, is allowed
to pass over the scrotum and the abdomen, involving these parts
in consequent inflammation, whilst the thighs and anal space are
exempt. The tunicse vaginales, which form the immediate coverings
of the testicles, cannot be entered by the urine, as they are dis¬
tinct sacs originally protruded from the abdomen. It is in conse¬
quence of the imperfect state of the inguino-perinaeal septum of
the fascia, that urine effused into one of the sacs is allowed to
enter the other.
Like all the other structures which join on either side of the
median line, the penis appears as a symmetrical organ, dd.
Fig. 2. While viewed in section, its two corpora cavernosa are
seen to unite anteriorly, and by this union to form a septum
“ pectiniformeposteriorly they remain distinct and lateral, f f,
DESCRIPTION OF THE FIGURES OF PLATE XXVII.
Figure 1.
A. The umbilicus.
B. The linea alba.
C. The suspensory ligament of the penis.
D D. The two corpora cavernosa penis.
E E ^ The hypogastric and scrotal superficial fascia.
FF. The spermatic cords.
Figuee 2.
A. The umbilicus.
B. The urethra.
C ^ The tunica vaginalis; c, the testicle invested by the tunic.
DD. The corpora cavernosa seen in section.
E. The scrotal raphe and septum scroti.
Figuee 3.
A B. The perinseal raphe.
C. The place of the coccyx.
D D. The projections of the ischiatic tuberosities.
BE. The line of section in lithotomy.
Figuee 4.
A. The superficial fascia covering the urethral space.
B. The sphincter ani.
C. The coccyx.
DD. The right and left ischiatic tuberosities.
H. The anus.
11. The glutei muscles.
Figuee 5.
A, B, C, D, H, I. The same parts as in Fig. 4.
E. The accelerator urinae muscle.
F F. Right and left erector penis muscle.
G G. Right and left transverse muscle.
COMMENTARY ON PLATE XXVII.
Fig. 5, being attached to the ischio-pubic rami as the crura penis.
The urethra, b, Fig. 2, is also composed of two sides, united along
the median line, but forming between them a canal by the cleavage
and partition of the urethral septum. All the other structures of
the perinaeum will be seen to be either double and lateral, or single
and median, according as they stand apart from, or approach, or
occupy the central line.
The perinaeum. Figs. 4, 5, is that space which is bounded above
by the arch of the pubes, behind by c, the os coccygis, and the
lower borders of, 11, the glutaai muscles and sacro-sciatic ligaments,
and laterally by D d, the ischiatic tuberosities. The osseous boun¬
daries can be felt through the integuments. Between the back of
the scrotum and the anus the perinaeum swells on both sides of the
raphe, A b. Fig. 3, and assumes a form corresponding with the bag
of the superficial fascia which encloses the structures connected
with the urethra. The anus is centrally situated in the depres¬
sion formed between d d, the ischiatic tuberosities, and the double
folds of the nates.
The perinaeum. Fig. 3, is, for surgical purposes, described as
divisible into two spaces (anterior and posterior) by a transverse
line drawn from one tuber ischii, D, to the other, d, and crossing
in front of the anus. The anterior space, add, contains the
urethra; the posterior space, ddc, contains the rectum. The
central raph6, a b c, traverses both these spaces. The anterior or
urethral space is (while viewed in reference to its osseous boun¬
daries) triangular in shape, the apex being formed by the pubic
symphysis beneath A, whilst two lines drawn from A to D d, would
coincide with the ischio-pubic rami which form its sides. The
raphfe in the anterior space indicates the central position of the
urethra, as may be ascertained by passing a sound into the bladder,
when the shaft of the instrument will be felt prominently between
the points ab. Behind the point b, the sound or statf sinks
deeper in the perinasum as it follows the curve of the urethra
towards the bladder, and becomes overlaid by the bulb, &c.
The ischiatic tuberosities, d d. Fig. 3, are, in all subjects,
sufficiently prominent to be felt through the integuments, &c. ;
and the line which, when drawn from one to the other, serves to
divide the two perinseal spaces, forms the base of the anterior one.
In well-formed subjects, the anterior space is equiangular, the
base being equal to each side; but according as the tuberosities
approach the median line, the base becomes narrowed, and the
triangle is thereby rendered acute. These circumstances influence
the direction in which the first incision in the lateral operation
of lithotomy should be made. When the tuberosity of the left
ischium stands well apart from the perinasal centre, the line of
incision, B E, Fig. 3, is carried obliquely from above downwards and
outwards; but in cases where the tuberosity approaches the centre,
the incision must necessaidly be made more vertical. The posterior
perinseal space may be described on the surface by two lines drawn
from D n, the ischiatic tuberosities, to c, the point of the coccyx,
whilst the transverse line between d and n bounds it above.
By removing the integument and superficial fascia, we expose
the superficial vessels and nerves, together with the muscles in the
neighbourhood of the urethra and the anus. The accelerator urina 3 ,
E, Fig. 5, which embraces the urethra, and the sphincter ani, b c,
which surrounds the anus, n, occupy the median line, and are
divided each into halves by a central tendon, e B c, which traverses
the perinaeum from before backwards, to the point of the coccyx.
On either side of the anus, in the ischio-rectal space, d d, Fig. 4, is
found a considerable quantity of granular adipose tissue, traversed
by the inferior hcemorrhoidal arteries and nerves—^branches of the
pudlc artery and nerve.
In front of the anus are seen two small muscles (transversae
perinaei), G G, Fig. 5, each arising from the tuber ischii of its own
side, and the two becoming inserted into, B, the central tendon.
These transverse muscles serve to mark the boundary between
the anterior and posterior perinajal spaces. Behind each muscle is
found a small artery, crossing to the median line. The left trans¬
verse muscle and artery are always divided in the lateral operation
of lithotomy. On the outer sides of the anterior perinaeal space are
seen the erectores penis muscles, f p, overlaying the crura penis.
Between each muscle and the accelerator urinae, the superficialis
perinaji artery and nerve course forwards to the scrotum, &c. ^
The perinasal muscles having been brought fully into vieAV,
Plate XXVIII., Fig. 1, their symmetrical arrangement on both
sides of the median line at once strikes the attention. On either
side of the anterior space appears a small angular interval l, formed
between b, the accelerator urini®, d, the erector penis, and e, the
transverse muscle. Along the surface of this interval, the super¬
ficial perinseal artery and nerve are seen to pass forwards; and
deep in it, beneath these, may also be observed, L, the artery of the
bulb, arising from the pudic, and crossing inwards, under cover of
the anterior layer of the menibrane named the deep perinssal
fascia. The first incision in the lateral operation of lithotomy is
commenced over the inferior inner angle of this interval.
The muscles occupying the anterior perinseal space require to
be removed. Fig. 2, in order to expose the urethra, b m, the cius
penis, D, and the deep perinseal fascia. The fascia will be now
seen stretched across the subpubic triangular space, reaching from
one ischio-pubic ramus to the other, ivhilst by its lower border,
corresponding with the line of the transversse perinsei muscles,
it becomes continuous with the superficisd fascia, in the manner
before described. The deep perinaeal fascia (triangular liga¬
ment) encloses between its tivo layers, c e, on either side of tlie
urethra, the pudic artery, the artery of the bulb, Cowper’s glands,
and some muscular fibres occasionally to be met with, to Avhich the
name “ Compressor urethrae” has been assigned. At this stage of
the dissection, as the principal vessels and parts composed of
erectile tissue are now in view, their relative situations should be
well noticed, so as to avoid ivounding them in the several cutting
operations required to be performed in their vicinity.
Along the median line (marked by the raphe) from the scrotum
to the coccyx, and close to this line on either side, the vessels are
unimportant as to size. The urethra lies .along the middle line in
the anterior perinasal space; the rectum occupies the middle in the
posterior space. When either of these parts specially require to
be incised—the urethra for impassable stricture, &c.,and the lower
part of the rectum for fistula in ano—the operation may be per¬
formed Avithout fear of inducing dangerous arterial haemorrhage.
With the object of preserAung from injury these iniport.ant parts,
deep incisions at, or approaching to, the middle line must be
avoided. The outer (ischio-pubic) boundaiy of the perinaeum is the
line along which the pudic artery passes. The anterior ludf of
this boundary supports also the crus penis; hence, therefore, in
order to avoid these, all deep incisions should be made parallel to,
but removed to a proper distance from this situation. The struc¬
tures placed at the middle line, b m f. Fig. 2, and those in con¬
nexion with the left perinaeal boundary, d gl, require (in order to
insure the safety of these parts) that the line of incision necessary
to gain access to the neck of the bladder in lithotomy shoidd be
made through the left side of the perinaeum from a jAoint midway
betAveen m, the bulb, and d, crus penis above, to a point, k,
midway between the anus, f, and tuber ischii, g, beloAV. As tlie
upper end of this incision is commenced over the situation of the
superficial perinaeal artery and the artery of the bulb, the hiife
at this place should only divide the skin and superficial fascia.
The lower end, k, just clears the outer side of the dilated lower
part of the rectum. The middle of the incision is over the left
lobe of the prostate gland and neck of the bladder, Avhich parts,
together with the membranous portion of the urethra, are still con¬
cealed by the deep perinasal fascia, the structures between its
layers, and the anterior fibres of k, the levator ani muscle. The
incision, if made in due reference to the relative situation of the
parts above noticed, Avill leave them untouched; but Avhen the
pudic artery, or some one of its branches, deviates from its
ordinary course and crosses the line of incision, a serious
haimorrhage will ensue, despite the anatomical knowledge of the
most experienced operator. When it is requisite to divide the
superfidal and deep sphincter ani as in the operation for complete
fistula in ano, if the incision be made transversely in the ischio¬
rectal fossa, the hsemorrhoidal arteries and nerves convergino-
towards the anus AviU be the more likely to escape being wounded'^
Ell^SSP^I^
H W*lv'%.V"',^, V r^ w.’V:
i#ifEtSi^%®
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COMMENTARY ON PLATE XXVIII.
THE SURGICAL DISSECTION OF THE DEEP STRUCTURES OF THE MALE PERINEUM.
^ THE LATERAL OPERATION OF LITHOTOMY.
The urethra, at its membranous part, m. Fig. 3, which commences
behind the bulb, perforates thecentre of the deep perinaial fascia, eb,
at about an inch and half in front of f, the anus. The anterior
layer of the fascia is continued forwards over the bulb, whilst the
posterior layer is reflected backwards over the prostate gland.
Behind the deep perimeal fascia, the anterior fibres of k, the levator
aiii muscle, arise from either side of the pubic symphysis posteriorly,
and descend obliquely downwards and forwards, to be inserted into
the sides of n n, the rectum above the anus. These fibres of the
muscle, and the lower border of the fascia which covers them, lie
immediately in front of the prostate, c c. Fig. 4, and must neces¬
sarily be divided in the operation of lithotomy. Previously to
disturbing the lower end of the rectum from its natural position in
the perinaium, its close relation to the prostate and base of the
bladder should be noticed. While the anus remains connected with
the deep perinaial fascia in front, the fibres of the levator ani muscle
of the left side may be divided; and by now inserting the finger
between them and the rectum, the left lobe of the prostate can be
felt in apposition with the forepart of the bowel, an inch or two
above the anus. It is owing to this connexion between these parts
that the lithotomist has to depress the bowel, lest it be wounded,
wliile the prostate is being incised. If either the bowel or the
bladder, or both together, be over-distended, they are brought into
closer apposition, and the rectum is consequently more exposed to
danger during the latter stages of the operation. The prostate
being in contact ■with the rectum, the surgeon is enabled to examine
by the touch, per anum^ the state of the gland. If the prostate
be diseased and irregularly enlarged, the urethra, which passes
through it, becomes, in general, so distorted, that the surgeon,
after passing the catheter along the urethra as far as the prostate,
will find it necessary to guide the point of the instrument into the
bladder, by the finger introduced into the bowel. The middle or
third lobe of the prostate being enlarged, bends the prostatic part
of the urethra upwards. But when either of the lateral lobes is
enlarged, the urethra becomes bent towards the opposite side.
By dividing the levator ani muscle on both sides of the rectum,
F, Fig. 4, and detaching and depressing this from the perinEeal
centre, the prostate, c c, and base of the bladder, p, are brought
into view. The pelvic fascia may be now felt reflected from the
inner surface of the levator ani muscle to the bladder at a level
corresponding with the base of the prostate, and the neck of the
bladder in front, and the vesiculae seminales, N N, laterally. In
tills manner the pelvic fascia serves to insulate the perineeal space
from the pelvic cavity. The prostate occupies the centre of the
perinseum. If the perinaeum were to be penetrated at a point
midway between the bulb of the urethra and the anus, and to
the depth of two inches straight backwards, the instrument would
transfix the apex of the gland. Its left lobe lies directly under
the middle of the line of incision which the lithotomist makes
through the surface; a fibrous membrane forms a capsule for the
gland, and renders its surface tough and unyielding, but its
proper substance is friable, and may be lacerated or dilated with
ease, after having partly incised its fibrous envelope. The mem¬
branous part of the urethra, M, Fig. 4, enters the apex of the
prostate, and traverses this part in a line, nearer to the upper
than to the under surface; and that portion of the canal which the
gland surrounds, is named prostatic. The prostate is separated
from the pudic artery by the levator ani muscle, and from the
artery of the bulb, by the deep perinasal fascia and the muscular
fibres enclosed between its two layers.
The prostate being a median structure, is formed of two lobes,
united at the median line. The bulbus urethrm being also a
median structure, is occasionally found notched in the centre, and
presenting a bifid appearance. On the base of the bladder, p.
Fig. 4, the two vasa deferentia, q q, are seen to converge from
behind forwards, and enter the base of the gland; a triangular
interval is thus formed between the vasa, narrower before than
behind, and at the middle of this place the point of the trocar is to
be passed (through the rectum,) for the purpose of evacuating the
contents of the bladder, when other measures fail. When this
operation is required to be performed, the situation of the prostate
is first to be ascertained through the bowel; and at a distance of an
inch behind the posterior border of the gland, precisely in the median
line, the distended base of the bladder may be safely punctured.
If the trocar pierce the bladder at this point, the seminal vessels
converging to the prostate from either side, and the recto-vesical
serous pouch behind, will escape being wounded. If the prostate
happen to be much enlarged, the relative position of the neigh¬
bouring parts will be found disturbed, and in such case the bladder
can be punctured above the pubes with greater ease and safety.
In cases of impassable stricture, when extravasation of urine is
threatened, or has already occurred, the urethra should be opened
in the perinaeum behind the place where the stricture is situated,
and this (in the present instance) certainly seems to be the more
effectual measure, for at the same time that the stricture is divided,
the contents of the bladder may be evacuated through the peri-
DESCRIPTION OF THE FIGURES OF PLATE XXVIII.
Figure 1.
A. The urethra.
B. Accelerator urinae muscle.
C. Central perinaeal tendon.
DD. Right and left erector penis muscle.
EE. The transverse muscles.
F. The anus.
GG. The ischiadic tuberosities.
H. The coccyx.
11. The glutei muscles.
KK. The levator ani muscle.
L. The left artery of the bulb.
Figure 2.
A. D, F, G, H, I, K, L refer to the same parts of Fig. 1.
B. The urethra.
C. Cowper’s glands between the two layers of—
E. The deep perinaeal fascia.
M. The bulb of the urethra.
Figure 3.
A, B, C, E, F, G, H, I, K, L refer to the same parts of Fig. 2.
D D. The two crura penis.
M. The urethra in section.
N N. The rectum.
O. The sacro-sciatic ligament.
Figure 4.
A, B, D, G, H, I, K, L, 0 refer to the same parts as in Fig. .3
C C. The two lobes of the prostate.
F. The rectum turned down.
M. The membranous part of the urethra.
N N. The vesiculae seminales.
P. The base of the bladder.
Q Q. The two vasa deferentia.
COMMENTARY ON PLATE XXVIII.
iiaium. If the membranous part of the urethra be that where the
stricture exists, a staff with a central groove is to be passed as far
as the strictured part, and having ascertained the position of the
instrument by the finger in the bowel, the perinasum should be
incised, at the middle line, between the bulb of the urethra and the
anus. The urethra in this situation wiU be found to curve back¬
wards at the depth of an inch or more from the surface. The
point of the stafif is now to be felt for, and the urethra is to be
incised upon it. The bistoury is next to be carried backwards
through the stricture till it enters that part of the urethra (usually
dilated in such cases) which intervenes between the seat of obstruc¬
tion and the neck of the bladder.
The lateral operation of lithotomy is to be performed according
to the above described anatomical relations of the parts concerned.
The bowel being empty and the bladder moderately fuU, a staff
with a groove in its left side is to be passed by the urethra into
the bladder. The position and size of the prostate is next to be
ascertained by the left fore-finger in the rectum. Having now
explored the surface of the perinseum in order to determine the
situation of the left tuberosity and ischio-pubic ramus, in relation
to the perinaaal middle line, the staff being held steadily against
the symphysis pubis, the operator proceeds to divide the skin and
superficial fascia on the left side of the perinseum, commencing
the incision on the left of the raphe about an inch in front of
the anus, and carrying it downwards and outwards midway between
the anus and ischiatic tuberosity, to a point below these parts.
The left forefinger is then to be passed along the incision for the
purpose of parting the loose cellular tissue; and any of the more
resisting structures, such as the transverse and levator ani muscles,
are to be divided by the knife. Deep in the forepart of the wound,
the position of the staff is now to be felt for, and the structures
which cover the membranous portion of the urethra are to be
cautiously divided. Recollecting now that the artery of the bulb
passes anterior to the staff in the urethra on a level with the bulb,
the vessel is to be avoided by inserting the point of the knife in the
groove of the staff as far backwards—-that is, as near the apex of the
prostate—as possible. The point of the knife having been inserted
in the groove of the staff, the bowel is then to be depressed by the
left forefinger; and now the knife, with its back to the staff, and its
edge lateralized (towards the lower part of the left tuber ischii), is
to be pushed steadily along the groove in the direction of the staff,
and made to divide the membranous part of the urethra and the
anterior two-thirds of the left lobe of the prostate. The gland
must necessarily be divided to this extent if the part of the urethra
which it surrounds be traversed by the knife. The extent to which
the prostate is divided depends upon the degree of the angle which
the knife, passing along the urethra, makes with the staff. The
greater this angle is, the greater the extent to which the gland will
be incised. The knife being next withdrawn, the left forefinger is
to be passed through the opening into the bladder, and the parts
are to be dilated by the finger as it proceeds, guided by the staff.
The staff is now to be removed while the point of the finger is in
the neck of the bladder, and the forceps is to be passed into the
bladder along the finger as a guide. The calculus, now in the
gripe of the forceps, is to be extracted by a slow undulating
motion.
The general rules to be remembered and adopted in performing
the operation of lithotomy are as follow:—1st, The incision through
the skin and sub-cutaneous cellular membrane should be freely
made, in order that the stone may be easily extracted and the
urine have ready egress. The incision which (judging from the
anatomical relations of the parts) appears to be best calculated to
effect these objects, is one which would extend from a point an
inch above the anus to a point in the posterior perinseal space an
inch or more below the anus.- The wound thus made would
depend in relation to the neck of the bladder; the important parts,
vessels, &c., in the anterior perinseal space would be avoided where
the incision, if extended upwards, would have no effect whatever
in facilitating the extraction of the stone or the egress of the
urine; and what is also of prime importance, the external opening
would directly correspond with the incision through the prostate
and neck of the bladder. 2nd, After the incision through the
skin and superficial fascia is made, the operator should separate
as many of the deeper structures as will admit of it, by the
finger rather than by the knife; and especially use the knife
cautiously towards the extremities of the wound, so as to avoid
the artery of the bulb, and the bulb itself in the upper part, and
the rectum below. The pudic artery will not be endangered if
the deeper parts be divided by the knife, with its edge directed
downwards and outwards, while its point slides securely along
the staff in the prostate. 3rd, The prostate should be incised
sparingly, for, in addition to the known fact that the gland when
only partly cut admits of dilatation to a degree sufficient to admit
the passage of even a stone of large size, it is also stated upon high
authority that by incising the prostate and neck of the bladder to
a length equal to the diameter of the stone, such a proceeding is
more frequently followed with disastrous results, owing to the
circumstance that the pelvic fascia being divided at the place
where it is reflected upon the base of the gland and the side and
neck of the bladder, allows the urine to infiltrate the cellular
tissue of the pelvis.*
The position in which the staff is held while the membranous
urethra and prostate are being divided should be regulated by
the operator himself. If he requires the perinajum to be protruded
and the urethra directed towards the place of the incision, he can
effect this by depressing the handle of the instrument a little
towards the right groin, taking care at the same time that the
point is kept beyond the prostate in the interior of the bladder.
« The object in following this method,” Mr. Liston observes, “is to
avoid all interference with the reflexion of the ilio-vesical fascia from the
sides of the pelvic cavity over the base of the gland and side of the bladder.
If this natural boundary betwixt the external and internal cellular tissue
IS broken up, there is scarcely a possibility of preventing infiltration of
the urine, which must almost certainly prove fatal. The prostate and
other parts around the neck of the bladder are very elastic and yielding
so that without much solution of their continuity, and without the leaS
laceration the opening can be so dilated as to admit the forefinger readily
through the same wound; the forceps can be introduced upon this as a
guide, and they can also be removed along with a stone of considerable
dimensions, say from three to nearly five inches in circumference, in one
direction and from four to six in the l&xgesV'—Practical Surgery, page 510
This doctrine (founded, no doubt, on Mr. Liston’s own great experience!
coincides ^>* ftat first expressed by Scarpa, Le Cat, and others. Sfi
Benjamin Brodie, Mr. Stanley, and Mr. Syme are also advocates for limited
incisions, extending no farther than a partial division of the prostate the
^st emg effected by dilatation. The experience, however, of Cheselden
Martineau and Mr. S. Cooper, inclined them in favour of a rather free
incision of the prostate and neck of the bladder proportioned to the size
of the calculus, so that this may be extracted freely, without lacerating or
contusing the parts, “ and,” says the distinguished lithotomist Klein “ upon
this basis rests the success of my operations; and hence I invariably maki
It a rule to let the incision be rather too large than too small, and never t.
dilate It with any blunt instrument when it happens to be too diminutive
but to enlarge it with a knife, introduced, if necessary, several times
Practische Ansichten der Bedeutendsten Chirurgische Operationen. Opinioni
of the highest authority being thus opposed, in reference to the questioi
whether free or limited incisions in the neck of the bladder are followec
respectively by the greater number of fatal or favourable results, and thes(
being thought mainly to depend upon whether the pelvic fascia be openec
or not one need not hesitate to conclude, that since facts seem to be
noticed in support of both modes of practice equally, the issue of the
cases themselves must really be dependent upon other circumstances, such
Tos ?on of" t ««"stitution, the state of the bladder, and the relative
p sition of the internal and external incisions. “Some individuab
(observes Sir B. Brodie) are good subjects for the operation, and recovei
perhaps without a bad symptom, although the operation may have
been very indifierently performed. Others may be truly said to be bad
nerfect ’ ZT operation be performed in the most
betweenTh Z constitutes the essential difference
between these two classes of cases ? It is, according to my experience
Or/nT"""" disease.”-Z»eW of the Urinary
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the, surgical dissection of the male bladder and DEETHRA.-LATERAL AND BILATERAL
LITHOTOMY COMPARED.
aving examined the surgical relations of the bladder and
a jacent structures, in reference to the lateral operation of litho¬
tomy, it remains to reconsider these same parts as they are con¬
cerned in the bilateral operation and in catheterism.
Ligube 1 represents the normal relations of the more important
parts concerned in lithotomy as performed at the perimeal region,
ihe median line, a a, drawn from the symphysis pubis above, to
the point of the coccyx below, is seen to traverse vertically the
centres of the urethra, the prostate, the base of the bladder, the
anus, and the rectum. These several parts are situated at dif¬
ferent depths from the perineal surface. The bulb of the urethra
and the lower end of the bowel are on the same plane compara¬
tively superficial. The prostate lies between these two parts, and
on a plane deeper than they. The base of the bladder is still
more deeply situated than the prostate; and hence it is that the
end of the bowel is allowed to advance so near the pendent bulb,
that those parts are in a great measure concealed by these. As
the apex of the prostate lies an inch (more or less) deeper than
the bulb, so the direction of the membranous urethra, which
intervenes between the two, is according to the axis of the pelvic
outlet; the prostatic end of the membranous urethra being deeper
than the part near the bulb. The scalpel of the lithotomist,
guided by the stalF in this part of the urethra, is made to enter
the neck of the bladder deeply in the same direction. On com¬
paring the course of the pudic arteries with the median line, a a,
we find that they are removed from it at a wider interval below
than above; and also that where the vessels first enter the
perinaeal space, winding around the spines of the ischia, they are
much deeper in this situation (on a level with the base of the
bladder) than they are when arrived opposite the bulb of the
urethra. The transverse line b b, drawn in front of the anus from
one tuber ischii to the other, is seen to divide the perinamm into
the anterior and posterior spaces, and to intersect at right angles
the median line A A. In the same way the line bb divfdes
transversely both pudic arteries, the front of the bowel, the base
of the prostate, and the sides of the neck of the bladder. Lateral
lithotomy is performed in reference to the line a a; the bilateral
operation in regard to the line b b. In order to avoid the bulb
and rectum at the median line, and the pudic artery at the outer
side of the perineum, the lateral incisions are made obliquely in
the direction of the lines c n. In the bilateral operation the
incision necessary to avoid the bulb of the urethra in front, the
rectum behind, and the pudic arteries laterally, is required to be
made of a semicircular form, corresponding with the forepart of the
bowel; the cornua of the incision being directed behind. In the
lateral operation, the incision c through the integument, crosses
at an acute angle the deeper incision d, which divides the neck of
the bladder, the prostate, &c. The left lobe of the prostate is
divided obliquely in the lateral operation; both lobes transversely
in the bilateral.
Figure 2.—If the artery of the bulb happen to arise from the
pudic opposite the tuber ischii, or if the inferior hemorrhoidal
arteries be larger than usual, these vessels crossing the lines of |
incision in both operations will be divided. If the superficial
lateral incision c. Fig. 1, be made too deeply at its forepart, the
artery of the bulb, even when in its usual place, will be wounded;
and if the deep lateral incision n be carried too far outwards, the
trunk of the pudic artery will be severed. These accidents are
incidental in the bilateral operation also, in performing which it
should be remembered that the bulb is in some instances so
large and pendulous, as to lie in contact with the front of the
rectum.
Figure 3—When the pudic artery crosses in contact with the
prostate, f, it must inevitably be divided in either mode of operation.
Judging from the shape of the prostate, I am of opinion that this
part, whether incised transversely in the line b b, or laterally in
the line n, will exhibit a wound in the neck of the bladder of
equal dimensions. When the calculus is large, it is recommended
to divide the neck of the bladder by an incision, combined of the
transverse and the lateral. The advantages gained by such a
combination are, that while the surface of the section made in the
line D is increased by “ notching” the right lobe of the prostate
in the direction of the line b, the sides of both sections are thereby
rendered more readily separable, so as to suit with the rounded
form of the calculus to be extracted. These remarks are equally
applicable as to the mode in which the superficial perimeal incision ■
should be made under the like necessity. If the prostate be
wholly divided in either line of section, the pelvic fascia adhering
to toe base of this body will be equally subject to danger. By
incising the prostate transversely, b b, the seminal ducts, g h, which
enter the base of this body, are likewise divided; but by the simple
lateral incision n being made through the forepart of the left lobe, f,
these ducts will escape injury.* On the whole, therefore, the
lateral operation appears preferable to the bilateral one.
Figure 4 —The muscular structures surrounding the mem¬
branous^ urethra and the neck of the bladder, and which are
divided in lithotomy, have been examined from time to time by
anatomists with more than ordinary painstaking, owing to the
circumstance that they are found occasionally to offer, by spas¬
modic contraction, an obstacle to the passage of the catheter along
the urethral canal. These muscles do not appear to exist in all
subjects alike. In some, they are altogether wanting; in others, a
few of them only appear; in others, they seem to be not naturally
separable from the larger muscles which are always present.
Hence it is that the opinions of anatomists respecting their form,
character, and even their actual existence, are so conflicting, not
only against each other, but against nature. In Fig, 4, I have
summed together all the facts recorded concerning them,f and on
comparing these facts with what I have myself observed, the
muscles seem to me to assume originally the form and relative
position of the parts bcdef viewed in their totality. Each
of these parts of muscular structure arises from the ischio-pubic
ramus, and is inserted at the median line A A. They appear to me,
therefore, to be muscles of the same category, which, if all were
present, would assume the serial order of b c n e f. When one or
more of them are omitted from the series, there occurs anatomical
* As to the mode in which the superficial and deep incisions in lateral
lithotomy should be made, a very eminent operating surgeon remarks_
a free incision of the skin I consider a most important feature in the
operation; but beyond this the application of the knife should, in my
opinion, be extremely limited. In so far a^s I can perceive, there should
be no hesitation in cutting any part of the gland which seems to offer
resistance, with the exception, perhaps, of its under surface, where the
position of the seminal ducts, and other circumstances, should deter the
surgeon from using a cutting instrument.”—Wm. Fergusson, Practical
Surgery^ p. 643.
t The part c is that alone described by Santorini, who named it
“ elevator urethrae,” as passing beneath the urethra. The part b is that
first observed and described by Mr. Guthrie as passing above the urethra.
The part F represents the well-known “ transversalis perinaei,” between
which and the part c there occasionally appears the part e, supposed to
be the “ transversalis alter” of Albinus, and also the part d, which is the
«ischio bulbosus” of Cruveilhier. It is possible that I may not have given
one or other of these parts its proper name, but this will not affect their
anatomy.
COMMENTARY ON PLATE XXIX.
variety, which of course occasions variety in opinion, fruitless though
never ending. By that interpretation of the parts which I here
venture to offer, and to which I am guided by considerations of a
higher law of formation, I encompass and bind together, as with
a belt, all the dismembered parts of variety, and of these I
construct a uniform whole. Forms become, when not viewed
under comparison, as meaningless hieroglyphics, as the algebraic
symbols a+c — d=ll are when the mind is devoid of the power
of calculation.
Figure 5— The membranous urethra a is also in some instances
embraced by two symmetrical fasciculi of muscular fibres bb,
which arising from the posterior and lower part of the symphysis
pubis, descend on either side of the canal and join beneath it.
The muscles b c. Fig. 4, are between the two layers of the deep
perinaeal fascia, while the muscle b b. Fig. 5, lies like the forepart
of the levator ani, c c, behind this structure and between it and the
anterior ligaments of the bladder.* As to the interpretation of
the muscle, I, myself, am inclined to believe that it is simply a
part of the levator ani, and for these reasons—1st, it arises from
the pubic symphysis, and is inserted into the perinaeal median line
with the levator ani; 2nd, the fibres of both muscles overlie the
forepart of the prostate, and present the same arrangement in
parallel order; 3rd, the one is not naturally separable from
the other.
Figure 6 represents by section the natural forms of the urethra
and bladder. The general direction of the urethra measured
during its relaxed state from the vesical orifice to the glans is
usually described as having the form of the letter S laid pro¬
cumbent to the right side ca or to the left 03 . But as the ante¬
rior half of the canal is moveable, and liable thereby to obliterate
the general form whfie the posterior half is fixed, I shall direct
attention to the latter half chiefly, since upon its peculiar form
and relative position depends most of the difficulty in the per¬
formance of catheterism. The portion of the urethra which
intervenes between the neck of the bladder, k, and the point E,
where the penis is suspended from the front of the symphysis pubis
by the suspensory ligament, assumes very nearly the form of a semi¬
circle, whose anterior half looks towards the forepart, and whose
posterior half is turned to the back of the pubis. The pubic arch,
A, spans crossways, the middle of this part of the urethra, G,
opposite the bulb h. The two extremes, e k, of this curve, and
the lower part of the symphysis pubis, occupy in the adult the
same antero-posterior level ; and it follows, therefore, that the
distance to which the urethra near its bulb, H, is removed from the
pubic symphysis above must equal the depth of its own curve,
which measures about an inch perpendicularly. The urethral
aperture of the triangular ligament appears removed at this distance
below the pubic symphysis, and that portion of the canal which
lies behind the ligament, and ascends obliquely backwards and
upwards to the vesical orifice on a level with the symphysis pubis in
the adult should be remembered, as varying both in direction and
length in individuals of the extremes of age. In the young, this
variation is owing to the usual high position of the bladder in the
pelvis, whilst in the old it may be caused by an enlarged state
of the prostate. The curve of the urethra now described is
permanent in all positions of the body, while that portion of the
canal anterior to the point e, which is free, relaxed, and moveable,
can by traction towards the umbilicus be made to continue in the
direction of the fixed curve e k, and this is the general form which
the urethra assumes when a bent catheter of ordinary shape is
passed along the canal into the bladder. The length of the urethra
varies at different ages and in dififerent individuals, and its struc¬
ture in the relaxed state is so very dilatable that it is not possible
to estimate the width of its canal with fixed accuracy. As a
general rule, the urethra is much more dilatable, and capable
consequently of receiving an instrument of much^arger bore in the
aged than in the adult.
The three portions into which the urethra is described as being
divisible, are the spongy, the membranous, and the prostatic.
These names indicate the difference in the structure of each part.
The spongy portion is the longest of the three, and extending from
the glans to the bulb may be said on a rough, but for practical
purposes, a sufficiently accurate estimate to comprise seven parts
of the whole urethra, which measures nine. The membranous
and prostatic portions measure respectively one part of the whole.
These relative proportions of the three parts are maintained in
different individuals of the same age, and in the same individual
at different ages. The spongy part occupies the inferior groove
formed between the two united corpora cavernosa of the penis, and
is subcutaneous as far back as the scrotum under the pubes, between
which point and the bulb it becomes embraced by the accelerator
urinse muscle. The bulb and glans are expansions or enlarge¬
ments of the spongy texture, and do not affect the calibre of the
canal. When the spongy texture becomes injected with blood,
the canal is rendered much narrower than otherwise. The canal
of the urethra is uniform-cylindrical. The meatus is the narrowest
part of it, and the prostatic part is the widest. At the point of
junction between the membranous and spongy portions behind the
bulb, the canal is described as being naturally constricted. Behind
the meatus exists a dilatation (fossa navicularis), and opposite the
bulb another (sinus of the bulb). Muscular fibres are said to
enter into the structure of the urethra, but whether such be the
case or not, it is at least very certain that they never prove
an obstacle to the passage of instruments, or form the variety of
stricture known as spasmodic. The urethra is lined by a delicate
mucous membrane presenting longitudinal folds, which become
obliterated by distention; and its entire surface is numerously
studded with the orifices of mucous cells (lacunte), one of which
larger than the rest, appears on the upper side of the canal near
the meatus. Some of these lacuniB are nearly an inch long, and
all of them open in an oblique direction forwards. Instruments
having very narrow apices are liable to enter these ducts and to
make false passages. The ducts of Cowper’s glands open by very
minute orifices on the sides of the spongy urethra anterior to and
near the bulb. On the floor of the prostatic urethra appears the
crest of the veru montanurn, upon which the two seminal ducts
open by orifices directed forwards. On either side of the veru
montanurn the floor of the prostate may be seen perforated by the
» excretory ducts” of this so-called ffknd. The part k, which is here
represented as projecting from the floor of the bladder, near its
neck, is named the “ uvula vesicae,” (Lieutaud.) It is the same
as that which is named the “third lobe of the prostate,” (Home.)
The part does not appear as proper to the bladder in the healthy
condition. Fig. 7. On either side of the point k may be seen the
orifices, M M, of the ureters, opening upon two ridges of fibrous
substance directed towards the uvula. These are the fibres which
have been named by Sir Charles BeU as “ the muscles of the
ureters;” but as they do not appear in the bladder when in a state
0 ealth I do not believe that nature ever intended them to
perform the function assigned to them by this anatomist. And
the same may be said of the fibres, which surrounding the vesical
orifice, are supposed to act as the “ sphincter vesicie.” The form
of that portion of the base of the bladder which is named “ triuone
vesical constitutes an equilateral triangle, and may be described
by two lines drawn from the vesical orifice to both openings of the
ureters, and another line reaching transversely between the latter
Behind the trigone a depression caUed “ bas fond” is formed in the
of the bladder. Fig. 7 represents the prostate of a ^ !
years of age. Fig. 8 represents that of a man aged forty years
A difference as to form and size, &o., is observable between^both.
^ Ihis IS the muscle, b b, which is described by Santorini as the
levatoi prostate; by Winslow as “ le prostatique superieur;” by Wilson
as the < pubo-urethrales;” by Muller as not existing; by Mr. Guthrie as
oiming(when existing), with the parts b c. Fig. 4, his « compressor isthmi
ureinrae;
ana by JVl. Cruveilhier as beina* varf nfthp /
:r.::rd
besl«„..i„.,em„so,ei„.be.e«rS:.rS^
10
ji- 4.1 . JiSHudi L
Pig .13
Pig 11
Pig 2G
PL, 30.
.Fi6 6.
tD
Eg 23
rig 1^.
COMMENTARY ON PLATE XXX.
CONGENITAL AND PATHOLOGICAL DEFORMITIES OF THE PREPUCE AND URETHRA.-STRICTURE AND
MECHANICAL OBSTRUCTIONS OF THE URETHRA.
When any of the central organs of the body presents in a form
differing from that which we term natural, or structurally per¬
fect and efficient, if the deformity be one which results as a
malformation, ascribable to an error in the law of development, it
is always characterized as an excess or defect of the substance of the
organ at, and in reference to, the median line. And when any of
the canals which naturally open upon the external surface at the
median line happens to deviate from its proper position, such
deviation, if it be the result of an error in the law of development,
always occurs, by an actual necessity, at the median line. On the
contrary, though deformities which are the results of diseased
action in a central organ may and do, in some instances, simulate
those which occur by an error in the process of development, the
former cannot bear a like interpretation with the latter, for those
are the effects of ever-varying circumstances, whereas these
are the effects of certain deviations in a natural process—a law,
whose course is serial, gradational, and in the sequent order of a
continuous chain of cause and effect.
Figure 1 represents the prepuce in a state of congenital phy-
mosis. The part hypertrophied and pendent projects nearly an
inch in front of the meatus, and forms a canal, continued forwards
from this orifice. As the prepuce in such a state becomes devoid
of its proper function, and hence must be regarded, not only as a
mere superfluity, but as a cause of impediment to the generative
function of the whole organ, it should be removed by an operation.
Figure 2 represents the prepuce in the condition of paraphy-
mosis following gonorrhoeal inflammation. The part appears
constricting the penis and urethra behind the corona glandis.
This state of the organ is produced in the following-mentioned
way:—the prepuce, naturally very extensible, becomes, while
covering the glans, inflamed, thickened, and its orifice con¬
tracted. It is during this state withdrawn forcibly backwards
over the glans, and in this situation, while being itself the
first cause of constriction, it induces another—namely, an arrest
to the venous circulation, which is followed by a turgescence of
the glans. In the treatment of such a case, the indication is, first,
to reduce by gradual pressure the size of the glans, so that the
prepuce may be replaced over it; secondly, to lessen the inflamma¬
tion by the ordinary means.
Figure 3 exhibits the form of a gonorrhceal phymosis. The
orifice of the prepuce is contracted, and the tissue of it infiltrated.
If in this state of the part, consequent upon diseased action, or in
that of Fig. 1, which is congenital, the foreskin be retracted over
the glans, a paraphymosis, like Fig. 2, will be produced.
Figure 4 shows a form of phymosis in which the prepuce
during inflammation has become adherent to the whole surface of
the glans. The orifice of the prepuce being directly opposite the
meatus, and the parts offering no obstruction to the flow of urine,
an operation for separating the prepuce from the glans would not
be required.
Figure 5.—In this figure is represented the form of the penis
of an adult, in whom the prepuce was removed by circumcision at
an. early age. The membrane covering the glans and the part
which is cicatrised becomes in these cases dry, indurated, and
deprived of its special sense.
Figure 6 .—In this figure the glans appears protruding through
the upper surface of the prepuce, which is thickened and cor¬
rugated. This state of the parts was caused by a venereal ulcera¬
tion of the upper part of the prepuce, sufficient to allow the glans
to press through the aperture. The prepuce in this condition
being superfluous, and acting as an impediment, should be
removed by operation.
Figure 7 _In this figure is shown a condition of the glans and
prepuce resembling that last mentioned, and the effect of a similar
cause. By the removal of the prepuce when in the position here
represented, or in that of Fig. 6, the organ may be made to
assume the appearance of Fig. 5.
Figure 8 represents the form of a congenital hypospadias. The
corpus spongiosum does not continue the canal of the urethra as
far forwards as the usual position of the meatus, but has become
defective behind the frasnum prseputii, leaving the canal open at
this place. In a case of this kind an operation on the taliacotian
principle might be tried in order to close the urethra where it
presents abnormally patent.
Figure 9 represents a congenital hypospadias, in which the
canal of the urethra opens by two distinct apertures along the
under surface of the corpus spongiosum at the middle line. A
probe traverses both apertures. In such a case, if the canal of
the urethra were perforate as far forwards as the meatus, and this
latter in its normal position, the two false openings should be
closed by an operation.
Figure 10 .—The urethra is here represented as having a false
opening on its under surface behind the fraenum. The perforation
was caused by a venereal ulcer. The meatus and urethra anterior
to the false aperture remained perforate. Part of a bougie appears
traversing the false opening and the meatus. In this state of the
organ an attempt should be made to close the false aperture
permanently.
Figure 11 shows a state of. the urethra similar to that of
Fig. 10, and the effect of the same cause. Part of a bougie is
seen traversing the false aperture from the meatus before to the
urethra behind. In this case, as the whole substance of the corpus
spongiosum was destroyed for half an inch in extent, the talia¬
cotian operation, by which lost quantity is supplied, is the measure
most likely to succeed in closing the canal.
Figure 12 —Behind the meatus, and on the right of the fr^num,
is represented a perforation in the urethra, caused by a venereal
ulcer. The meatus and the false opening have approached by the
contraction of the cicatrix; in consequence of which, also, the
apex of the glans is distorted towards the urethra; a bougie
introduced by the meatus occupies the urethral canal.
Figure 13.—In this figure the canal of the urethra appears
turning upwards and opening at the median line behind the
corona glandis. This state of the urethra was caused by a
venereal ulcer penetrating the canal from the dorsum of the penis.
The proper direction of the canal might be restored by obliterating
the false passage, provided the urethra remained perforate in the
direction of the meatus.
Figure 14 exhibits the form of a congenital epispadias, in which
the urethra is seen to open on the dorsal surface of the prepuce
at the median line. The glans appears cleft and deformed. The
meatus is deficient at its usual place. The prepuce at the dorsum
is in part deficient, and bound to the glans around the abnormal
orifice.
Figure 15 represents in section a state of the parts in which the
urethra opened externally by one fistulous aperture, a, behind the
scrotum; and by another, 5, in front of the scrotum. At the
latter place the canal beneath the penis became imperforate for an
inch in extent. Parts of catheters are seen to enter the urethra
through the fistulous openings ah ; and another instrument, c, is
seen to pass by the proper meatus into the urethra as far as the
point where this portion of the canal fails to communicate with
the other. The under part of the scrotum presents a cleft cor¬
responding with the situation of the scrotal septum. This state
of the urinary passage may be the effect either of congenital
deficiency or of disease. When caused by disease, the chief fea-
COMMENTARY ON PLATE XXX.
tures ill its history, taking these in the order of their occurrence,
are, 1st, a stricture in the anterior part of the urethra; 2ndly, a
rupture of this canal behind the stricture; Srdly, the formation
(on an abscess opening externally) of a fistulous communication
between the canal and the surface of some part of the perinieum;
4 thly, the habitual escape of the urine by the false aperture;
5thly, the obliteration of the canal to a greater or less extent
anterior to the stricture; 6thly, the parts situated near the
urethral fistula become so consolidated and confused that it is
difficult in some and impossible in many cases to find the situation
of the urethra, either by external examination or by means of
the catheter passed into the canal. The original seat of the
stricture becomes so masked by the surrounding disease, and the
stricture itself, even if found by any chance, is generally of so
impassable a kind, that it must be confessed there are few opera¬
tions in surgery more irksome to a looker-on than is the fruitless
effort made, in such a state of the parts, by a hand without a
guide, to pass perforce a blunt pointed instrument like a catheter
into the bladder. In some instances the stricture is slightly
j)ervious, the urine passing in small quantity by the meatus. In
others, the stricture is rendered wholly imperforate, and the canal
either contracted or nearly obliterated anteriorly through disuse.
Of these two conditions, the first is that in which catheterism may
be tried with any reasonable hope of passing the instrument into
the bladder. In the latter state, catheterism is useless, and the
only means whereby the urethra may be rendered pervious in the
proper direction is that of incising the stricture from the perinaeum,
and after passing a catheter across the divided part into the
bladder, to retain the instrument in this situation till the wound
and the fistulae heal and close under the treatment proper for this
end. (Mr. Syme.)
Eigtjee 16.—In this figure the urethra appears communicating
with a sac like a scrotum. A bougie is represented entering by
the meatus, traversing the upper part of the sac, and passing into
the membranous part of the urethra beyond. This case which
was owing to a congenital malformation of the urethra, exhibits a
dilatation of the canal such as might be produced behind a
stricture wherever situated. The urine impelled forcibly by the
whole action of the abdominal muscles against the obstructing
part dilates the urethra behind the stricture, and by a repetition
of such force the part gradually yields more and more, till it
attains a very large size, and protrudes at the perinaeum as a
distinct fluctuating tumour, every time that an effort is made to
void the bladder. If the stricture in such a case happen to cause a
complete retention of urine, and that a catheter cannot be passed
into the bladder, the tumour should be punctured prior to taking
measures for the removal of the stricture, (Sir B. Brodie.)
Figure 17 represents tAvo close strictures of the urethra; one of
which is situated at the bulb, and the other at the adjoining
membranous part. These are the two situations in which
strictures of the organic kind are said most frequently to occur,
(Hunter, Home, Cooper, Brodie, Phillips, Velpeau.) False
passages likewise are mentioned as more liable to be made in
these places than elseAvhere in the urethral canal. These occur¬
rences—^t.he disease and the accident—Avould seem to follow each
other closely, like cause and consequence. The frequency with
which false passages occur in this situation appears to me to
be chiefly oAving to the anatomical fact, that the urethra at
and close to the bulb is the most dependent part of the curve,
E K, Fig. 6, Plate 29; and hence, that instruments descend¬
ing to this part from before push forcibly against the urethra,
and are more apt to protrude through it than to have their
points turned so as to ascend the curve towards the neck of
the bladder. If it be also true that strictures happen here
more frequently than elseAvhere, this circumstance aagU of course
favour the accident. An additional cause why the catheter
happens to be frequently arrested at this situation and to perforate
the canal, is OAving to the fact, that the triangular ligament is
liable to oppose it, the urethral opening in this structure not
happening to coincide with the direction of the point of the
instrument. In the figure part of a bougie traverses the urethra
through both strictures and lodges upon the enlarged prostate.
Another instrument, after entering the first stricture, occupies
a false passage which was made in the canal between the two
constricted parts.
Figure 18.—A calculus is here represented lodging in the
urethra at the bulb. The walls of the urethra around the
calculus appear thickened. Behind the obstructing body the
canal has become dilated, and, in front of it, contracted. In some
instances the calculus presents a perforation through its centre,
by which the urine escapes. In others, the urine makes its exit
between the calculus and the side of the urethra, which it dilates.
In this latter way the foreign body becomes loosened in the canal
and gradually pushed forAvards as far as the meatus, within
which, owing to the narrowness of this aperture, it lodges per¬
manently. If the calculus forms a complete obstruction to the
passage of the urine, and its removal cannot be etfected by other
means, an incision should be made to etfect this object.
Figure 19 represents the neck of the bladder and neighbouring
part of the urethra of an ox, in which a polypous groAvth is seen
attached by a long pedicle to the veru montanum and blocking up
the neck of the bladder. Small irregular tubercles of organized
lymph, and tumours formed by the lacun* distended by their own
secretion, their orifices being closed by inflammation, are also
found to obstruct the urethral canal.
Figure 20. —In this figure is represented a small calculus
impacted in and dilating the membranous part of the urethra.
Figure 21 _Two strictures are here shoAvn to exist in the
urethra, one of which is situated immediately in front of the bulb,
and the other at a point midway between the bulb and the meatus.
Figure 22.—A stricture is here shoAvn situated at the bulb.
Figure 23 represents a stricture of the canal in front of the bulb.
Figure 24 represents the form of an old callous stricture half
an inch long, situated midway between the bulb and the meatus.
This is perhaps the most common site in which a stricture of this
kind is found to exist. In some instances of old neglected cases
the corpus spongiosum appears converted into a thick gristly
cartilaginous mass, several inches in extent^ the passage here
being very much contracted, and clfiefly so at the middle of the
stricture. When it becomes impossible to dilate or pass the canal
of such a stricture by the ordinary means, it is recommended to
divide the part by the lancetted stilette. (Stafibrd.) Division
of the stricture, by any means, is no doubt the readiest and most
effectual measure that can be adopted, provided we know clearly
that the cutting instrument engages fairly the part to be divided.
But this is a knoAvledge less likely to be attained if the stricture
be situated behind than in front of the triangular ligament.
Figure 25 exhibits a lateral vieAv of the muscular parts Avhich
surround the membranous portion of the urethra and the prostate;
a, the membranous urethra embraced by the compressor urethrie
muscle; 5, the levator prostate muscle; c, the prostate; the
anterior ligament of the bladder.
Figure 26.—A posterior vieAv of the parts seen in Fig. 25; a
the urethra divided in front of the prostate; h h, the levator
prostatse muscle; c c, the compressor urethrie; d d, parts of the
obturator muscles; e e, the anterior fibres of the levator ani
muscle; f the triangular ligament enclosing between its layers
the artery of the bulb, CoAvper’s glands, the membranous urethra,
and the muscular parts surrounding this portion of the canal
The fact that the flow of urine through the urethra happens occa¬
sionally to be suddenly arrested, and this circumstance contrasted
with the opposite fact that the organic stricture is of slow forma¬
tion^ originated the idea that the former occurrence arose from
a spasmodic muscular contraction. By many this spasm Avas
supposed to be due to the urethra being itself muscular. By others.
It was demonstrated as being dependent upon the muscles which
suriound the m mbranous part of the urethra, and which act upon
this part and constrict it. From my own observations I have
foimed the settled opinion that the urethra itself is not muscular.
And though, on the one hand, I believe that this canal, per se,
never causes by active contraction the spasmodic form of stricture,
I am far from supposing, on the other, that all sudden arrests to
the passage of urine through the urethra are solely attributable
to spasm of the muscles which embrace this canal.
1S-IT.- Sanluit Ml. aMtsrs .
/
.‘II
COMMENTARY ON PLATE XXXI.
THE VARIOUS FORMS AND POSITIONS OF STRICTURES AND OTHER OBSTRUCTIONS OF THE URETHRA-
FALSE PASSAGES—ENLARGEMENTS AND DEFORMITIES OF THE PROSTATE.
Impediments to the passage of the urine through the urethra may
arise from different causes, such as the impaction of a small cal¬
culus in the canal, or any morbid growth (a polypus, &c.) being
situated therein, or from an abscess which, though forming exter¬
nally to the urethra, may press upon this tube so as either to
obstruct it partially, by bending one of its sides towards the other,
or completely, by surrounding the canal on all sides. These
causes of obstruction may happen in any part of the urethra, but
there are two others (the prostatic and the spasmodic) which are,
owing to anatomical circumstances, necessarily confined to the
posterior two-thirds of the urethra. The portion of the urethra
surrounded by the prostate can alone be obstructed by this body
when it has become irregularly enlarged, while the spasmodic stric¬
ture can only happen to the membranous portion of the urethra,
and to an inch or two of the canal anterior to the bulb, these
being the parts which are embraced by muscular structures. The
urethra itself not being muscular, cannot give rise to the spas¬
modic form of stricture. But that kind of obstruction which is
common to all parts of the urethra, and which is dependent, as
well upon the structures of which the canal is uniformly composed,
as upon the circumstance that inflammation may attack these in
any situation and produce the same effect, is the permanent or
organic stricture. Of this disease the forms are as various as the
situations are, for as certainly as it may reasonably be supposed
that the plastic lymph, effused in an inflamed state of the urethra
from any cause, does not give rise to stricture of any special or
particular form, exclusive of all,others; so as certainly may it be
inferred that, in a structurally uniform canal, inflammation points
to no one particular place of it, whereat by preference to establish
the organic stricture. The membranous part of the canal is, how¬
ever, mentioned as being the situation most prone to the disease;
but I have little doubt, nevertheless, that owing to general rules
of this kind being taken for granted, upon imposing authority,
many more serious evils (false passages,- &c.) have been effected
by catheterism than existed previous to the performance of this
operation.*
Figuees 1 and 2.—In these figures are presented seven forms
of organic stricture occurring in different parts of the urethra.
In a. Fig. 1, the mucous membrane is thrown into a sharp circular
fold, in the centre of which the canal appears much contracted; a
section of this stricture appears in Fig. 2. In Fig. 1, the canal
is contracted laterally by a prominent fold of the mucous membrane
at the opposite side. In c. Fig. 1, an organized band of lymph is
stretched across the canal; this stricture is seen in section in c.
Fig. 2. In e. Fig. 1, a stellate band of organized lymph, attached
by pedicles to three sides of the urethra, divides the canal into
three passages. In c?. Fig. 1, the canal is seen to be much con¬
tracted towards the left side by a crescentic fold of the lining
membrane projecting from the right. In / the canal appears con¬
tracted by a circular membrane, perforated in the centre; a section
of which is seen at a. Fig. 2. The form of the organic stric¬
ture varies therefore according to the three following circum¬
stances : — 1st. When lymph becomes efiused within the canal
upon the surface of the lining mucous membrane, and contracts
adhesions across the canal. 2ndly. When lymph is effused
external to the lining membrane, and projects this inwards,
thereby narrowing the diameter of the canal. 3rdly. When the
outer and inner walls of a part of the urethra are involved in the
effused organizable matter, and on contracting towards each other,
encroach at the same time upon the area of the canal. This latter
state presents the form, which is known as the old callous tough
stricture, extending in many instances for an inch or more along
the canal. In cases where the urethra becomes obstructed by
tough bands of substance, c e, which cross the canal directly, the
points of flexible catheters, especially if these be of slender shape,
are apt to be bent upon the resisting part, and on pressure being
continued, the operator may be led to suppose that the instrument
traverses the stricture, while it is most probably perforating the
wall of the urethra. But in those cases where the diameter of the
canal is circularly contracted, the stricture generally presents a
conical depression in front, which, receiving the point of the
instrument, allows this to enter the central passage unerringly.
A stricture formed by a crescentic septum, such as is seen in b d,
Fig. 1, offers a more effectual obstacle to the passage of a catheter
than the circular septum like af.
Figuee 3.—In this there are seen three separate strictures, a, c,
situated in the urethra, anterior to the bulb. In some cases there
are many more strictures (even to the number of six or seven)
situated in various parts of the urethra ; and it is observed that
when one stricture exists, other slight tightnesses in different parts
of the canal frequently attend it. (Hunter.) When several stric¬
tures occur in various parts of the urethra, they may occasion as
much difficulty in passing an instrument as if the whole canal
between the extreme constrictions were uniformly narrowed.
Figuee 4.—In this the canal is constricted at the point a, mid¬
way between the bulb and glans. A false passage has been made
under the urethra by an instrument which passed out of the canal
at the point/, anterior to the stricture a, and re-entered the canal
at the point c, anterior to the bulb. When a false passage of this
kind happens to be made, it will become a permanent outlet for
the urine, so long as the stricture remains. For it can be of no
avail that we avoid re-opening the anterior perforation by the
catheter, so long as the urine prevented from flowing by the natural
canal enters the posterior perforation. Measures should be at once
taken to remove the stricture.
Figuee 5.—The stricture a appears midway between the bulb
and glans, the area of the passage through the stricture being
sufficient only to admit a bristle to pass. It would seem almost
impossible to pass a catheter through a stricture so close as this,
unless by a laceration of the part., combined with dilatation.
Figuee 6 .—Two instruments, a, have made false passages
beneath the mucous membrane, in a case where no stricture at all
* Home describes “ a natural constriction of the urethra, directly behind
the bulb, which is probably formed with a power of contraction to
prevent,” &c. This is the part which he says is “ most liable to the
disease of stricture.” {Strictures of the Urethra.) Now, if any one, even
among the acute observing microscopists, can discern the structure to
which Home alludes, he will certainly prove this anatomist to be a marked
exception amongst those who, for the enforcement of any doctrine, can
see any thing or phenomenon they wish to see. And, if Hunter were as
the mirror from which Home’s mind was reflected, then the observation
must be imputed to the Great Original. Upon the question, however, as
to which is the most frequent seat of stricture, I find that both these
anatomists do not agree. Hunter stating that its usual seat is just in front
of the bulb, while Home regrets, as it were, to be obliged to differ from
“ his immortal friend,” and avers its seat to be an infinitesimal degree
behind the bulb. Sir A. Cooper again, though arguing that the most
usual situation of stricture is that mentioned by Hunter, names, as next
in order of frequency, strictures of the membranous and prostatic parts
of the urethra. Does it not appear strange now, how questions of this
import should have occupied so much of the serious attention of our
great predecessors, and of those, too, who at the present time form the
vanguard of the ranks of science ? Upon what circumstance, either ana¬
tomical or pathological, can one part of the urethra be more liable to the
organic stricture than another ?
COMMENTARY ON PLATE XXXI.
existed. The resistance which the instruments encountered in
passing out of the canal having been mistaken, no doubt, for
that of passing through a close stricture.
Figure 7.—A bougie, h J, is seen to perforate the urethra
anterior to the stricture c, situated an inch behind the glans, and
after traversing the substance of the right corpus cavernosum rf,
for its whole length, re-enters the neck of the bladder through the
body of the prostate.
Figure 8 —A bougie, c c, appears tearing and passing beneath
the lining membrane, d c?, of the prostatic urethra. It is remarked
that the origin of a false passage is in general anterior to the
stricture. It may, however, occur at any part of the canal in
which no stricture exists, if the hand that impels the instrument
be not guided by a true knowledge of the form of the urethra; and
perhaps the accident happening from this cause is the more general
rule of the two.
Figure 9. —Two strictures are represented here, the one, e, close
to the bulb d, the other, /, an inch anterior to this part. In the
prostate, a Z>, are seen irregularly shaped abscess pits, eommuni-
cating with each other, and projecting upwards the floor of this
body to such a degree, that the prostatic canal appears nearly
obliterated.
Figure 10 .—Two bougies, d e, are seen to enter the upper wall
of the urethra, c, anterior to the prostate, a h. This accident
happens when the handle of a rigid instrument is depressed too
soon, with the object of raising its point over the enlarged third
lobe of the prostate.
Figure 11 —Two instruments appear transfixing the prostate,
of which body the three lobes, a, h, c, are much enlarged. The
instrument d perforates the third lobe, d, while the instrument e
penetrates the right lobe, c, and the third lobe, a. This accident
occurs Avhen instruments not possessing the proper prostatic bend
are forcibly pushed forwards against the resistance at the neck of
the bladder.
Figure 12 .—In this case an instrument, dd, after passing
beneath part of the lining membrane, e e, anterior to the bulb,
penetrates the right lobe of the prostate. A second instrument,
cc, penetrates the left lobe. A third smaller instrument, yy, is seen
to pass out of the urethra anterior to the prostate, and after
transfixing the right vesicula seminalis external to the neck of the
bladder, enters this viscus at a point behind the prostate. The
resistance which the two larger instruments met with in pene¬
trating the prostate, made it seem, perhaps, that a tight stricture
existed in this situation, to match which the smaller instrument
yy was afterwards passed in the course marked out.
Figures 13 to 17 represent a series of prostates, in which the
third lobe gradually increases in size. In Fig. 13, which shows
the healthy state of the neck of the bladder, unmarked by the
prominent lines which are said to bound the space named “trigone
vesical, or by those which indicate the position of the “ muscles
of the ureters,” the third lobe does not exist. In Fig. 14 it
appears as the uvula vesicse, a. In Fig. 15 the part a is increased,
and under the name now of third lobe is seen to contract and
bend upwards the prostatic canal. In Fig. 16 the efiect which the
growth of the lobe, a, produces upon the form of the neck of the
bladder becomes more marked, and the part presenting perfora¬
tions, e e, produced by instruments, indicates that by its shape
it became an obstacle to the egress of the urine as well as to the
entrance of instruments. A calculus of irregular form is seen to
lodge behind the third lobe, and to be out of the reach of the
point of a sound, supposing this to enter the bladder over the apex
of the lobe. In Fig. 17 the three lobes are enlarged, but the third
is most so, and while standing on a narrow pedicle attached to
the floor of the prostate, completely blocks up the neck of the
bladder.*
Figure 18.—The prostatic canal is bent upwards by the
enlarged third lobe to such a degree as to form a right angle with
the membranous part of the canal. A bougie is seen to perforate
the third lobe, and this is the most frequent mode in which, under
such circumstances, and with instruments of the usual imperfect
form, access may be gained to the bladder for the relief of retention
of urine. “ The new passage may in every respect be as eflicient
as one formed by puncture or incision in any other way.”
(Fergusson.)
Figure 19—The three lobes of the prostate, a, c, are equally
enlarged. The prostatic canal is consequently much contracted
and distorted, so that an instrument on being passed into the
bladder has made a false passage through the third lobe. When a
catheter is suspected to have entered the bladder by perforating
the prostate, the instrument should be retained in the newly made
passage till such time as this has assumed the cylindrical form of
the instrument. If this be done the neiv passage will be the more
likely to become permanent. It is ascertained that all false
passages and fistulte by which the urine escapes, become after a time
lined with a membrane similar to that of the urethra. (Stafibrd.)
Figure 20. —The three lobes, u, c, of the prostate are irregu¬
larly enlarged. The third lobe, a a, projecting from below, distorts
the prostatic canal upwards and to the right side.
Figure 21 .—The right lobe, acc, of the prostate appears
hollowed out so as to form the sac of an abscess which, by its
projection behind, pressed upon the forepart of the rectum, and
by its projection in front, contracted the area of the prostatic
canal, and thereby caused an obstruction in this part. Not
unfrequently when a catheter is passed along the urethra, for the
relief of a retention of urine caused by the swell of an abscess in
this situation, the sac becomes penetrated by the instrument, and,
instead of urine, pus flows. The sac of a prostatic abscess fre¬
quently opens of its own accord into the neighbouring part of the
urethra, and when this occurs it becomes necessary to retain a
catheter in the neck of the bladder, so as to prevent the urine
entering the sac.
Figure 22 . The prostate presents four lobes of equal size, and
all projecting largely around the neck of the bladder. The
prostatic canal is almost completely obstructed, and an instru¬
ment has made a false passage through the lobe a.
Figure 23—The third lobe of the prostate is viewed in section,
and shows the track of the false passage made by the catheter, d,
through it, from its apex to its base. The proper canal is bent
upwards from its usual position, which is that at present marked
by the instrument in the false passage.
Figure 24—The prostatic lobes are uniformly enlarged, and
cause the corresponding part of the urethra to be uniformly con¬
tracted, so as closely to embrace the catheter, dd, occupying it, and
to offer considerable resistance to the passage of the instrument.
^ Figure 25.—The prostate, be, is considerably enlarged ante¬
riorly, h, m consequence of which the prostatic canal appears more
horizontal even than natural. The catheter, d, occupying the
canal lies nearly straight. The lower wall, c, of the prostate is
much diminished in thickness. A nipple-shaped process, a, is seen
to be attached by a pedicle to the back of the upper part, h, of the
prostate, and to act like a stopper to the neck of the bladder. The
0 y a being moveable, it will be perceived how, while the bladder
IS distended with urine, the pressure from above may block up
the neck of the organ with this part, and thus cause complete
retention which, on the introduction of a catheter, becomes readily
relieved by the instrument pushing the obstructing body aside
* On comparing this series of figures, it must appear that the third
lobe of the prostate is the product of diseased action, in so far at least as
an unnatural hypertrophy of a part may be so designated. It is not
proper to the bladder in the healthy state of this organ, and where it does
manifest itself by increase it performs no healthy function in the economy
When Home, therefore, described this part as a new fact in anatomy, he
7'”’ J *7" xiorm'aTanatomy. Li";,
V
I
H d<i If. Bkniiai't lith., Hmniexs
COMMENTARY ON PLATE XXXIL
DEFORMITIES OF THE PROSTATE.—DISTORTIONS AND OBSTRUCTIONS OF THE PROSTATIC URETHRA.
The prostate is liable to such frequent and varied deformities, the
consequence of diseased action, whilst, at the same time, its healthy
function (if it have any) in the male body is unknown, that it
admits at least of one interpretation which may, according
to fact, be given of it—namely, that of playing a principal part in
effecting some of the most distressing of “ the thousand natural ills
that flesh is heir to.” But heedless of such a singular explanation
of a final cause, the practical surgeon will readily confess the.
fitting application of the interpretation, such as it is, and rest
contented with the proximate facts and proofs. As physiologists,
however, it behoves us to look further into nature, and search for
the ultimate fact in her prime moving law. The prostate is peculiar
to the male body, the uterus to the female. With the exception
of these two organs there is not another which appears in the one
sex but has its analogue in the opposite sex; and thus these two
organs, the prostate and the uterus, appear by exclusion of the
rest to approach the test of comparison, by which their analogy
becomes as fully manifested as that between the two quantities,
a — h, and a + b the only difference which exists depends upon the
subtraction or the addition of the quantity, h. The difference
between a prostate and a uterus is simply one of quantity, such as
we see existing between the male and the female breast. The
prostate is to the uterus absolutely what a rudimentary organ is
to its fully developed analogue. The one, as being superfluous,
is in accordance with nature’s law of nihil supervacaneum nihil
fnistra, arrested in its development, and in such a character
appears the prostate. This body is not a gland any more than is
the uterus, but both organs being quantitatively, and hence
functionally different, I here once more venture to caU down an
interpretation of the part from the unfrequented bourne of com¬
parative anatomy, and turning it to lend an interest to the
accompanying figures even with a surgical bearing, I remark that
the prostatic or rudimentary uterus, like a. germ not wholly
blighted, is prone to an occasional sprouting or increase beyond its
prescribed dimensions—a hypertrophy in barren imitation, as it
were, of gestation.*
Figure 1. —The prostate, a b, is here represented thinned in its
walls above and below. The lower wall is dilated into a pouch
caused by the points of misdirected instruments in catheterism
having been rashly forced against it.
Figure 2 .—The prostate, ab^ is here seen to be somewhat more
enlarged than is natural. A tubercle, b, surmounts the lower part,
c, of the prostate, and blocks up the vesical orifice. Catheters
introduced by the urethra for retention of urine which existed in
this case, have had their points arrested at the bulb, and on being
pushed forwards in this direction, have dilated the bulb into the
form of a pouch, seen at d. The sinus of the bulb, being the
lowest part of the urethral canal, is very liable to be distorted or
perforated by the points of instruments descending upon it from
above and before.f
Figure 3. —A cyst, c, is seen to grow from the left side of the
base of the prostate, a &, and to form an obstruction at the
vesical orifice.
Figure 4.—A globular excrescence, g, appears blocking up the
vesical orifice, and giving to this the appearance of a crescentic
slit, corresponding to the shape of the obstructing body. The
prostate, b b, is enlarged in both its lateral lobes. A small bougie,
c, is placed in the prostatic canal and vesical opening.
Figure 5 .—The prostate, d, is considerably enlarged, and the
vesical orifice is girt by a prominent ring, b 6, from the right
border of which the nipple-shaped body, a, projects and occupies
the outlet. Owing to the retention of urine caused by this state
of the prostate, the ureters, c c, have become very much dilated.
Figure 6 .—The lateral lobes of the prostate, cc, are seen
enlarged, and from the inner side and base of each, irregularly
shaped masses, a, &, d^ project, and bend the prostatic urethra first
to the right side, then to the left. The part, a, resting upon the
part, 6, acts like a valve against the vesical outlet, which would
become closed the tighter according to the degree of super¬
incumbent pressure. A flexible catheter would, in such a case
as this, be more likely, perhaps, to follow the sinuous course of
the prostatic passage than a rigid instrument of metal.
Figure 7 .—A globular mass, a, of large size, occupies the neck
of the bladder, and gives the vesical orifice, c, a crescentic shape,
convex towards the right side. The two lobes of the prostate,
b, are much enlarged.
* This expression of the fact to which I allude will not, I trust, be
extended beyond the limits I assign to it. Though I have every reason
to believe, that between the prostate of the male and the uterus of the
female, the same amount of analogy exists, as between a coccygeal
ossicle and the complete vertebral form elsewhere situated in the spinal
series, I am as far from regarding the two former to be in all respects
structurally or functionally alike, as I am from entertaining the like
idea in respect to the two latter. But still I maintain that between
a prostate and a uterus, as between a coccygeal bone and a vertebra,
the only difference which exists is one of quantity, and that hence
arises the functional difference. A prostate is part of a uterus, just
as a coccygeal bone is part (the centrum) of a vertebra. That this
is the absolute signification of the prostate I firmly believe, and were
this the proper place, I could prove it in detail, by the infallible rule
of analogical reasoning. John Hunter has observed that the use of the
prostate was not sufficiently known to enable us to form a judgment of
the bad consequences of its diseased state. When the part becomes
morbidly enlarged, it acts as a mechanical impediment to the passage of
urine from the bladder, but from this circumstance we cannot reasonably
infer, that while of its normal healthy proportions, its special function
is to facilitate the egress of the urine, for the female bladder, though
wholly devoid of the prostate, performs its own function perfectly. It
appears to me, therefore, that the real question should be, not what is the
use of the prostate? but has it any proper function? If the former
question puzzled even the philosophy of Hunter, it was because the
latter question must be answered in the negative. The prostate has no
function proper to itself per se. It is a thing distinct from the urinary
apparatus, and distinct likewise from the generative organs. It may be
hypertrophied or atrophied, or changed in texture, or wholly destroyed
by abscess, and yet neither of the functions of these two systems of
organs will be impaired, if the part while diseased act not as an obstruc¬
tion to themr In texture the prostate is similar to an unimpregnated
uterus. In form it is, like the uterus, symmetrical. In position it cor¬
responds to the uterus. The prostate has no ducts proper to itself.
Those ducts which are said to belong to it (prostatic ducts) are merely
mucous cells, similar to those in other parts of the urethral lining mem¬
brane. The seminal ducts evidently do not belong to it. The texture
of the prostate is not such as appears in glandular bodies generally. In
short, the facts which prove what it is not, prove what it actually is—
namely, a uterus arrested in its development, and as a sign of that all-
encompassing law in nature, which science expresses by the term unity
in variety.” This interpretation of the prostate, which I believe to be
true to nature, will last perhaps till such time as the microscopists shall
discover in its “ secretion"' some species of mannikins, such as may pair
with those which they term spermatozoa.
t When a stricture exists immediately behind the bulb, this circum¬
stance will, of course, favour the occurrence of the accident. False
passages (observes Mr. Benjamin Phillips) are less frequent here (in the
membranous part of the urethra) than in the bulbous portion of the canal.
The reason of this must be immediately evident: false passages are ordi¬
narily made in consequence of the difficulty experienced in the endeavour
to pass an instrument through the strictured portion of the tube. Stricture
is most frequently seated at the point of junction between the bulbous
and membranous portions of the canal; consequently, the false passage
will be usually anterior to this latter point.”—(On the Urethra, its Diseases,
&c., p. 15.)
COMMENTARY ON PLATE XXXII.
Figuee 8 —The lateral lobes, h b, of the prostate are irregularly
enlarged, and the urinary passage is bent towards the right side,
c, from the membranous portion, which is central. Surmounting
the vesical orifice, c, is seen the tuberculated mass, a, which being
moveable, can be forced against the vesical orifice and thus produce
complete retention of urine. In this case, also, a flexible catheter
would be more suitable than a metallic one.
Figitee 9 —The lateral lobes, b b, of the prostate are enlarged.
The third lobe, a, projects at the neck of the bladder, distorting
the vesical outlet. A small calculus occupies the prostatic
urethra, and being closely impacted in this part of the canal, would
arrest the progress of a catheter, and probably lead to the sup¬
position that the instrument grated against a stone in the interior
of the bladder, in which case it would be inferred that since the
urine did not flow through the catheter no retention existed.
Figure 10 .—Both lateral lobes, b c, of the prostate appear much
increased in size. A large irregular shaped mass, a, grows from
the base of the right lobe, and distorts the prostatic canal and
vesical orifice. When the lobes of the prostate increase in size in
this direction, the prostatic canal becomes much more elongated
than natural, and hence the instrument which is to be passed for
relieving the existing retention of urine should have a wide and
long curve to correspond with the form of this part of the
urethra.*
Figure 11.— Both lobes of the prostate are enlarged, and from
the base of each a mass projects prominently around the vesical
orifice, a b. The prostatic urethra has been moulded to the shape
of the instrument, which was retained in it for a considerable
time.
Figure 12 .—The prostate, c&, is enlarged and dilated, like a
sac. Across the neck, a, of the bladder the prostate projects in
an arched form, and is transfixed by the instrument, d. The
prostate may assume this appearance, as well from instruments
having been forced against it, as from an abscess cavity formed
in its substance having received, from time to time, a certain
amount of the urine, and retained this fluid under the pressure of
strong eflbrts, made to void the bladder while the vesical orifice
was closed above.
Figure 13.—The lateral lobes, d e, of the prostate are enlarged;
and, occupying the position of the third lobe, appear as three masses,
ab c, plicated upon each other, and directed towards the vesical
orifice, which they close like valves. The prostatic urethra
branches upwards into three canals, formed by the relative
position of the parts, e,c,b,a,d, at the neck of the bladder.
The ureters are dilated, in consecjuence of the regurgitation
of the contents of the bladder during the retention which
existed.
Figure 14 exhibits the lobes of the prostate greatly increased
in size. The part, a b, girds irregularly, and obstructs the vesical
outlet, while the lateral lobes, c d^ encroach upon the space of the
prostatic canal. The walls of the bladder are much thickened.
Figure 15.—The three lobes, a, 5, c, of the prostate are enlarged
and of equal size, moulded against each other in such a way that
the prostatic canal and vesical orifice appear as mere clefts between
them. The three lobes are encrusted on their vesical surfaces
with a thick calcareous deposit. The surface of the third lobe,
(i, which- has been half denuded of the calcareous crust, 5, in
order to show its real character, appeared at first to be a stone
impacted in the neck of the bladder, and of such a nature it
certainly would seem to the touch, on striking it with the point
of a sound or other instrument.
Figure 16 represents the prostate with its three lobes enlarged,
and the prostatic canal and vesical orifice narrowed. The walls
of the bladder are thickened, fasciculated, and sacculated; the
two former appearances being caused by a hypertrophy of the
vesical fibres, while the latter is in general owing to a protrusion
of the mucous membrane between the fasciculi.
Figure 17.—The prostate presents four lobes, a, b, c, d, each
being of large size, and projecting far into the interior of the
bladder, from around the vesical orifice which they obstruct.
The bladder is thickened, and the prostatic canal is elongated.
The urethra and the lobes of the prostate have been perforated by
instruments, passed for the retention of urine which existed. A
stricturing band, e, is seen to cross the membranous part of the
canal.
Figure 18.—The prostate, a a, is greatly enlarged, and projects
high in the bladder, the walls of the latter, b b, being very’much
thickened. The ureters, c, are dilated, and perforations made by
instruments are seen in the prostate. The prostatic canal being
directed almost vertically, and the neck of the bladder being raised
nearly as high as the upper border of the pubic symphysis, it must
appear that if a stone rest in the has fond of the bladder, a sound or
statf cannot reach the stone, unless by perforating the prostate; and
if, while the stalF occupies this position, lithotomy be performed, the
incisions will not be required to be made of a greater depth than
if the prostate were of its ordinary proportions. On the contrary,
if the staff happen to have surmounted the prostate, the incision,
in order to divide the whole vertical thickness of this body, will
require to be made very deeply from the perinieal surface, and
this circumstance occasions what is termed a “ deep perinaeum.”
Figure 19.— The lower half, c, 5,/, of the prostate, having
become the seat of abscess, appears hollowed out in the form of
a sac. This sac is_ separated from the bladder by a horizontal
septum, e e, the proper base of the bladder, g g. The prostatic
urethra, between ae, has become vertical in respect to the
membranous part of the canal, in consequence of the upward
pressure of the abscess. The sac opens into the urethra, near
the apex of the prostate, at the point c; and a catheter passed
along the urethra has entered the orifice of the sac, the interior
of which the instrument traverses, and the posterior wall of
which it perforates. The bladder contains a large calculus,
The bladder and sac do. not communicate, but the urethra is
a canal common to both. In a case of this sort it becomes
evident that, although symptoms may strongly indicate either
a retention of urine, or the presence of a stone in the bladder,
any instrument taking the position and direction of d d, cannot
relieve the one or detect the other; and such is the direction
in which the instrument must of necessity pass, while the sac
presents its orifice more in a line with the membranous part of
the urethra than the neck of the bladder is. The sac will intervene
between the rectum and the bladder; and on examination of the
parts through the bowel, an instrument in the sac will readily be
mistaken for being in the bladder, while neither a calculus in the
bladder, nor this organ in a state of even extreme distention, can
be detected by the touch any more than by the sound or catheter.
If, while performing lithotomy in such a state of the parts, the
staff occupy the situation of dd d^ then the knife, following the
statf, AviU open, not the bladder which contains the stone, but the
sac, which, moreover, if it happen to be filled with urine regur-
gitated from the urethra, will render the deception more complete.
Figure 20 —The walls, a a, of the bladder, appear greatly
thickened, and the ureters, b, dilated. The sides, c c c, of the
prostate are thinned; and in the jirostatic canal are two calculi,
d d^ closely impacted. In such a state of the parts it would be
impossible to pass a catheter into the bladder for the relief of a
retention of urine, or to introduce a statf as a guide to the knife
in lithotomy. If, however, the statf can be passed as far as the
situation of the stone, the parts may be held with a sufiicient
degree of steadiness to enable the operator to incise the prostate
upon the stone.
* Both lobes of the prostate are equally liable to chronic enlargement.
Home believed the left lobe to be oftener increased in size than the
right. Wilson (on the Male Urinary and Genital Organs) mentions
several instances of the enlargement of the right lobe. No reason can be
assigned why one lobe should be more prone to hypertrophy than the
, uc luaicer or lact, wuicli it is not. But the o1
vations made by Cruveilhier (Anat. Pathol.), that the lobulated projectio
the prostate always take place internally at its vesical aspect, is as true a
manner in which he accounts for the fact is plausible. The dense fibrou
velope of the prostate is sufficient to repress its irregular growth extern
: •'■ v^
COMMENTARY ON PLATE XXXIII.
DEFORMITIES OF THE DEINAET BLADDER—THE OPERATIONS OF SOUNDING FOR STONE,
OF CATHETERISM AND OF PUNCTURING THE BLADDER ABOVE THE PUBES.
The urinary bladder presents two kinds of deformity—viz.,
congenital and patbological. As examples of the former, may be
mentioned, that in which the organ is deficient in front, and has
become everted and protruded like a fungous mass through an
opening at the median line of the hypogastrium; that in which
the rectum terminates in the bladder posteriorly; and that in
which the foetal urachus remains pervious as an uniform canal, or
assumes a sacculated shape between the summit of the bladder
and the umbilicus. The pathological deformities are, those in
which vesical fistula, opening either above the pubes, at the peri-
naeum, or into the rectum, have followed abscesses or the opera¬
tion of puncturing the bladder in these situations, and those in
which the walls of the organ appear thickened and contracted, or
thinned and expanded, or sacculated- externally, or ridged inter¬
nally, in consequence of its having been subjected to abdominal
pressure while overdistended with its contents, and while incapable
of voiding these from some permanent obstruction in the urethral
canal.* The bladder is liable to become sacculated from two
causes—from a hernial protrusion of its mucous membrane
through the separated fasciculi of its fibrous coat, or from the
cyst of an abscess which has formed a communication with the
bladder, and received the contents of this organ. Sacs, when pro¬
duced in the former way, may be of any number, or size, or in
any situation; when caused by an abscess, the sac is single, is
generally formed in the prostate, or corresponds to the base of the
bladder, and may attain to a size equalling, or even exceeding,
that of the bladder itself. The sac, however formed, will be found
lined by mucous membrane. The cyst of an abscess, when
become a recipient for the urine, assumes after a time a lining
membrane similar to that of the bladder. If the sac be situated
at the summit or back of the bladder, it will be found invested by
peritonaBum; but, whatever be its size, structure, or position, it
may be always distinguished from the bladder by being devoid of
the fibrous tunic, and by having but an indirect relation to the
vesical orifice.
Figure 1.—The lateral lobes of the prostate, 3, 4, are en¬
larged, and contract the prostatic canal. Behind them the
third lobe of smaller size occupies the vesical orifice, and com¬
pletes the obstruction. The walls of the bladder have hence
become fasciculated and sacculated. One sac, 1, projects from
the summit of the bladder; another, 2, containing a stone, pro¬
jects laterally. When a stone occupies a sac, it does not give
rise to the usual symptoms as indicating its presence, nor can it
be always detected by the sound.
Figure 2.—The prostate, 2, 3, is enlarged, and the middle lobe,
2 , appears bending the prostatic canal to an almost vertical
position, and obstructing the vesical orifice. The bladder, 1, 1, 1,
is thickened; the ureters, 7, are dilated; and a large sac, 6, 6,
projects from the base of the bladder backwards, and occupies the
recto-vesical fossa. The sac, equal in size to the bladder, com¬
municates with this organ by a small circular opening, 8, situated
between the orifices of the ureters. The peritonaeum is reflected
from the summit of the bladder to that of the sac. A catheter, 4,
appears perforating the tkird lobe of the prostate, 2, and entering
the sac, 5, through the base of the bladder, below the opening, 8.
In a case of this kind, a catheter occupying the position 4, 5,
would, while voiding the bladder through the sac, make it seem as
if it really traversed the vesical orifice. If a stone occupied the
bladder, the point of the instrument in the sac could not detect it,
whereas, if a stone lay within the sac, the instrument, on striking
it here, would give the impression as if it lay within the bladder.
Figure 3.—The urethra being strictured, the bladder has
become sacculated. In the has fond of the bladder appears a
circular opening, 2, leading to a sac of large dimensions, which
rested against the rectum. In such a case as this, the sac,
occupying a lower position than the base of the bladder, must
first become the recipient of the urine, and retain this fluid even
after the bladder has been evacuated, either voluntarily or by
means of instruments. If, in such a state of the parts, retention
of urine called for puncturation, it is evident that this operation
would be performed with greater efiect by opening the depending
sac through the bowel, than by entering the summit of the
bladder above the pubes.
Figure 4.—The vesical orifice is obstructed by two portions,
3, 4, of the prostate, projecting upwards, one from each of its
lateral lobes, 6, 6. The bladder is thickened and fasciculated, and
from its summit projects a double sac, 1, 2, which is invested by
the peritonaeum.
Figure 5.—The prostatic canal is constricted and bent upwards
by the third lobe. The bladder is thickened, and its base is
dilated in the form of a sac, which is dependent, and upon which
rests a calculus. An instrument enters the bladder by perforating
the third lobe, but does not come into contact with the calculus,
owing to the low position occupied by this body.
Figure 6 .—Two sacs appear projecting on either side of the base
of the bladder. The right one, 5, contains a calculus, 6; the left
one, of larger dimensions, is empty. The rectum lay in contact
with the base of the bladder between the two sacs.
.Figure 7.—Four calculi are contained in the bladder. This
organ is divided by two sept^, 2, 4, into three compartments, each
of which, 1, 3, 5, gives lodgment to a calculus; and another, 6, of
these bodies lies impacted in the prostatic canal, and becomes a
* On considering these cases of physical impediments to the passage of
urine from the vesical reservoir through the urethral conduit, it seems to
me as if these were sufficient to account for the formation of stone in the
bladder, or any other part of the urinary apparatus, without the necessity
of ascribing it to a constitutional disease, such as that named the Kthic
diathesis by the humoral pathologists.
The urinary apparatus (consisting of the kidneys, ureters, bladder,
and urethra) is known to be the principal ernunctory for eliminating and
voiding the detritus formed by the continual decay of the parts comprising
the animal economy. The urine is this detritus in a state of solution.
The components of urine are chemically similar to those of calculi, and as
the components of the one vary according to the disintegration occurring
at the time in the vital alembic, so do those of the other. While, therefore,
a calculus is only as urine precipitated and solidified, and this fluid only
as calculous matter suspended in a menstruum, it must appear that the
lithic diathesis is as natural and universal as structural disintegration is
constant and general in operation. As every individual, therefore, may be
said to void day by day a dissolved calculus, it must follow that its form
of precipitation within some part of the urinary apparatus alone constitutes
the disease, since in this form it cannot be passed. On viewing the subject
in this light, the question that springs directly is, (while the lithic diathesis
is common to individuals of all ages and both sexes,) why the lithic sedi¬
ment should present in the form of concrement in some and not iu
others.? The principal, if not the sole, cause of this seems to me to be
obstruction to the free egress of the urine along the natural passage. Aged
individuals of the male sex, in whom- the prostate is prone to enlargement,
and the urethra to organic stricture, are hence more subject to the
formation of stone in the bladder, than youths, in whom these causes
of obstruction are less frequent, or than females of any age, in whom
the prostate is absent, and the urethra simple, short, readily dilatable,
and seldom or never strictured. When an obstruction exists, lithic
concretions take place in the urinary apparatus in the same manner as
sedimentary particles cohere or crystallize elsewhere. The urine
becoming pent up and stagnant while charged with saline matter,
either deposits this around a nucleus introduced into it, or as a surplus
when the menstruum is insufficient to suspend it. The most depending
part of the bladder is that where lithic concretions take place; and if a
sacculus exist here, this, becoming a recipient for the matter, will favour
the formation of stone.
COMMENTARY ON PLATE XXXTII.
complete bar to the passage of a catheter. Supposing lithotomy
to be performed in an instance of this kind, it is probable that,
after the extraction of the calculi, 6, 5, the two upper ones,
3, 1, would, owing to their being embedded in the walls of the
bladder, escape the forceps.
Figure 8 .—Two large polypi, and many smaller ones, appear
growing from the mucous membrane of the prostatic urethra and
vesical orifice, and obstructing these parts. In examining this
case during life by the sound, the two larger growths, 1, 2, were
mistaken by the surgeon for calculi. Such a mistake might well
be excused if they happened to be encrusted with lithic matter.
Figure 9.—The base of the bladder, 8, 8, appears dilated into
a large uniform sac, and separated from the upper part of the
organ by a circular horizontal fold, 2, 2. The ureters are also
dilated. The left ureter, 3, 4, opens into the sac below this fold,
while the right ureter opens above it into the bladder. In all
cases of retention of urine from permanent obstruction of the
urethra, the ureters are generally found more or less dilated.
Two circumstances combine to this effect—while the renal secre¬
tion continues to pass into the ureters from above, the contents
of the bladder under abdominal pressure are forced regurgitating
into them from below, through their orifices.
Figure 10 .—The bladder, 6, appears symmetrically sacculated.
One sac, 1, is formed at its summit, others, 3, 2, project laterally,
and two more, 5, 4, from its base. The ureters, 7, 7, are dilated,
and enter the bladder between the lateral and inferior sacs.
Figure 11 .—The prostate is greatly enlarged, and forms a
narrow ring around the vesical orifice. Through this an instru¬
ment, 12, enters the bladder. The walls of the bladder are
thickened and sacculated. On its left side appear numerous sacs,
2, 3, 4, 5, 6, 7, 8, and on the inner surface of its right side appear
the orifices of as many more. On its summit another sac is
formed. The ureters, 9, are dilated.
Figure 12 .—The prostate is enlarged, its canal is narrowed, and
the bladder is thickened and contracted. A calculus, 1, 2, appears
occupying nearly the whole vesical interior. The incision in the
neck of the bladder in lithotomy must necessarily be extensive, to
admit of the extraction of a stone of this size.
Figure 13.—The prostatic canal is contracted by the lateral
lobes, 4, 5; resting upon these, appear three calculi, 1, 2, 3, which
nearly fill the bladder. This organ is thickened and fasciculated.
In cases of this kind, and that last mentioned, the presence of stone
is readily ascertainable by the sound.
Figure 14.—The three prostatic lobes are enlarged, and appear
contracting the vesical orifice. In the walls of the* bladder are
embedded several small calculi, 2, 2, 2, 2, which, on being struck
with the convex side of a sound, might give the impression as
though a single stone of large size existed. In performing litho¬
tomy, these calculi would not be within reach of the forceps.
Figure 15—Two sacculi, 4, 5, appear projecting at the middle
line of the base of the bladder, between the vasa deferentia, 7, 7,
and behind the prostate, in the situation where the operation of
puncturing the bladder per anum is recommended to be per¬
formed in retention of urine.
Figure 16.—A sac, 4, is situated on the left side of the bladder,
3, 3, immediately above the orifice of the ureter. In the sac was
contained a mass of phosphatic calculus. This substance is said
to be secreted by the mucous lining of the bladder, while in a
state of chronic inflammation, but there seems nevertheless very
good reason for us to believe that it is, like aU other calculous
matter, a deposit from the urine.
Figure 17 represents, in section, the relative position of the
parts concerned in catheterism.* In performing this operation,
the patient is to belaid supine; his loins are to be supported
on a pillow; and his thighs are to be flexed and drawn apart from
each other. By this means the perineum is brought fully into
view, and its structures are made to assume a fixed relative
position. The operator, standing on the patient’s left side, is
now to raise the penis so as to render the urethra, 8, 8, 8, as
straight as possible between the meatus, a, and the bulb, 7. The
* It may be necessary for me to state that, with the exception of this
figure (which is obviously a plan, but sufficiently accurate for the purposes
it is intended to serve) all the others representing pathological conditions
instrument (the concavity of its curve being turned to the left
groin) is now to be inserted into the meatus, and while being gent y
impelled through the canal, the urethra is to be drawn forwards, by
the left hand, over the instrument. By stretching the urethra, Ave
render its sides sufficiently tense for facilitating the passage of the
instrument, and the orifices of the lacunae become closed.^ While
the instrument is being passed along this part of the canal, its point
should be directed fairly towards the urethral opening, Q*, of the
triangular ligament, which is situated an inch or so below the
pubic symphysis, 11. With this object in view, we should avoid
depressing its handle as yet, lest its point be prematurely tilted
up, and rupture the upper side of the urethra anterior to the
ligament. As soon as the instrument has arrived at the
bulb, its further progress is liable to be arrested, from these
causes:—1st, This portion of the canal is the lowest part
of its perinteal curve, 3, 6, 8, and is closely embraced by the
middle fibres of the accelerator urime muscle. 2nd, It is im¬
mediately succeeded by the commencement of the membranous
urethra, which, while being naturally narrower than other
parts, is also the more usual seat of organic stricture, and is
subject to spasmodic constriction by the fibres of the compressor
urethrie. 3rd, The triangular ligament is behind it, and if the
urethral opening of the ligament be not directly entered by the
instrument, this will bend the urethra against the front of that
dense structure. On ascertaining these to be the causes of re¬
sistance, the instrument is to be withdrawn a little in the canal,
so as to admit of its being readjusted for engaging precisely the
opening in the triangular ligament. As this structure, 6, is
attached to the membranous urethra, 6*, ivhich perforates it,
both these parts may be rendered tense, by drawing the penis
forwards, and thereby the instrument may be guided towards
and through the aperture. The instrument having passed
the ligament, regard is now to be paid to the direction of
the pelvic portion of the canal, which is upwards and backivards
to the vesical orifice, 3, d, 3. In order that the point of the in¬
strument may freely traverse the urethra in this direction, its
handle, a, requires to be depressed, b c, slowly towards the peri-
meum, and at the same time to be impelled steadily back in the
line d, d, through the pubic arch, 11. If the third lobe of the
prostate happen to be enlarged, the vesical orifice will accord¬
ingly be more elevated than usual. In this case, it becomes
necessary to depress the instrument to a greater extent than is
otherwise required, so that its point may surmount the obstacle.
But since the suspensory ligament of the penis, 10, and the
perinieal structures prevent the handle being depressed beyond a
certain degree, which is insufidcient for the object to be attained,
the instrument should possess the prostatic curve, c c, compared
with c b.
In the event of its being impossible to pass a catheter by the
urethra, in cases of retention of urine threatening rupture, the
base or the summit of the bladder, according as either part may
be reached with the greater safety to the peritonaeal sac, will
require to be punctured. If the prostate be greatly and irregu¬
larly enlarged, it Avill be safer to puncture the bladder above the
pubes, and here the position of the organ in regard to the perito¬
naeum, 1, becomes the chief consideration. The shape of the
bladder varies very considerably from its state of collapse, 3, 3, 5,
to those of mediate, 3, 3, 2, 1, and extreme distention, 3, 3, 4.
This change of form is chiefly eflfected by the expansive elevation
of its upper half, which is invested by the peritonaeum. As the
summit of the bladder falls below, and rises above the level of the
upper margin of the pubic symphysis, it carries the peritonaeum
with it in either direction. While the bladder is fully expanded,
4, there occurs an interval between the margin of the symphysis
pubis and the point of reflexion of the peritonaeum, from the recti
muscles, to the summit of the viscus. At this interval, close to
the pubes, and in the median line, the trocar may be safely
passed through the front wall of the bladder. The instrument,
should, in all cases, be directed downwards and backivards, h, h,
in a line pointing to the hollow of the sacrum.
and congenital deformities of the urethra, the prostate, and the bladder,
have been made by myself from natural specimens in the museums and hos¬
pitals of London and Paris.
Jil. ^5^ Hsuliart litli.
ftiiLTers.
COMMENTARY ON PLATE XXXIV.
THE SURGICAL DISSECTION OF THE POPLITEAL SPACE AND THE POSTERIOR
CRURAL REGION.
On comparing the bend of the knee with the bend of the elbow,
as evident a correspondence can be discerned between these two
regions, as exists between the groin and the axilla.
Behind the knee-joint, the muscles which connect the leg with
the thigh enclose the space named popliteal. When the integu¬
ments and subcutaneous substance are removed from this place,
the dense fascia lata may be seen binding these muscles so closely
together as to leave but a very narrow interval between them at
the mesial line. On removing this fascia, b B M m, Figure 1, the
muscles part asunder, and the popliteal space as usually described
is thereby formed. This region now presents of a lozenge-shaped
form, B j D K, of which the widest diameter, n j, is opposite the
knee-joint. The flexor muscles, c d j, in diverging from each
other as they pass down from the sides of the thigh to those of the
upper part of the leg, form the upper angle of this space; whilst
its lower angle is described by the two heads of the gastrocnemius
muscle, E E, arising inside the flexors, from the condyles of the
femur. The popliteal space is filled with adipose substance, in
which are embedded several lymphatic bodies and through which
pass the principal vessels and nerves to the leg.
In the dissection of the popliteal space, the more important
parts first met with are the branches of the great sciatic nerve.
In the upper angle of the space, this nerve will be found dividing
into the peronaeal, i, and posterior tibial branches, h k. The
peronjeal nerve descends close to the inner margin of the tendon, j,
of the biceps muscle; and, having reached the outer side of the
knee, i*. Figure 2, below the insertion of the tendon into the head
of the fibula, winds round the neck of this bone under cover of the
peronseus longus muscle, s, to join the anterior tibial artery. The
posterior tibial nerve, h k, Figure 1, descends the popliteal space
midway to the cleft between the heads of the gastrocnemius; and,
after passing beneath this muscle, to gain the inner side of the
vessels, h*. Figure 2, it then accompanies the posterior tibial artery.
On the same plane with and close to the posterior tibial nerve in the
popliteal space, wiU be seen the terminal branch of the lesser sciatic
nerve, together with a small artery and vein destined for distribu¬
tion to the skin and other superficial parts on the back of the knee.
Opposite the heads of the gastrocnemius, the peronaeal and posterior
tibial nerves give olF each a branch, both of which descend along
the mesial line of the calf, and joining near the upper end of the
tendo Achillis, the single nerve here, n. Figure 1, becomes super¬
ficial to the fascia, and thence descends behind the outer ankle to
gain the external border of the foot, where it divides into
cutaneous branches and others to be distributed to the three or
four outer toes. In company with this nerve will be seen the
posterior saphena vein, l, which, commencing behind the outer
ankle, ascends the mesial line of the calf to join the popliteal vein,
G, in the cleft between the heads of the gastrocnemius.
On removing next the adipose substance and lymphatic glands,
we expose the popliteal vein and artery. The relative position
of these vessels and the posterior tibial nerve, may now
be seen. Between' the heads of the gastrocnemius, the nerve,
H, giving off large branches to this muscle, lies upon the
popliteal vein, g, where this is joined by the posterior saphena
vein. Beneath the veins lies the popliteal artery, f. On tracing
the vessels and nerve from this point upwards through the popli¬
teal space, we find the nerve occupying a comparatively super¬
ficial position at the mesial line, while the vessels are directed
upwards, forwards, and inwards, passing deeply, as they become
covered by the inner flexor muscles, c d, to the place where they
perforate the tendon of the adductor magnus on the inner side of
the lower third of the femur.
The popliteal artery, f. Figure 2, being the continuation of the
femoral, extends from the opening in the great adductor tendon at
the junction of the middle and lower third of the thigh, to the point
where it divides, in the upper, and back part of the leg, at the lower
border of the popliteus muscle, l, into the anterior and posterior
tibial branches. In order to expose the vessel through this extent,
we have to divide and reflect the heads of the gastrocnemius muscle,
E E, and to retract the inner flexors. The popliteal artery will
now be seen lying obliquely over the middle of the back of the
joint. It is deeply placed in its whole course. Its upper and
lower thirds are covered by large muscles; whilst the fascia and a
quantity of adipose tissue overlies its middle. The upper part of
the artery rests upon the femur, its middle part upon the posterior
ligament of the joint, and its lower part upon the popliteus muscle.
The popliteal vein, g, adheres to the artery in its whole course, being
situated on its outer side above, and posterior to it below. The
vein is not unfrequently found to be double; one vein lying to
either side of the artery, and both having branches of communica¬
tion with each other, which cross behind the artery. In some
instances the posterior saphena vein, instead of joining the popli-
DESCRIPTION OF THE FIGURES OF PLATE XXXIV.
Figure 1.
A. Tendon of the gracilis muscle.
B B. The fascia lata.
C C. Tendon of the semimembranosus muscle.
D. Tendon of the semitendinosus muscle.
E E. The two heads of the gastrocnemius muscle.
F. The popliteal artery.
G. The popliteal vein joined by the short saphena vein.
H. The middle branch of the sciatic nerve.
I. The outer (peronaeal) branch of the sciatic nei've.
K. The posterior tibial nerve continued from the middle branch of the
sciatic, and extending to K, behind the inner ankle.
L. The posterior (short) saphena vein.
M M. The fascia covering the gastrocnemius muscle.
N. The short (posterior) saphena nerve, formed by the union of branches
from the peronaeal and posterior tibial nerves.
O. The posterior tibial artery appearing from beneath the soleus muscle
in the lower part of the leg.
P. The soleus muscle joining the tendo Achillis.
Q. The tendon of the flexor longus communis digitorum muscle.
R. The tendon of the flexor longus pollicis muscle.
S. The tendon of the peronmus longus muscle.
T. The peronaeus brevis muscle.
U U. The internal annular ligament binding down the vessels, nerves,
and tendons in the hollow behind the inner ankle.
V V. The tendo Achillis.
W. The tendon of the tibialis posticus muscle.
X. The venae comites of the posterior tibial ai'tery.
Figure 2.
ACDEFGHI indicate the same parts as in Figure 1,
B. The inner condyle of the femur.
K. The plantai’is muscle lying upon the popliteal artery.
L. The popliteus muscle.
M M M. The tibia.
N N. The fibula.
0 0. The posterior tibial artery.
P. The peronaeal artery.
Q R S T U V W. The parts shown in Figure 1.
X. The astragalus.
COMMENTARY ON PLATE XXXIV.
teal vein, ascends superficially to terminate in some of the large
veins of the thigh. Numerous lymphatic vessels accompany the
superficial and deep veins into the popliteal space, where they join
the lymphatic bodies, which here lie in the course of the artery.
The branches derived from the popliteal artery are the mus¬
cular and the articular. The former spring from the vessel opposite
those parts of the several muscles which lie in contact with it;
the latter are generally five in number—two superior, two infe¬
rior, and one median. The two superior articular branches arise
from either side of the artery, and pass, the one beneath the outer,
the other beneath the inner flexors, above the knee-joint; and the
two inferior pass off from it, the one internally, the other exter¬
nally, beneath the heads of the gastrocnemius below the joint;
while the middle articular enters the joint through the posterior
ligament. The two superior and inferior articular branches anas¬
tomose freely around the knee behind, laterally, and in front,
where they are joined by the terminal branches of the anastomotic,
from the femoral, and by those of the recurrent, from the anterior
tibial. The main vessel, having arrived at the lower border of the
popliteus muscle, divides into two branches, of which one passes
through the interosseous ligament to become the anterior tibial;
while the other, after descending a short way between the bones
of the leg, separates into the peronseal and posterior tibial arteries.
In some rare instances the popliteal artery is found to divide above
the popliteus muscle into the anterior, or the posterior tibial, or
the peronseal.
The two large muscles, (gastrocnemius and soleus,) forming
the calf of the leg, have to be removed together with the deep
fascia in order to expose the posterior tibial, and peronseal vessels
and nerves. The fascia forms a sheath for the vessels, and binds
them close to the deep layer of muscles in their whole course down
the back of the leg. The point at which the main artery, p. Figure 2,
gives off the anterior tibial, is at the lower border of the popliteus
muscle, on a level with n, the neck of the fibula; that at which the
artery again subdivides into the peronseal, p, and posterior tibial
branches, o, is in the mesial line of the leg, and generally on a level
with the junction of its upper and middle thirds. From this
place the two arteries diverge in their descent; the peronseal being
directed along the inner border of the fibula towards the back of
the outer ankle; while the posterior tibial, approaching the inner
side of the tibia, courses towards the back of the inner ankle. The
gastrocnemius and soleus muscles overlie both arteries in their
upper two thirds; but as these muscles taper towards the mesial
line where they end in the tendo AchiUis, v v. Figure 1, they leave
the posterior tibial artery, o, with its accompanying nerve and
vein, uncovered in the lower part of the leg, except by the skin
and the superficial and deep layers of fascise. The peronseal artery
is deeply situated in its whole course. Soon after its origin,
it passes under cover of the flexor longus pollicis, e, a muscle of
large size arising from the lower three fourths of the fibula, N, and
will be found overlapped by this muscle on the outer border of the
tendo AchiUis, as low down as the outer ankle. The two arteries
are accompanied by venae comites, which, with the short saphena
vein, form the popliteal vein. The posterior tibial artery is
closely followed by the posterior tibial nerve. In the popliteal
space, this nerve crosses to the inner side of the posterior tibial
artery, where both are about to pass under the gastrocnemius
muscle, to which they give large branches. Near the middle of the
leg, the nerve recrosses the artery to its outer side and in this rela¬
tive position both descend to a point about midway between the
inner ankle and calcaneum, where they appear having the tendons
of the tibialis posticus and flexor longus digitorum to their inner
side and the tendon of the flexor longus pollicis on their outer side.
Numerous branches are given off from the nerve and artery to
the neighbouring parts in their course.
The varieties of the posterior crural arteries are these—the
tibial vessel, in some instances, is larger than usual, whUe the
peronseal is small, or absent; and, in others, the peroneal
supplies the place of the posterior tibial, when the latter is
diminished in size. The peronseal has been known to take the
position of the posterior tibial in the lower part of the leg, and to
supply the plantar arteries. In whatever condition the two
vessels may be found, thei’e will always be seen ramifying around
the ankle-joint, articular branches, which anastomose freely with
each other and with those of the anterior tibial.
The popliteal artery is unfavourably circumstanced for the
application of a ligature. It is very deeply situated, and the vein
adheres closely to its posterior surface. Numerous branches
(articular and muscular) arise from it at short intervals; and
these, besides being a source of disturbance to a ligature, are
liable to be injured in the operation, in which case the collateral
circulation cannot be maintained after the main vessel is tied.
There is a danger, too, of injuring the middle branch of the sciatic
nerve, in the incisions required to reach the artery; and, lastly,
there is a possibility of this vessel dividing higher up than usual.
Considering these facts in reference to those cases in which it
might be supposed necessary to tie the popliteal artery—such
cases, for example, as aneurism of either of the crural arteries,
or secondary hasmorrhages occurring after amputations of the
leg at a time when the healing process was far advanced
and the bleeding vessels inaccessible,—it becomes a question
whether it would not be preferable to tie the femoral, rather than
the popliteal artery. But when the popliteal artery itself becomes
afiected with aneurism, and when, in addition to the anato¬
mical circumstances which forbid the application of a ligature
to this vessel, we consider those which are pathological,—such as
the coats of the artery being here diseased, the relative position
of the neighbouring parts being disturbed by the tumour, and the
large irregular wound which would be required to isolate the
disease, at the risk of danger to the health from profuse suppura¬
tion, to the limb from destruction of the collateral branches, or to
the joint from cicatrization, rendering it permanently bent,_we
must acknowledge at once the necessity for tying the femoral part
of the main vessel.
When the popliteal artery happens to be divided in a wound, it
will be required to expose its bleeding oriflces, and tie both these in
the wound. For this purpose, the following operation usually re¬
commended for reaching the vessel may be necessary. The skin and
fascia lata are to be incised in a direction corresponding to that of
the vessel. The extent of the incision must be considerable, (about
three inches,) so as the more conveniently to expose the artery in
its deep situation. On laying bare the outer margin of the semi¬
membranosus muscle, while the knee is straight, it now becomes
necessary to flex the joint, in order that this muscle may admit of
being pressed inwards from over the vessel. The external margin
of the wound, including the middle branch of the sciatic nerve,
should be retracted outwards, so as to ensure the safety of that
nerve, while room is gained for making the deeper incisions. The
adipose substance, which is here generally abundant, should now
be divided, between the mesial line and the semimembranosus, till
the sheath of the vessels be exposed. The sheath should be
incised at its inner side, to avoid wounding the popliteal vein.
, The pulsation of the artery will now indicate its exact position.
As the vein adheres flrmly to the coats of the artery, some care is
required to separate the two vessels, so as to pass the ligature
around each end of the artery from without inwards, while
excluding the vein. While this operation is being performed in a
case of wound of the popliteal artery, the hemorrhage may be
arrested by compressing the femoral vessel, either against the
femur or the os pubis.
In the operation for tying the posterior tibial artery near its
middle, an incision of three or four inches in extent is to be
made through the skin and fascia, in a line corresponding with
the inner posterior margin of the tibia and the great muscles of
the calf. The long saphena vein should be here avoided. The
origins of the gastrocnemius and soleus muscles require to be
detached from the tibia, and then the Imee is to be flexed and the
oot extended, so as to allow these muscles to be retracted from
the plane of the vessels. This being done, the deep fascia which
covers the artery and its accompanying nerve is next to be
• pulsating at a situation an
inch from the edge of the tibia. While the ligature is being-
passed around the artery, due care should be taken to exclude the
venm comites and the nerve.
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COMMENTARY ON PLATE XXXV.
THE SURGICAL DISSECTION OF THE ANTERIOR CRURAL REGION, THE ANKLES,
AND THE FOOT.
Beneath the integuments and subcutaneous adipose tissue on the
fore part of the leg and foot, the fascia h h. Figure 2, is to be seen
stretched over the muscles and sending processes between them,
thus encasing each of these in a special sheath.
The fascia is here of considerable density. It is attached on the
inner side of the leg to the spine of the tibia, D, Figure 2, and on
the outer side it passes over the peroneal muscles to those forming
the calf. Between the extensor communis digitorum, B Z>, and the
peronseus longus, E, it sends in a strong process to be attached to
the fibula, E. In front of the ankle joint, the fascia is increased in
density, constituting a band (anterior annular ligament) which
extends between the malleoli, forms sheaths for the several
extensor tendons, and binds these down in front of the joint.
From the lower border of the annular ligament, the fascia is con¬
tinued over the dorsum of the foot, forming sheaths for the tendons
and muscles of this part. Behind the inner malleolus, cZ, Figure 1,
the fascia attached to this process and to the inner side of the
os calcis appears as the internal annular ligament, which being
broad and strong, forms a kind of arch, beneath which in special
sheaths the flexor tendons, and the posterior tibial vessel and nerve,
pass to the sole of the foot. On tracing the fascia from the front
to the back of the leg, it will be seen to divide into two layers—
superficial and deep; the former passes over the muscles of the calf
and their common tendon (tendo Achillis) to which it adheres,
while the latter passes between these muscles and the deep flexors.
The deep layer is that which immediately overlies the posterior
tibial and peronseal vessels and nerves. While exposing the fascia
on the forepart of the leg and dorsum of the foot, we meet with
the musculo-cutaneous branch of the peronseal nerve, which pierces
the fascia at about the middle of the limb, and descends super¬
ficially in a direction between the fibula, and the extensor longus
digitorum muscle, and after dividing . into branches a little above
the outer ankle, these traverse in two groups the dorsum of the
foot, to be distributed to the integuments of the five toes. On the
inner side of the tibia, n. Figure 1, wiU be seen the internal or long
saphena vein, B B, which commencing by numerous branches on the
dorsal surface of the foot ascends in front of the inner ankle, to
gain the inner side of the leg, after which it ascends behind the
inner side of the knee and thigh, till it terminates at the saphenous
opening, where it joins the femoral vein. In its course along the
lower part of the thigh, the leg and the foot, this vein is closely
accompanied by the long saphenous nerve, derived from the
anterior crural, and also by a group of lymphatics.
By removing the fascia from the front of the leg and foot, we
expose the several muscles and tendons which are situated in these
parts. In the upper part of the leg the tibialis anticus. A, Figure 2,
and extensor-communis muscle, b, are adherent to the fascia which
covers them, and to the intermuscular septum which divides them.
In the lower part of the leg where these muscles and the extensor
pollicis, c, terminate in tendons, ah they are readily separable
from one another. The tibialis anticus lies along the outer side of
the tibia, from which, and from the head of the fibula and interos"
seous ligament, it arises tendinous and fleshy. This muscle is super¬
ficial in its whole length; its tendon commencing about the middle
of the leg, passes in a separate loose sheath of the annular liga¬
ment in front of the inner ankle, to be inserted into the inner side
of the cuneiform bone and base of the metatarsal bone of the great
toe. The extensor communis digitorum, lies close to the outer
side of the anterior tibial muscle, and arises from the upper three-
fourths of the fibula, from the interosseous ligament and inter¬
muscular septum. At the lower part of the leg, this muscle ends
in three or four flat tendons, which pass through a ring of the
annular ligament, and extending forwards, b b bb, over the dorsum
of the foot, become inserted into the four ' outer toes. ' The
perongeus tertius or anterior, is that part of the common ex¬
tensor muscle which is inserted into the base of the fifth meta-
DESCRIPTIQN OF THE FIGURES OF PLATE XXXV.
Figure 1.
A. The tendon of the tibialis anticus muscle.
B B. The long saphena vein.
C C. The tendon of the tibialis posticus muscle.
D. The tibia ; d, the inner malleolus.
E E. The tendon of the flexor longus digitorum muscle.
F. The gastrocnemius muscle; f, the tendo Achillis.
G. The soleus muscle.
H. The tendon of the plantaris muscle.
I I. The venae comites.
K K. The posterior tibial artery.
L L. The posterior tibial nerve.
Figure 2.
A. The tibialis anticus muscle; a, its tendon.
B. The extensor longus digitorum muscle ; b b b b,its four tendons.
C C. The extensor longus pollicis muscle.
D D. The tibia.
E. The fibula; e, the outer malleolus.
F F. The tendon of the peronaBus longus muscle.
G G. The peronaeus brevis muscle; i, the peronaeus tertius.
H H. The fascia.
K. The extensor brevis digitorum muscle; k A, its tendons.
L L. The anterior tibial artery and nerve descending to the dorsum of
the foot.
Figure 3.
A. The calcaneum.
B. The plantar fascia and flexor brevis digitorum muscle cut; b b b^ its
tendons.
C. The abductor minimi digiti muscle.
D. The abductor pollicis muscle.
E. The flexor accessorius muscle. ^
F. The tendon of the flexor longus digitorum muscle, subdividing into
ffff, tendons for the four outer toes.
G. The tendon of the flexor pollicis longus muscle.
H. The flexor pollicis brevis muscle.
111 I. The four lumbricales muscles.
K. The external plantar nerve.
L. The external plantar artery.
M. The internal plantar nerve and artery.
Figure 4.
A. The heel covered by the integument.
B. The plantar fascia and flexor brevis digitorum muscle cut; b b the
tendons of the muscle.
C. The abductor minimi digiti.
D. The abductor pollicis.
E. The flexor accessorius cut.
F. The tendon of the flexor digitorum longus cut; fff, its digital ends.
G. The tendon of the flexor pollicis.
H. The head of the first metatarsal bone.
I. The tendon of the tibialis posticus.
K. The external plantar nerve.
L L. The arch of the external plantar artery.
M M M M. The four interosseus muscles.
N. The external plantar nerve and artery cut.
COMMENTAKY ON PLATE XXXV.
tarsal bone. On separating the anterior tibial, and common
extensor muscles, we find the extensor pollicis, c c, which,
concealed between the two, arises from the middle of the fibula,
and the interosseous ligament; its tendon passes beneath the
annular ligament in front of the ankle joint, and after traversing
the inner part of the dorsum of the foot, becomes inserted into the
three phalanges of the great toe. Beneath the tendons of the
extensor communis on the instep, will be seen the extensor
digitorum brevis K k, lying in an oblique direction, between the
upper and outei' part of the os calcis from which it arises, and the
four inner toes into each of which it is inserted by a small flat
tendon which joins the corresponding tendon of the long common
extensor.
The anterior tibial artery, l. Fig. 2, extends from the upper
part of the interosseous ligament which it perforates, to the bend
of the ankle, whence it is continued over the dorsum of the foot.
In the upper third of the leg, the ainterior tibial artery lies deeply
situated between the tibialis anticus, and flexor communis
muscles. Here it will be found, close in front of the interosseous
ligament, at about an inch and-a-half in depth from the anterior
suiTace, and removed from the spine of the tibia at an interval
equal to the width of the tibialis anticus muscle. In its course
down the leg, the vessel passes obliquely from a point close to the
inner side of the neck of the fibula, to midway between the ankles.
In its descent, it becomes gradually more superficial. In the
middle of the leg, the vessel passes between the extensor longus
pollicis, and the tibialis anticus muscles. Above, beneath, and
below the annular ligament, this artery will be found to pass raid-
way between the extensor pollicis tendon, and those of the
extensor communis, and to hold the same relation to these parts
in traversing the dorsum of the foot, till it gains the interval
betAveen the two inner metatarsal bones, where it divides into two
branches, one of which passes forwards in the first interdigital
space, Avhile the other sinks between the bones, to inosculate with
the plantar arteries. The innermost tendon of the short common
extensor crosses in front of the dorsal artery of the foot near its
termination. Between the ankle and the first interosseous space
the artery lies comparatively superficial, being here covered only
by the skin and fascia and cellular membrane. Two veins accom¬
pany the anterior tibial artery, and its continuation on the dorsum
of the foot. The anterior tibial nerve, a branch of the peroneeal,
jons the outer side of the artery, about the middle of the leg, and
accompanies it closely in this position, till both have passed
beneath the annular ligament. On the dorsum of the foot the
nerve will be found to the inner side of the artery.
The branches of the anterior tibial artery are articular and
muscular. From its upper end arises the recurrent branch
Avhich anastomoses in front of the knee with the articular
■ branches of the popliteal artery. Near the ankle, arise on either
side of the vessel two malleolar branches, internal and external,
the former communicating with branches of the posterior tibial,
the latter with those of the peronaeal. Numerous muscular
branches arise, at short intervals, from the vessel in its passage
down the leg. Tarsal, metatarsal, and small digital branches spring
from the dorsal artery of the foot. The anterior tibial artery is
rarely found to deviate from its usual course; in some cases it
appears of less or of greater size than usual. When this vessel
appears deficient, its place is usually supplied by some branch of
the peroneal or posterior tibial, which pierces the interosseous
ligament from behind.
The anterior tibial artery when requiring a ligature to be
applied to it m any part of'its course, may be exposed by an
incision, extending for three or four inches, (more or less, ac¬
cording to the depth of the vessel) along the outer border of the
tibialis anticus muscle. The fibrous septum between this muscle
and the extensor communis, will serve as a guide to the vessel
in the upper third of the leg, where it lies deeply on the interos¬
seous ligament. In the middle of the leg, the vessel is to be
sought for, between the anterior tibial and extensor longus pollicis
muscles. In the lower part of the leg, and on the dorsum of the
foot, it will be found between the extensor longus pollicis, and
extensor communis tendons, the former being taken as a guide
for the incision. In passing the ligature around this vessel at
either of these situations, care is required to avoid including the
venae comites and the accompanying nerve.
The sole of the foot is covered by a hard and thick integument,
beneath which Avill be seen a large quantity of granulated adipose
tissue so intersected by bands of fibrous structure as to form a
firm, but elastic cushion, in the situations particularly of the heel
and joints of the toes. On removing this structure, we expose the
plantar fascia, B, Fig. 3, extending from the os calcis a, to the
toes. This fascia is remarkably strong, especially its middle and
outer parts, which serve to retain the arched form of the foot, and
thereby to protect the plantar structures from superincumbent
pressure during the erect posture. The superficial plantar muscles
become exposed on removing the ■ plantar fascia, to which they
adhere. In the centre will be seen the thick fleshy flexor digitoimm
brevis muscle, b, arising from the inferior part of the os calcis, and
passing forwards to divide into four small tendons, b bb b, for the
four outer toes. On the inner side of the foot appears the abductor
pollicis, D, arising from the inner side of the os calcis and internal
annular ligament, and passing to be inserted with the flexor
pollicis brevis, H, into the sesamoid bones and base of the first
phalanx of the great toe. On the external border of the foot is
situated the abductor minimi digiti, c, arising from the outer
side of the os calcis, and passing to be inserted with the flexor
brevis minimi digiti into the base of the first phalanx of the little
toe. When the flexor brevis digitorum muscle is removed, the
plantar arteries, lm, and nerves, are brought partially into vieAv;
and by further dividing the abductor pollicis, d, their continuity
with the posterior tibial artery and nerves, k l. Fig. 1, behind
the inner ankle may be seen.
The plantar branches of the posterior tibial artery are the
internal and external, both of which are deeply placed between the
superficial and deep plantar muscles. The internal plantar artery
is much the smaller of the two. The external plantar artery, l. Fig.
3, is large, and seems to be the proper continuation of the posterior
tibial. It corresponds, in the foot, to the deep palmar arch in the
hand. Placed at first between the origin of the abductor pollicis and
the calcaneum, the external plantar artery passes outwards between
the short common flexor, b, and the flexor accessorius, e, to gain
the inner borders of the muscles of the little toe; from this place
it curves deeply inwards between the tendons of the long common
flexor of the toes, r//, and the tarso-metatarsal joints, to gain
the outer side of the first metatarsal bone, h. Fig. 4. In this
course it is covered in its posterior half by the flexor brevis
digitorum, and in its anterior half by this muscle, together with
the tendons of the long flexor, f. Fig. 3, of the toes and the
lumbricales muscles, i i i i. From the external plantar artery
are derived the principal branches for supplying the structures in
the sole of the foot. The internal plantar nerve divides into four
branches, for the supply of the four inner toes, to which they pass
between the superficial and deep flexors. The external plantar
nerve, passing along the inner side of the corresponding artery,
sends branches to supply the outer toe and adjacent side of the
next, and then passes, with the artery, between the deep common
flexor tendon and the metatarsus, to be distributed to the deep
plantar muscles.
The posterior tibial artery may be tied behind the inner ankle,
on being laid bare in the following way:—A curved incision (the
concavity forwards) of two inches in length, is to be made mid¬
way between the tendo AchiUis and the ankle. The skin and
superficial fascia having been divided, we expose the inner annular
ligament, which will be found enclosing the vessels and nerve
in a canal distinct from that of the tendons. Their fibrous sheath
having been slit open, the artery wiU be seen between the vense
comites, and with the nerve, in general, behind it.
When any of the arteries of the leg or the foot are wounded,
and the haemorrhage cannot be commanded by compression it
wiU be necessary to search for the divided ends of the vessel in
the wound, and to apply a ligature to both. The expediency of
t IS measure must become fully apparent when we consider the
requent anastomoses existing between the collateral branches of
the crural arteries, and that a ligature applied to any one of these
above the seat of injury wiU.not arrest the recurrent circulation
through the vessels of the foot.
V
CONCLUDING COMMENTARY.
ON THE FORM AND DISTRIBUTION OF THE VASCULAR SYSTEM AS A WHOLE-ANOMALIES.
RAMIFICATION.—ANASTOMOSIS.
I-— The heart, in all stages of its development, is to the vascular
system what the point of a circle is to the circumference—namely,
at once the beginning and the end. The heart, occupying, it may
be said, the centre of the thorax, circulates the blood in the same
by similar channels, to an equal extent, in equal pace, and
at the same period of time, through both sides of the body. In
its adult normal condition, the heart presents itself as a double or
symmetrical organ. The two hearts, though united and appearing
single, are nevertheless, as to their respective cavities, absolutely
distinct. Each heart consists again of two compartments—an
auricle and a ventricle. The two auricles are similar in structure
and form. The two ventricles are similar in the same respects.
A septum divides the two auricles, and another—the two
ventricles. Between the right auricle and ventricle, forming the
right heart, there exists a valvular apparatus (tricuspid), by
which these two compartments communicate; and a similar valve
(bicuspid) admits of communication between the left auricle and
ventricle. The two hearts being distinct, and the main vessels
arising from each respectively being distinct likewise, it follows
that the capillary peripheries of these vessels form the only
channels through which the blood issuing from one heart can
enter the other.
II. —As the aorta of the left heart ramifies throughout aU parts
of the body, and as the countless ramifications of this vessel
terminate in an equal number of ramifications of the principal
veins of the right heart, it will appear that between the systemic
vessels of the two hearts respectively, the capillary anastomotic
circulation reigns universal.
III. —The body generally is marked by the median line, from
the vertex to the perinaeum, into corresponding halves. All
parts excepting the main bloodvessels in the neighbourhood of the
heart are naturally divisible by this line into equals. The vessels
of each heart, in being distributed to both sides of the body alike,
cross each other at the median line, and hence they are inseparable
according to this line, unless by section. If the vessels proper to
each heart, right and left, ramified alone within the limits of their
respective sides of the body, then their capillary anastomosis could
only take place along the median line, and here in such case they
might be separated by median section into two distinct systems.
But as each system is itself double in branching into both sides of
the body, the two would be at the same time equally divided by
vertical section. From this it will appear that the vessels
belonging to each heart form a symmetrical system, corresponding
to the sides of the body, and that the capillary anastomosis of
these systemic veins and arteries is divisible into two great fields.,
one situated on either side of the median line, and touching at
this line.
IV. —The vessels of the right heart do not communicate at
their capillary peripheries, for its veins are systemic, and its
arteries are pulmonary. The vessels of the left heart do not
anastomose, for its veins are pulmonary, and its arteries are
systemic. The arteries of the right and left hearts cannot anas¬
tomose, for the former are pulmonary, and the latter are systemic;
and neither can the veins of the right and left hearts, for a similar
reason. Hence, therefore, there can be, between the vessels of
both hearts, but two provinces of anastomosis —viz., that of the
lungs, and that of the system. In the lungs, the arteries of the
right heart and the veins of the left anastomose. In the body
generally (not excepting the lungs), the arteries of the left heart,
and the veins of the right, anastomose; and thus in the pulmo¬
nary and the systemic circulation, each heart plays an equal part
through the medium of its proper vessels. The pulmonary bear
to the systemic vessels the same relation as a lesser circle contained
within a greater; and the vessels of each heart form the half of
each circle, the arteries of the one being opposite the veins of the
other.
V.—The two hearts being, by the union of their similar forms,
as one organ in regard to place, act, by an agreement of their
corresponding functions, as one organ in respect to time. The
action of the auricles is synchronous ; that of the ventricles is the
same ; that of the auricles and ventricles is consentaneous; and
that of the whole heart is rhythmical, or harmonious—the diastole
of the auricles occurring in harmonical time with the systole of
the ventricles, and vice versA. By this correlative action of both
hearts, the pulmonary and systemic circulations take place syn¬
chronously; and the phenomena resulting in both reciprocate
and balance each other. In the pulmonary circulation, the
blood is aerated, decarbonized, and otherwise depurated; whilst
in the systemic circulation, it is carbonized and otherwise dete¬
riorated.
VI—The circulation through the lungs and the system is
carried on through vessels having the following form and relative
position, which, as being most usual, is accounted normal. The
two brachio-cephalic veins joining at the root of the neck, and the
two common iliac veins joining in front of the lumbar vertebrje,
form the superior and inferior venas cavse, by which the blood is
returned from the upper and lower parts of the body to the right
auiTcle, and thence it enters the right ventricle, by which it is
impelled through the pulmonary artery into the two lungs; and
from these it is returned (aerated) by the pulmonary veins to the
left auricle, which passes it into the left ventricle, and by this it is
impelled through the systemic aorta, which branches throughout
the body in a similar way to the systemic veins, with which the
aortic branches anastomose generally. On viewing together the
system of vessels proper to each heart, they will be seen to exhibit
in respect to the body a figure in doubly symmetrical arrange¬
ment, of which the united hearts form a duplex centre. At this
centre, which is the theatre of metamorphosis, the principal
abnormal conditions of the bloodvessels appear; and in order to
find the signification of these, we must retrace the stages of
development.
VII.—From the first appearance of an individualized centre in
the vascular area of the human embryo, that centre (punctum
saliens) and the vessels immediately connected with it, undergo a
phaseal metamorphosis, till such time after birth as they assume
their permanent character. In each stage of metamorphosis, the
embryo heart and vessels typify the normal condition of the organ
in one of the lower classes of animals. The several species of the
organ in these classes are parallel to the various stages of change
in the human organ. In its earliest condition, the human heart
presents the form of a simple canal, similar to that of the lower
Invertebrata, the veins being connected with its posterior end,
while from its anterior end a single artery enianates. The canal
next assumes a bent shape, and the vessels of both its ends become
thereby approximated. The canal now being folded upon itself
in heart-shape, next becomes constricted in situations, marking out
the future auricle and ventricle and arterial bulb, which stiU com¬
municate with each other. From the artery are given off on either
side symmetrically five branches (branchial arches), which arch
laterally from before, outwards and backwards, and unite in front
of the vertebrse, forming the future descending aorta. In this
condition, the human heart and vessels resemble the Piscean type.
The next changes which take place consist in the gradual sub¬
division, by means of septa, of the auricle and ventricle respectively
into two cavities. On the separation of the single auricle into
two, while the ventricle as yet remains single, the heart presents
that condition which is proper to the Reptilian class. The inteiv
auricular and interventricular septa, by gradual development
from without inwai’ds, at length meet and coalesce, thereby
dividing the two cavities into four—two auricles and two
ventricles—a condition proper to the Avian and Mammalian
classes generally. In the centre of the interauricular septum of
CONCLUDING COMMENTARY.
the human heart, an aperture {foramen ovale) is left as being
necessary to the fcetal circulation. While the septa are being
completed, the arterial bulb also becomes divided by a partition
formed in its interior in such a manner as to adjust the two
resulting arteries, the one in connexion Avith the right, the other
Avith the left ventricle. The right ventricular artery (pulmonary
aorta) so formed, has assigned to it the fifth (posterior) opposite
pair of arches, and of these the right one remaining pervious to
the point where it gives off the right pulmonary branch, becomes
obliterated beyond this point to that where it joins the descending
aorta, Avhile the left arch remains pervious during foetal life, as
the ductus arteriosus still communicating with the descending
aorta, and giving off at its middle the left pulmonary branch.
The left A^entricular artery (systemic aorta) is formed of the
fourth arch of the left side, Avhile the opposite arch (fourth right)
is altogether obliterated. The third and second arches remain
pervious on both sides, afterAvards to become the right and left
brachio-cephalic arteries. The first pair of arches, if not converted
into the vertebral arteries, or the thyroid axes, are altogether
metamorphosed. By these changes the heart and primary
arteries assume the character in which they usually present
themselves at birth, and in all probability the primary veins corre¬
sponded in form, number, and distribution with the arterial vessels,
and underwent, at the same time, a similar mode of metamorphosis.
One point in respect to the original symmetrical character of the
primary veins is demonstrable—^namely, that in front of the aortic
branches the right and left brachio-cephalic veins, after joining by
a cross branch, descend separately on either side of the heart, and
enter (as two superior venae cavae) the right auricle by distinct
orifices. In some of the lower animals, this double condition of
the superior veins is constant, but in the human species the left
vein beloAV the cross branch (left brachio-cephalic) becomes
obliterated, whilst the right vein (vena cava superior) receives the
tAvo brachio-cephalic veins, and in this condition remains through¬
out life. After birth, on the commencement of respiration, the
foramen ovale of the interauricular septum closes, and the ductus
arteriosus becomes impervious. This completes the stages of
metamorphosis, and changes the course of the simple fcetal circu¬
lation to one of a more complex order—viz., the systemic-pulmonary
characteristic of the normal state in the adult body.
VIII.—Such being the phases of metamorphosis of the primary
(branchial) arches Avhich yield the vessels in their normal adult
condition, we obtain in this history an explanation of the signifi¬
cation not only of such of their anamolies as are on record, but of
such also as are potential in the law of development; a feAv of them
Avill suffice to illustrate the meaning of the whole number:—Is^.
The interventricular as Avell as the interauricular septum may be
arrested in growth, leaving an aperture in the centre of each; the
former condition is natural to the human foetus^ the latter to the
reptilian class, while both would be abnormal in the human adult.
Und. The heart may be cleft at its apex in the situation of the
interventricular septum—a condition natural to the Dugong. A
similar cleavage may divide the base of the heart in the situation
of the interauricular septum. 2)rd. The partitioning of the bulbus
arteriosus may occur in such a manner as to assign to the two
aortae a relative position, the reverse of that which they normally
occupy—^the pulmonary aorta springing from the left ventricle and
the systemic aorta arising from the right, and giving off from its
arch the primary branches in the usual order.* Ath. As the two
aortoe result from a division of the common primary vessel {bulbus
arteriosus), an arrest in the growth of the partition would leave
them still as one vessel, which (supposing the ventricular septum
remained also incomplete) would then arise from a single ventricle.
5 th. The ductus arteriosus may remain pervious, and while co-exist¬
ing with the proper aortic arch, two arches would then appear on
the left side. %th. The systemic normal aortic arch may be oblite¬
rated as far up as the innominate branch, and while the ductus
arteriosus remains pervious, and leading from the pulmonary
artery to the descending part of the aortic arch, this vessel would
then present the appearance of a branch ascending from the left side
and giving off the brachio-cephalic arteries. The right ventricular
artery would then, through the medium of the ductus arteriosus,
supply both the lungs and the system. Such a state of the vessels
Avould require, (in order that the circulation of a mixed blood
might be carried on) that the two ventricles freely communicaffi.
1th. liihB fourth arch of the right side remained pervious opposite
the proper aortic arch, there would exist two aortic arches placed
symmetrically, one on either side of the vertebral column, and,
joining below, would include in their circle the trachea and
oesophagus. %th. If the fifth arch of the right side remained per¬
vious opposite the open ductus arteriosus, both vessds would
present a similar arrangement, as two symmetrical ducti artenosi
co-existing with symmetrical aortic arches, ^th. If the vessels
appeared co-existing in the two conditions last mentioned, they
would represent four aortic arches, two on either side of the vertebral
column, mh. If the fourth right arch, instead of the fourth left
(aorta), remained pervious, the systemic aortic arch would then
be turned to the right side of the vertebral column, and have the
trachea and oesophagus on its left. 11th. When the bulbus arte¬
riosus divides itself into three parts, the two lateral pai ts, in
becoming connected with the left ventricle, will represent a double
ascending systemic aorta, and having the pulmonary artery passing
between them to the lungs, mh. When of the two original superior
venae cavce the right one instead of the left suffers metamorphosis,
the vena cava superior will then appear on the left side of the
normal aortic arch.^ Of these malformations, some are rathei
frequently met Avith, others very seldom, and others cannot exist
compatible Avith life after birth. Those which involve a more or
less imperfect discharge of the blood-aerating functions of the
lungs are in those degrees more or less fatal, and thus nature
aborting as to the fitness of her creation, cancels it.
IX.—The portal system of veins passing to the liver, and the
hepatic veins passing from this organ to join the inferior vena
cava, exhibit in respect to the median line of the body an example
of a-symmetry, since appearing on the right side, they have no
counterparts on the left. As the law of symmetry seems do pre¬
vail universally in the development of organized beings, foras¬
much as every lateral organ or part has its counterpart, Avhile
every central organ is double or complete, in having two similar
sides, then the portal system, as being an exception to this law,
is as a natural note of interrogation questioning the signification
of that fact, and in the following observations, it appears to me,
the answer may be found. Every artery in the body has its com¬
panion vein or veins. The inferior vena cava passes sidelong Avith
the aorta in the abdomen. Every branch of the aorta Avhich
ramifies upon the abdominal parietes has its accompanying vein
returning either to the vena cava or the vena azygos, and entering
either of these vessels at a point on the same level as that at which
itself arises. The renal vessels also have this arrangement. But
all the other veins of the abdominal viscera, instead of entering
the vena cava opposite their corresponding arteries, unite into a
single trunk (vena portae), which enters the liver. The special
purpose of this destination of the portal system is obvious, but
the function of a part gives no explanation of its form or relative
position, whether singular or otherAAUse. On vieAving the vessels
in presence of the general law of symmetrical development, it
occurs to me that the portal and hepatic veins form one continuous
system, which taken in the totality, represents the companion veins
of the arteries of the abdominal viscera. The liver under this
interpretation appears as a gland developed midway upon these
veins, and dismembering them into a mesh of countless capillary
vessels, (a condition necessary for all processes of secretion,) for
the special purpose of decarbonizing the blood. In this great
function the liver is an organ correlative or compensative to the
lungs, whose office is similar. The secretion of the liver (bile) is
fluidform; that of the lungs is aeriform. The bile being necessary
to the digestive process, the liver has a duct to convey that pro¬
duct of its secretion to the intestines. The trachea is as it were
* This physiological truth has, I find, been applied by Dr. R. Quain to
the explanation of a numerous class of malformations connected with the
origins of the great vessels from the heart, and of their primary branches.
See The Lancet, vol. 1. 1842.
t For an analysis of the occasional peculiarities of these primary veins in
the human subject, see an able and original monograph in the Philosophical
Transactions, Part I., 1850, entitled, “ On the Development of the Great
Anterior Veins in Man and Mammalia.” By John Marshall, F.R.C.S., &c.
CONCLUDING COMMENTARY.
the duct of the lungs. In the liver, then, the fortal and hepatic
veins being continuous as veins^ the two systems, notwithstanding
their apparent distinctness caused by the inteiwention of the
hepatic lobules, may be regarded as the veins corresponding with
the arteries of the cceliac axis, and the two mesenteric. The
hepatic artery and the hepatic veins evidently do not pair
in the sense of afferent and efferent, with respect to the liver, both
these vessels having destinations as different as those of the
bronchial artery and the pulmonary veins in the lungs. The
bronchial artery is attended by its vein proper, while the vein
which corresponds to the hepatic artery joins either the hepatic or
portal veins traversing the liver, and in this position escapes notice.*
X. — The heart, though being itself the recipient, the prime
mover, and the dispenser of the blood, does not depend either for
its growth, vitality, or stimulus to action, upon the blood under
these uses, but upon the blood circulating through vessels which
are derived from its main systemic artery, and disposed in capil¬
lary ramifications through its substance, in the manner of the
nutrient vessels of all other organs. The two corollary arteries
of the heart arise from the systemic aorta immediately outside the
semilunar valves, situated in the root of this vessel, and in pass¬
ing right and left along the auriculo-ventricular furrows, they send
off some branches for the supply of the organ itself, and others
by which both vessels antastomose freely around its base and apex.
The vasa cordis form an anastomotic circulation altogether isolated
from the vessels of the other thoracic organs, and also from those
distributed to the thoracic parietes. The coronary arteries are
accompanied by veins which open by distinct orifices (/ommma
Thebesii) into the right auricle. Like the heart itself, its main
vessels do not depend for their support upon the blood conveyed
by them, but upon that circulated by the small arteries (vasa
vasorum) derived either from the vessel upon which they are
distributed, or from some others in the neighbourhood. These
little arteries are attended by veins of a corresponding size
(venules) which enter the venae comites, thus carrying out the
general order of vascular distribution to the minutest particular.
Besides the larger nerves which accompany the main vessels, there
are delicate filaments of the cerebro-spinal and sympathetic system
distributed to their coats, for the purpose, as it is supposed, of
governing their “ contractile movements.” The vasa vasorum form
an anastomosis as well upon the inner surface of the sheath as
upon the artery contained in this part; and hence in the operation
for tying the vessel, the rule should be to disturb its connexions
as little as possible, otherwise its vitality, which depends upon
these minute branches, will, by their rupture, he destroyed in the
situation of the ligature, where it is most needed.
XI_ The branches of the systemic aorta form frequent anasto¬
moses with each other in all parts of the body. This anastomosis
occurs chiefly amongst the tn'anches of the main arteries proper to
either side. Those branches of the opposite vessels which join at
the median line are generally of very small size. There are but
few instances in which a large bloodvessel crosses the central line
from its own side to the other. Anastomosis at the median line
between opposite vessels happens either by a, fusion of their sides
lying parallel, as for example (and the only one) that of the two
vertebral arteries on the basilar process of the occipital bone; or
else by a direct end-to-end union, of which the lateral pair of cere¬
bral arteries, forming the circle of Willis, and the two labial
arteries, forming the coronary, are examples. The branches of
the main arteries of one side form numerous anastomoses in the
muscles and in the cellular and adipose tissue generally. Other
special branches derived from the parent vessel above and below
the several joints ramify and anastomose so very freely over the
surfaces of these parts, and seem to pass in reference to them out
of their direct course, that to elfect this mode of distribution
appears to be no less immediate a design than to support the
structures of which the joints are composed.
XII.— The innominate artery. When this vessel is tied, the
free direct circulation through the principal arteries of the right
arm, and the right side of the neck, head, and brain, becomes
arrested; and the degree of strength of the recurrent circulation
depends solely upon the amount of anastomosing points between
the following arteries of the opposite sides. The small terminal
branches of the two occipital, the two auricular, the two super¬
ficial temporal, and the two frontal, inosculate with each other
upon the sides, and over the vertex of the head; the two vertebral,
and the branches of the internal carotid, at the base and over the
surface of the brain; the two facial with each other, and with the
frontal above and mental below, at the median line of the face;
the two internal maxillary by their palatine, pharyngeal, menin¬
geal, and various other branches upon the surface of the parts to
which they are distributed; and lastly, the two superior thyroid
arteries inosculate around the larynx and in the thyroid body.
By these anastomoses, it will be seen that the circulation is restored
* In instancing these facts, as serving under comparison to explain how
the hepatic vessels constitute no radical exception to the law of symmetry
which presides over the development and distribution of the vascular
system as a whole, I am led to inquire in what respect (if in any) the
liver as an organ forms an exception to this general law either in shape, in
function, or in relative position. While seeing that every central organ is
single and symmetrical by the union of two absolutely similar sides, and
that each lateral pair of organs is double by the disunion of sides so similar
to each other in all respects that the description of either side serves for
the other opposite, it has long since seemed to me a reasonable inference
that, since the liver on the right has no counterpart as a liver on the left,
and that, since the spleen on the left has no counterpart as a spleen on the
right, so these two organs (the liver and spleen) must themselves corre¬
spond to each other, and as such, express their respective significations.
Under the belief that every exception (even though it be normal) to a
general law or rule, is, like the anomaly itself, alone explicable according
to such law, and expressing a fact not more singular or isolated from other
parallel facts than is one form from another, or from all others constitut¬
ing the graduated scale of being, I would, according to the light of this
evidence alone, have no hesitation in stating that the liver and spleen, as
opposites, represent corresponding organs, even though they appeared at
first view more dissimilar than they really are. In support of this analogy
of both organs, which is here, so far as I am aware, originally enunciated
for anatomical science, I record the following observations:—Isi. Between
the opposite parts of the same organic entity (between the opposite leaves
of the same plant, for example), nature manifests no such absolute diffe¬
rence in any case as exists between the leaf of a plant and of a book.
2ndly. When between two opposite parts of the same organic form there
appears any differential character, this is simply the result of a modifica¬
tion or mietamorphosis of one of the two perfectly similar originals or
archetypes, but never carried out to such an extreme degree as to annihi¬
late all trace of their analogy, ^rdly. The liver and the spleen are oppo¬
site parts; and as such, they are associated by arteries which arise by a
single trunk (cceliac axis) from the aorta, and branch right and left, like
indices pointing to the relationship between both these organs, in the
same manner as the two emulgent arteries point to the opposite renal
organs. Uhly. The liver is divided into two lobes, right and left; the left
is less than the right; that quantity which is wanting to the left lobe is
equal to the quantity of a spleen; and if in idea we add the spleen to the
left lobe of the liver, both lobes of this organ become quantitatively equal,
and the whole liver symmetrical; hence,as the liverthe spleen repre¬
sents the whole structural quantity, so the liver mmus the spleen signifies
that the two organs now dissevered still relate to each other as parts of
the same whole, bthly. The liver, as being three-fourths of the whole,
possesses the duct which emanates at the centre of all glandular bodies.
The spleen, as being one-fourth of the whole, is devoid of the duct. The
liver having the duct, is functional as a gland, while the spleen having no
duct, cannot serve any such function. If, in thus indicating the function
which the spleen does not possess, there appears no proof positive of the
function which it does, perhaps the truth is, that as being the ductless
portion of the whole original hepatic quantity, it exists as a thing degene¬
rate and functionless, for it seems that the animal economy suffers no loss
of function when deprived of it. Qtlily. In early foetal life, the left lobe of
the liver touches the spleen on the left side ; but in the process of abdominal
development, the two organs become separated from each other right and
left. Ithly. In aniinals devoid of the spleen, the liver appears of a sym¬
metrical shape, both its lobes being equal; for that quantity which in other
animals has become splenic, is in the former still hepatic, ^thly. In cases
of transposition of both organs, it is the right lobe of the liver—that nearest
the spleen, now on the right side—which is the smaller of the two lobes,
proving that whichever lobe be in this condition, the spleen, as being
opposite to it, represents the minus hepatic quantity. From these, among
other facts, I infer that the spleen is the representative of the liver on the
left side, and that as such, its signification being manifest, there exists no
exception to the law of animal symmetry. “ Tam miram uniformitatem
in planetarum systemate, necessario fatendum est intelligentia et concilio
fuisse effectam. Idemque dici possit de uniformitate ilia quae est in cor-
poribus animalium. Habent videlicet animalia pleraque omnia, bina
latera, dextrum et sinistrum, forma consimili: et in lateribus illis, a poste-
riore quidem corporis sui parte, pedes binos; ab anteriori autem parte,
binos armos, vel pedes, vel alas, humeris affixes; interqne humeros collum,
in spinam excuri'ens, cui affixum est caput; in eoque capite binas aures,
binos oculos, nasum, os et linguam ; similiter posita omnia, in omnibus
fere animalibus.”— Newton, Optices, sive de reflex, ^c. p. 411.
CONCLUDING COMMENl'ARY
to the branches of the common carotid almost solely. In regai
to the subclavian artery, the circulation would be
through the anastomosing branches of the two inferior t yioi
the thyroid body; of the two vertebral, in the cranium an upon
the cervical vertebra; of the two internal mammary, each
other behind the sternum, and ivith the thoracic branches o ^
axillary and the superior intercostal laterally; lastly, throug e
anastomosis of the ascending cervical with the descending branc i
of the occipital, and with the small lateral offsets of the vertebra .
JAll.—The common carotid arteries. Of these two vesse s, e
left one arising, in general, from the arch of the aorta, is longer
than the right one by the measure of the innominate artery Torn
which the right arises. When either of the common carotids is
tied, the circulation will be maintained through the anastomosing
branches of the opposite vessels as above specified. r
vertebral or the inferior thyroid branch arises from the middle o
the common carotid, this vessel will have an additional^ source o
supply if the ligature be applied to it below the origin of such
branch. In the absence of the innominate artery, the right as
well as the left carotid will be found to spring directly from the
XIV.- The subclavian arteries. When a ligature is applied to
the inner third, of this vessel within its primary branches, the
collateral circulation is carried on by the anastomoses of the arte¬
ries above mentioned; but if the vertebral or the inferior thyroid
arises either from the aorta or the common carotid, the sources of
arterial supply in respect to the arm will, of course, be less nume¬
rous. When the outer portion of the subclavian is tied between
the scalenus and the clavicle, while the branches arise from its
inner part in their usual position and number, the collateral circu¬
lation in reference to the arm is maintained by the following anas¬
tomosing branches:—viz. those of the superficialis cdli, and the
supra and posterior scapular, with those of the acromial thoracic;
the subscapular, and the anterior and posterior circumflex around
the shoulder-joint, and over the dorsal surface of the scapula; and
those of the internal mammary and superior intercostal, with
those of the thoracic arteries arising from the axillary. What¬
ever be the variety as to their mode or place of origin, the
branches emanating from the subclavian artery are constant as to
their destination. The length of the inner portion of the right
subclavian will vary according to the place at which it arises,
whether from the innominate artery, from the ascending, or from
the descending part of the aortic arch.
XT.—The axillary artery. As this vessel gives off throughout
its Avhole length, numerous branches which inosculate principally
with the scapular, mammary, and superior intercostal branches
of the subclavian, it will be evident that, in tying it above its
own branches, the anastomotic circulation will with much greater
freedom be maintained in respect to the arm, than if the ligature
be apphed below those branches. Hence, therefore, when the
axillary artery is affected with aneurism, thereby rendering it
unsafe to apply a ligature to this vessel, it becomes not only
pathologically, but anatomically, the more prudent measure to
tie the subclavian immediately above the clavicle.
XVI.— The brachial artery. When this artery is tied imme¬
diately below the axilla, the collateral circulation will be weakly
maintained, in consequence of the small number of anastomosing
branches arising from it above and below the seat of the ligature.
The two circumflex humeri alone send down branches to inoscu¬
late with the small muscular offsets from the middle of the
brachial artery. When tied in the middle of the arm between the
origins of the superior and inferior profunda arteries, the collateral
circulation will depend chiefly upon the anastomosis of the former
vessel with the recurrent branch of the radial, and of muscular
branches with each other. When the ligature is applied to the
lower third of the vessel, the collateral circulation will be compa¬
ratively free through the anastomoses of the two profundi and
and anastomotic branches with the radial, interosseous,, and ulnar
recurrent branches. If the artery happen to divide in the upper
part of the arm into either of the branehes of the forearm, or into
all three, a ligature applied to any one of them will, of course, be
insufficient to arrest the direct circulation through the forearm, if
this be the object in view.
XVII.— The- radial artery. If this vessel be tied in any part of
Un+or.o1 rirculation will depend principally upon
its course, t e co - i,g^.^veen it and the ulnar, through the
the free deep palmar arches and those of
rci:-s« -MX? •”"
this vessel is tied the colla.
teral circulation will depend upon the anastomosis of the pa mar
arches as in the case last mentioned. While the radial, ulnai,
and interosseous arteries spring from the same mam vessel, and
are continuous with each other in the hand they represent th
condition of a circle of which, when either side is tied, the blood
°n pass in a current of almost equal strength towards the sea o
rhe 4atu- from above and below-a circumstance which renders
it necessary to tie both ends of the vessel in cases of wounds.
XIX -Tl^e common iliac artery. When a ligature is apphed
to the middle of this artery, the direct circulation becomes arrested
in the lower limb and side of the pelvis corresponding to the
vessel operated on. The collateral circulation will then be carried
on by the anastomosis of the following branches-viz., those of
the lumbar, the internal mammary, and the epigastric arteries of
that side with each other, and with their fellows in the anterior
abdominal parietes; those of the middle and lateral sacra ; those
of the superior with the middle and inferior hiemorrhoidal; those
of the aortic and internal iliac uterine branches in the female;
and of the aortic and external iliac spermatic branches m the
male The anastomoses of these arteries with their opposite
fellows along the median line, are much less frequent than those
of the arteries of the neck and head.
XX._ The external iliac artery. This vessel, when tied at its
middle* will have its collateral circulation carried on by the anas¬
tomoses of the internal mammary ivith the epigastric; by those
of the ilio-lumbar with the circumflex ilii; those of the internal
circumflex femoris, and superior perforating arteries of the pro¬
funda femoris, with the obturator, when this branch arises from
the internal iliac; those of the gluteal with the external circum¬
flex; those of the latter with the sciatic; and those of both obtu¬
rators, with each other, when arising—the one from the internal,
the other from the external iliac. Not unfrequently either tlie
epigastric, obturator, ilio-lumbar, or circumflex ilii, arises from
the middle of the external iliac, in which case the ligature should
be placed above such branch.
Xll.—The common femoral artery. On considering the circles
of inosculation formed around the innominate bone between Uie
branches derived from the iliac arteries near the sacro-iliac
junction, and those emanating from the common femoral, above
and below Poupart’s ligament, it will at once appear that, in
respect to the lower limb, the collateral circulation will occur more
freely if the ligature be applied to the main vessel (external iliac)
than if to the common femoral below its branches.
XXII.—77te superficial femoral -artery. When a ligature is
applied to this vessel at the situation where it is overlapped by
the sartorius muscle, the collateral circulation will be maintained
by the following arteriesthe long descending branches of Uie
external circumflex beneath the rectus muscle, inosculate with
the muscular branches of the anastomotica magna springing from
the lower third of the main vessel; the three perforating branches
of the profunda inosculate with the latter vessel, with the sciatic, and
with the articular and muscular branches around the knee-joint.
XXIII.— The popliteal artery. When any circumstance ren¬
ders it necessary to tie this vessel in preference to the femoral,
the ligature should be placed above its upper pair of articular
branches; for by so doing a freer collateral circulation Avill take
place in reference to the leg. The ligature in this situation will
lie between the anastomotic and articular arteries, which freely
communicate with each other.
XXIV_ The anterior and posterior tibial and peronceal arteries.
As these vessels correspond to the arteries of the forearm, the
observations which apply to the one set apply also to the other.*
* For a complete history of the general vascular system, see The Ana¬
tomy of the Arteries of the Human Body, by Richard Quain, F.R.S., &c., in
which work, besides the results of the author’s own great experience and
original observations, will be found those of Haller’s, Scarpa’s, Tiede-
mann’s, &c., systematically arranged with a view to operative surgery.