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+The Project Gutenberg eBook of Surgical Anatomy

+    

+This ebook is for the use of anyone anywhere in the United States and

+most other parts of the world at no cost and with almost no restrictions

+whatsoever. You may copy it, give it away or re-use it under the terms

+of the Project Gutenberg License included with this ebook or online

+at www.gutenberg.org. If you are not located in the United States,

+you will have to check the laws of the country where you are located

+before using this eBook.

+

+Title: Surgical Anatomy

+

+Author: Joseph Maclise

+

+Release date: January 28, 2008 [eBook #24440]

+                Most recently updated: October 22, 2023

+

+Language: English

+

+Credits: Produced by Don Kostuch

+

+

+*** START OF THE PROJECT GUTENBERG EBOOK SURGICAL ANATOMY ***

+

+

+

+

+[Transcriber's Notes]

+

+Thanks to Carol Presher of Timeless Antiques, Valley, Alabama,  for

+lending the original book for this production. The 140 year old binding

+had disintegrated, but the paper and printing was in amazingly good

+condition, particularly the multicolor images.

+

+Thanks also to the Mayo Clinic. This book has increased my appreciation

+of their skilled care of my case by showing the many ways that things

+could go wrong.

+

+Footnotes are indicated by "[Footnote]" where they appear in the text.

+The body of the footnote appears immediately following the complete

+paragraph. If more than one footnote appears in the same paragraph, they

+are numbered.

+

+A few obvious misspellings have been corrected. Several cases of

+alternate spelling of the same(?) word have not been modified.

+

+Pages have been reorganized to avoid splitting sentences and paragraphs.

+Each image is inserted immediately following its description.

+

+Some of the plates did not fit on the scanner and were captured as two

+separate images. The merged images show some artifacts of the merge

+process due to slightly different lighting of the page. The contrast and

+gamma values have been adjusted to restore the images.

+

+Here are the definitions of some words used in the text. Medical terms

+are defined only relating to humans. Words are omitted that have

+ambiguous or technical meanings not expressible in lay language.

+

+

+acromial (acromion)

+  Outward end of the spine of the scapula or shoulder blade.

+

+adipose

+  Consisting of, resembling, or relating to fat.

+

+anasarca

+  Pronounced, generalized edema; accumulation of serous fluid in various

+  tissues and cavities of the body.

+

+anastomosing (anastomoses, anastomosis)

+  Communication between blood vessels by means of collateral channels,

+  when usual routes are obstructed. Opening between two organs or spaces

+  that normally are not connected.

+

+aneurism

+  Localized blood-filled dilatation of a blood vessel caused by disease

+  or weakening of the vessel's wall.

+

+anthropotomist (anthropotomy)

+  One versed in human anatomy.

+

+aorta (aortic)

+  Main trunk of the arterial system, conveying blood from the left

+  ventricle of the heart to all of the body except the lungs.

+

+apices (plural of apex)

+  Pointed end of an object; the tip.

+

+aponeurosis

+  Sheet-like fibrous membrane, resembling a flattened tendon, that

+  serves as a fascia to bind muscles together or as a means of

+  connecting muscle to bone.

+

+armamentaria

+  Complete equipment of a physician or medical institution, including

+  books, supplies, and instruments.

+

+auscultation

+  Listening, either directly or through a stethoscope or other

+  instrument, to sounds within the body as a method of diagnosis.

+

+axilla (axillary)

+  Armpit.

+

+azygos

+  Occurring singly; not one of a pair.

+

+bifid

+  Separated or cleft into two equal parts or lobes.

+

+biliary

+  Relating to bile, the bile ducts, or the gallbladder; transporting

+  bile.

+

+bistoury

+  Long, narrow surgical knife for minor incisions.

+

+bougie

+  Slender, flexible instrument introduced into body passages, to dilate,

+  examine, or medicate.

+

+brachial (brachio)

+  Belonging to the arm.

+

+bubonocele

+  Inguinal hernia, in which the protrusion of the intestine is limited

+  to the region of the groin.

+

+cannula

+  Metal tube for insertion into the body to draw off fluid or to

+  introduce medication.

+

+carotid

+  Two large arteries, one on each side of the head.

+

+cephalic

+  Relating to the head.

+

+cervical

+  Pertaining to the neck.

+

+chlorotic

+  Benign iron-deficiency anemia in adolescent girls, marked by a pale

+  yellow-green complexion.

+

+clavicle

+  Either of two slender bones extending from the upper part of the

+  sternum (breastbone) to the shoulder.

+

+coaptation

+  Joining together of two surfaces, such as the edges of a wound or the

+  ends of a broken bone.

+

+condyle

+  Smooth surface area at the end of a bone, forming part of a joint.

+

+costal

+  Pertaining to the ribs or the upper sides of the body.

+

+cremaster

+  Suspensory muscle of the testis.

+

+crural

+  Relating to the leg or thigh.

+

+director

+  A smoothly grooved instrument used with a knife to limit the incision

+  of tissues.

+

+distal

+  Situated away from the point of origin or attachment.

+

+dropsy (dropsical) (edema)

+  Swelling from excessive accumulation of watery fluid in cells,

+  tissues, or serous cavities

+

+emphysema

+  Chronic, irreversible disease of the lungs; abnormal enlargement of

+  air spaces in the lungs accompanied by destruction of the tissue

+  lining the walls of the air spaces.

+

+emunctory

+  Organ or duct that removes or carries waste from the body.

+

+epigastric (epigastrium)

+  Upper middle region of the abdomen.

+

+episternal

+  See sternum.

+

+esophagus

+  See oesophagus.

+

+euphoneously (euphoniously)

+  Pleasant in sound; agreeable to the ear;

+

+exigence

+  Urgency, need, demand, or requirement intrinsic to a circumstance.

+

+extravasation

+  Exuding or passing out of a vessel into surrounding tissues; said of

+  blood, lymph or urine

+

+fascia

+  A band of connective tissue supporting, or binding together internal

+  organs or parts of the body.

+

+femoral

+  Pertaining to, or situated at, in, or near the thigh or femur.

+

+fistula

+  Abnormal duct or passage resulting from injury, disease, or a

+  congenital disorder that connects an abscess, cavity, or hollow organ

+  to the body surface or to another hollow organ.

+

+foramen (foramina)

+  Opening, orifice, or short passage, as in a bone.

+

+fossa (fossae)

+  Small cavity or depression, as in a bone.

+

+hepatic

+  Pertaining to the liver.

+

+herniae (hernia)

+  Protrusion of an organ or tissue through an opening in its surrounding

+  walls, especially in the abdomen.

+

+humerus

+  Bone in the arm of humans extending from the shoulder to the elbow.

+

+hydragogue

+  Cathartics that aid in the removal of edematous fluids and thus

+  promote the discharge of watery fluid from the bowels.

+

+hydrocele

+  An accumulation of serous fluid, usually about the testis.

+

+hydrops

+  See dropsy. Edema.

+

+iliac artery

+  Common iliac artery--either of two large arteries that conduct blood

+  to the pelvis and the legs. External iliac artery--the outer branch of

+  an iliac artery that becomes the femoral artery. Hypogastric

+  artery--internal iliac artery; the inner branch of an iliac artery

+  that conducts blood to the gluteal region.

+

+infundibuliform

+  Shaped like a funnel.

+

+inguinal

+  Relating to, or located in the groin.

+

+innominate

+  Designated parts otherwise unnamed; as, the innominate artery, a great

+  branch of the arch of the aorta; the innominate vein, a great branch

+  of the superior vena cava.

+

+inosculate

+  Unite by openings; connect or join so as to become or make continuous,

+  as fibers; blend, unite intimately

+

+integument

+  Natural covering, coating, enclosure, etc., as a skin, shell, or rind.

+

+laryngotomy

+  Cutting into the larynx, from the outside of the neck, to assist

+  respiration, or to remove foreign bodies.

+

+ligature

+  Thread or wire for constriction of blood vessels or for removing

+  tumors by strangulation.

+

+lithotomy

+  Surgery to remove one or more stones from an organ or duct.

+

+meatus

+  Body opening such as the opening of the ear or the urethral canal.

+

+metamorphosis

+  Profound change in form from one stage to the next, as from the

+  caterpillar to the pupa and from the pupa to the adult butterfly.

+

+micturition

+  Passing urine; urination.

+

+

+nares (naris)

+  Nostrils or the nasal passages.

+

+nisus

+  Effort or endeavor to realize an aim.

+

+occiput

+  Back part of the head or skull.

+

+oesophagus (esophagus)

+  Muscular membranous tube for the passage of food from the pharynx to

+  the stomach.

+

+osseous

+  Bone, bony;

+

+palmar

+  Pertaining to, or located in the palm of the hand.

+

+paracentesis

+  Puncture of the wall of a cavity to drain off fluid.

+

+parietes

+  Wall of a body part, organ, or cavity.

+

+parotid

+  Salivary gland situated at the base of each ear; near the ear.

+

+percussion

+  Striking or tapping the surface the body for diagnostic or therapeutic

+  purposes.

+

+pericardii (pericardium)

+  A double membranous sac protecting the heart. The layer in contact

+  with the heart is referred to as the visceral layer, the outer layer

+  in contact with surrounding organs is the parietal pericardium.

+

+peritoneum (peritonaeum)

+  Serous membrane that lines the walls of the abdominal cavity and folds

+  inward to enclose the viscera.

+

+pharynx (pharyngeal)

+  The cavity, with its surrounding membrane and muscles, that connects

+  the mouth and nasal passages with the esophagus.

+

+physiology (physiologist)

+  Biological study of the functions of living organisms and their parts.

+

+platysma

+  Broad, thin muscle on each side of the neck, from the upper part of

+  the shoulder to the corner of the mouth. They wrinkle the skin of the

+  neck and depresses the corner of the mouth.

+

+pleura

+  Thin serous membrane in mammals that envelops each lung and folds back

+  to make a lining for the chest cavity.

+

+pleuritic (pleurisy)

+  Inflammation of the pleura, often as a complication of a disease such

+  as pneumonia, accompanied by accumulation of fluid in the pleural

+  cavity, chills, fever, and painful breathing and coughing.

+

+plexus

+  Network, as of nerves or blood vessels.

+

+pneumothorax

+ Air or gas in the pleural cavity.

+

+popliteal

+  Relating to the hollow part of the leg behind the knee joint.

+

+probang

+  Long, slender, elastic rod with a sponge at the end. It is introduced

+  into the esophagus or larynx to remove foreign bodies or introduce

+  medication.

+

+pudic

+  Pertaining to the external organs of generation.

+

+pyriform

+  Shaped like a pear.

+

+radius

+  Bone of the forearm on the thumb side. (See ulnar)

+

+ramus

+  A branch, as of a nerve, or blood vessel.

+

+raphe

+  Seamlike union between two parts or halves of an organ.

+

+ratiocination

+  Logical reasoning.

+

+sacculated

+  Formed with or having saclike expansions.

+

+scirrhus

+  Hard dense cancerous growth usually arising from connective tissue.

+

+septa

+  Thin partition dividing two cavities or soft masses of tissue.

+

+sternum

+  Bones extending along the middle line of the ventral portion of the

+  body of most vertebrates, consisting in humans of a flat, narrow bone

+  connected with the clavicles and the true ribs; breastbone.

+

+stricture

+  Abnormal narrowing of a duct or passage.

+

+subclavian

+  Beneath the clavicle.

+

+submaxillary

+  Pertaining to the lower jaw.

+

+sui generis

+  The only example of its kind; a class of its own; unique

+

+superficies

+  Outward appearance.

+

+sutural

+  Junction of two bones.

+

+symphysis

+  Growing together, or the fixed or nearly fixed union, of bones.

+

+taxis

+  Replacing of a displaced part, or the reducing of a hernia, by

+  manipulation without cutting.

+

+tegument (tegumentary, integument)

+  Natural outer covering.

+

+thorax (thoracic)

+  Trunk between the neck and the abdomen, containing the cavity enclosed

+  by the ribs, sternum, and certain vertebrae, containing the heart,

+  lungs, etc.; chest.

+

+trachea (tracheal)

+  Tube descending from the larynx to the bronchi and carrying air to the

+  lungs. Windpipe.

+

+trephine (trephining)

+  Small circular saw with a center pin mounted on a strong hollow metal

+  shaft, used to remove circular disks of bone from the skull.

+

+trocar

+  Sharp-pointed instrument enclosed in a cannula, used for withdrawing

+  fluid from a cavity, as the abdominal cavity.

+

+tunica vaginalis

+  Pouch of serous membrane covering the testis and derived from the

+  peritoneum.

+

+venesection (venisection, phlebotomy)

+  Opening a vein by incision or puncture to remove blood as a

+  therapeutic treatment.

+

+viz.

+  Contraction of  the Latin "videre licet" meaning "it is permissible to

+  see," The -z- is not a letter, but originally a twirl, representing

+  the symbol for the ending -et. Usually read as "namely."

+

+ulnar

+  Bone of the forearm on the side opposite to the thumb. (See radius)

+

+[End Transcriber's Notes]

+

+

+

+

+SURGICAL ANATOMY

+

+BY

+JOSEPH MACLISE

+

+FELLOW OF THE ROYAL COLLEGE OF SURGEONS.

+

+WITH SIXTY-EIGHT COLOURED PLATES.

+

+PHILADELPHIA:

+BLANCHARD AND LEA.

+1859.

+

+

+

+

+I INSCRIBE THIS WORK TO THE GENTLEMEN

+WITH WHOM AS A FELLOW-STUDENT I WAS ASSOCIATED AT THE

+London University College:

+

+AND IN AN ESPECIAL MANNER, IN THEIR NAME AS WELL AS MY OWN,

+I AVAIL MYSELF OF THE OPPORTUNITY TO RECORD, ON THIS PAGE,

+ALBEIT IN CHARACTERS LESS IMPRESSIVE THAN THOSE WHICH ARE

+WRITTEN ON THE LIVING TABLET OF MEMORY,

+THE DEBT OF GRATITUDE WHICH WE OWE TO THE LATE

+

+SAMUEL COOPER, F.R.S., AND ROBERT LISTON, F.R.S.,

+

+TWO AMONG THE MANY DISTINGUISHED PROFESSORS OF THAT

+INSTITUTION, WHOSE PUPILS WE HAVE BEEN,

+AND FROM WHOM WE INHERIT THAT BETTER POSSESSION THAN LIFE

+ITSELF, AN ASPIRATION FOR THE LIGHT OF SCIENCE.

+

+JOSEPH MACLISE.

+

+

+

+PREFACE.

+

+The object of this work is to present to the student of medicine and the

+practitioner removed from the schools, a series of dissections

+demonstrative of the relative anatomy of the principal regions of the

+human body. Whatever title may most fittingly apply to a work with this

+intent, 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 wherever a 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 animal body,

+is almost wholly isolated from the main questions of physiological and

+transcendental interest, and cannot, therefore, be supposed to speak in

+those comprehensive views which anatomy, taken in its widest

+signification as a science, necessarily includes. While the anatomist

+contents himself with 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

+to the whole design of the form or machine of whatever species this may

+be, whether organic or inorganic. The descriptive anatomist of the human

+body aims at no higher walk in science than this, and hence his

+nomenclature is, as it is, a barbarous jargon of words, barren of all

+truthful signification, inconsonant with nature, and blindly

+irrespective of the cognitio certa ex principiis certis exorta.

+

+Still, however, this anatomy of form, although so much requiring

+purification of its nomenclature, in order to clothe it in the high

+reaching dignity of a science, does not disturb the medical or surgical

+practitioner, so far as their wants are concerned. Although it may, and

+actually does, trammel the votary who aspires to the higher

+generalizations and the development of a law of formation, yet, as this

+is not the object of the surgical anatomist, the nomenclature, such as

+it is, will answer conveniently enough the present purpose.

+

+The anatomy of the human form, contemplated in reference to that of all

+other species of animals to which it bears comparison, constitutes the

+study of the comparative anatomist, and, as such, establishes the

+science in its full intent. But the anatomy of the human figure,

+considered as a species, per se, is confessedly the humblest walk of the

+understanding in a subject which, as anatomy, is relationary, and

+branches far and wide through all the domain of an animal kingdom. While

+restricted to the study of the isolated human species, the cramped

+judgment wastes in such narrow confine; whereas, in the expansive gaze

+over all allying and allied species, the intellect bodies forth to its

+vision the full appointed form of natural majesty; and after having

+experienced the manifold analogies and differentials of the many, is

+thereby enabled, when it returns to the study of the one, to view this

+one of human type under manifold points of interest, to the appreciation

+of which the understanding never wakens otherwise. If it did not happen

+that the study of the human form (confined to itself) had some practical

+bearing, such study could not deserve the name of anatomical, while

+anatomical means comparative, and whilst comparison implies inductive

+reasoning.

+

+However, practical anatomy, such as it is, is concerned with an exact

+knowledge of the relationship of organs as they stand in reference to

+each other, and to the whole design of which these organs are the

+integral parts. The figure, the capacity, and the contents of the

+thoracic and abdominal cavities, become a study of not more urgent

+concernment to the physician, than are the regions named cervical,

+axillary, inguinal, &c., to the surgeon. He who would combine both modes

+of a relationary practice, such as that of medicine and surgery, should

+be well acquainted with the form and structures characteristic of all

+regions of the human body; and 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 acquainted with the subject matter of both. It is, 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 will 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 subject, will

+always be found to pursue the speciality according to the light of

+reason and science.

+

+Anatomy--the [Greek words], the knowledge based on principle--is the

+foundation of the curative art, cultivated as a science in all its

+branchings; and comparison is the nurse of reason, which we are fain to

+make our guide in bringing the practical to bear productively. 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 well as in those of the philosophic generalizer of anatomical facts,

+gathered through the extended survey of an animal kingdom. We 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 a knowledge of what we know to be normal

+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 laid particular emphasis on imitating

+the character of the normal form of the human figure, taken as a whole;

+that of its several regions as parts of this whole, and that of the

+various organs (contained within those regions) as its integrals or

+elements. And in order to present this subject of relative anatomy in

+more vivid reality to the understanding of the student, I have chosen

+the medium of illustrating by figure rather than by that of written

+language, which latter, taken alone, is almost impotent in a study of

+this nature.

+

+It is wholly impossible for anyone to describe form in words without the

+aid of figures. Even the mathematical strength of Euclid would avail

+nothing, if shorn of his diagrams. The professorial robe is impotent

+without its diagrams. Anatomy being a science existing by demonstration,

+(for as much as form in its actuality is the language of nature,) must

+be discoursed of by the instrumentality of figure.

+

+An anatomical illustration enters the understanding straight-forward 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

+an axiom encompassed in a frame-work of self-evident truth. The best

+substitute for Nature herself, upon which to 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

+reality of form and figure. Scarpa was his own draughtsman.

+

+If there may be any novelty now-a-days possible to be recognised upon

+the out-trodden track of human relative anatomy, it can only be in

+truthful and well-planned illustration. Under this view alone may the

+anatomist plead an excuse for reiterating a theme which the beautiful

+works of Cowper, Haller, Hunter, Scarpa, Soemmering, and others, have

+dealt out so respectably. Except the human anatomist turns now to what

+he terms the practical ends of his study, and marshals his little

+knowledge to bear upon those 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,

+Muller has completed 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. All 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 Fontenelle, "que l'on

+joindra en un corps regulier ces membres epars; et, s'ils sont tels

+qu'on le souhaite, ils s'assembleront en quelque sorte d'eux-memes.

+Plusieurs verites separees, des qu'elles sont en assez grand nombre,

+offrent si vivement a l'esprit leurs rapports et leur mutuelle

+dependance, qu'il semble qu'apres les avoir detachees par une espece de

+violence les unes des autres, elles cherchent naturellement a se

+reunir."--(Preface sur l'utilite des Sciences, &c.)

+

+The comparison of facts already known must henceforward be the scalpel

+which we are to take in hand. We must return by the same road on which

+we set out, and reexamine the things and phenomena which, as novices, we

+passed by too lightly. The travelled experience may now sit down and

+contemplate.

+

+That which I have said and proved elsewhere in respect to the skeleton

+system may, with equal truth, be remarked of the nervous system--namely,

+that the question is not in how far does the limit of diversity extend

+through the condition of an evidently common analogy, but by what rule

+or law the uniform ens is rendered the diverse entity? The womb of

+anatomical science is pregnant of the true interpretation of the law of

+unity in variety; but the question is of longer duration than was the

+life of the progenitor. Though Aristotle and Linnaeus, and Buffon and

+Cuvier, and Geoffroy St. Hilaire and Leibnitz, and Gothe, have lived and

+spoken, yet the present state of knowledge proclaims the Newton of

+physiology to be as yet unborn. 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 narrow

+range of a subject, perceives herself to be imprisoned, and quenches her

+guiding light in despair. Originality has outlived itself; and discovery

+is a long-forgotten enterprise, except as pursued in the microcosm on

+the field of the microscope, which, it must be confessed, has drawn

+forth demonstrations only commensurate in importance with the magnitude

+of the littleness there seen.

+

+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 Promethean 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, ever to

+hope to reveal any great truth for science, and dispel the mists which

+still hang over the phenomena of the nervous system. He is steeped too

+deeply in the base nomenclature of the antique school, and too indolent

+to question the import of Pons, Commissure, Island, Taenia, Nates,

+Testes, Cornu, Hippocamp, Thalamus, Vermes, Arbor Vitro, 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 him 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 realised at the Ecole Pratique, and School of Anatomy

+adjoining the Hospital La Pitie, 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 endeavoured to give it.

+

+The unbroken surface of the human figure is as a map to the surgeon,

+explanatory of the anatomy arranged beneath; and I have therefore left

+appended to the dissected regions as much of the undissected as was

+necessary. My object was to indicate the interior through the

+superficies, and thereby illustrate the whole living body which concerns

+surgery, through its dissected dead counterfeit. We dissect the dead

+animal body in order to furnish the memory with as clear an account of

+the structure contained in its living representative, which we are not

+allowed to analyse, as if this latter were perfectly translucent, and

+directly demonstrative of its component parts.

+

+J. M

+

+

+

+TABLE OF CONTENTS.

+

+PREFACE

+

+INTRODUCTORY TO THE STUDY OF ANATOMY AS A SCIENCE.

+

+COMMENTARY ON PLATES 1 & 2

+

+THE FORM OF THE THORAX, AND THE RELATIVE POSITION OF ITS

+CONTAINED PARTS--THE LUNGS, HEART, AND LARGER BLOOD VESSELS.

+

+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.

+

+

+COMMENTARY ON PLATES 3 & 4

+

+THE SURGICAL FORM OF THE SUPERFICIAL, CERVICAL, AND FACIAL

+REGIONS, AND THE RELATIVE POSITION OF THE PRINCIPAL BLOOD

+VESSELS, 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.

+

+

+COMMENTARY ON PLATES 5 & 6

+

+THE SURGICAL FORM OF THE DEEP CERVICAL AND FACIAL REGIONS,

+AND THE RELATIVE POSITION OF THE PRINCIPAL BLOOD VESSELS,

+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.

+

+

+COMMENTARY ON PLATES 7 & 8

+

+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. Relative 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. Reasons of

+the unfavourable results of this proceeding.

+

+

+COMMENTARY ON PLATES 9 & 10

+

+THE SURGICAL DISSECTION OF THE EPISTERNAL OR TRACHEAL

+REGION, AND THE RELATIVE POSITION OF ITS MAIN BLOOD VESSELS,

+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.

+

+

+COMMENTARY ON PLATES 11 & 12

+

+THE SURGICAL DISSECTION OF THE AXILLARY AND BRACHIAL

+REGIONS, DISPLAYING THE RELATIVE POSITION OF THEIR CONTAINED PARTS.

+

+The operation for tying the axillary artery. Remarks 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.

+

+

+COMMENTARY ON PLATES 13 & 14

+

+THE SURGICAL FORMS OF THE MALE AND FEMALE AXILLAE

+COMPARED.

+

+The mammary and axillary glands in health and disease. Excision of these

+glands. Axillary abscess. General surgical observations on the axilla.

+

+

+COMMENTARY ON PLATES 15 & 16

+

+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.

+

+

+COMMENTARY ON PLATES 17, 18, & 19

+

+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.

+

+

+COMMENTARY ON PLATES 20 & 21.

+

+THE RELATIVE POSITION OF THE CRANIAL, NASAL,

+ORAL, AND PHARYNGEAL CAVITIES, ETC.

+

+Fractures of the cranium, and the operation of trephining anatomically

+considered. Instrumental measures in reference to the fauces, tonsils,

+oesophagus, and lungs.

+

+

+COMMENTARY ON PLATE 22

+

+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. Physiological remarks on wounds of the thorax and on

+pleuritic effusion. Symmetry of the organs, &c.

+

+

+COMMENTARY ON PLATE 23

+

+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. Relative capacity of the thorax and abdomen as influenced by the

+motions of the diaphragm. Abdominal respiration. Physical causes of

+abdominal herniae. Enlarged liver as affecting the capacity of the

+thorax and abdomen. Physiological remarks on wounds of the lungs.

+Pneumothorax, emphysema, &c.

+

+

+COMMENTARY ON PLATE 24

+

+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.

+Paracentesis 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.

+

+

+COMMENTARY ON PLATE 25

+

+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

+conditions. Varieties as to the length of these arteries considered

+surgically. Measurements of the abdomen and thorax compared.

+Anastomosing branches of the thoracic and abdominal parts of the aorta.

+

+

+COMMENTARY ON PLATE 26

+

+THE RELATION OF THE INTERNAL PARTS TO THE EXTERNAL SURFACE.

+

+In health and disease. Displacement of the lungs from pleuritic

+effusion. Paracentesis thoracis. Hydrops pericardii. Puncturation.

+Abdominal and ovarian dropsy as influencing the position of the viscera.

+Diagnosis of both dropsies. Paracentesis abdominis. Vascular

+obstructions and their effects.

+

+

+COMMENTARY ON PLATE 27

+

+THE SURGICAL DISSECTION OF THE SUPERFICIAL PARTS AND

+BLOODVESSELS OF THE INGUINO-FEMORAL REGION.

+

+Physical causes of the greater frequency of inguinal and femoral

+herniae. The surface considered in reference to the subjacent parts.

+

+

+COMMENTARY ON PLATES 28 & 29

+

+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 PLATES 30 & 31

+

+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 PLATES 32, 33, & 34

+

+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 herniae in the female.

+

+

+COMMENTARY ON PLATES 35, 36, 37, & 38

+

+THE DISTINCTIVE DIAGNOSIS BETWEEN EXTERNAL AND INTERNAL

+INGUINAL HERNIAE, THE TAXIS, SEAT OF STRICTURE, AND THE OPERATION.

+

+Both herniae 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 PLATES 39 & 40

+

+DEMONSTRATIONS OF THE NATURE OF CONGENITAL AND

+INFANTILE INGUINAL HERNIAE, 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 PLATES 41 & 42

+

+DEMONSTRATIONS OF THE ORIGIN AND PROGRESS

+OF INGUINAL HERNIAE 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 PLATES 43 & 44

+

+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 PLATES 45 & 46

+

+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 performing 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 47

+

+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.

+Ligature of the external iliac artery according to the seat of aneurism.

+

+

+COMMENTARY ON PLATES 48 & 49

+

+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 peritonaeum. Neck of the bladder. The prostate.

+Puncturation of the bladder by the rectum. The pudic artery.

+

+

+COMMENTARY ON PLATES 50 & 51

+

+THE SURGICAL DISSECTION OF THE SUPERFICIAL

+STRUCTURES OF THE MALE PERINAEUM.

+

+Remarks on the median line. Congenital malformations. Extravasation of

+urine into the sac of the superficial fascia. Symmetry of the parts.

+Surgical boundaries of the perinaeum. Median and lateral important parts

+to be avoided in lithotomy, and the operation for fistula in ano.

+

+

+COMMENTARY ON PLATES 52 & 53

+

+THE SURGICAL DISSECTION OF THE DEEP STRUCTURES OF THE MALE

+PERINAEUM; 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 perinaeum.

+General rules for lithotomy.

+

+

+COMMENTARY ON PLATES 54, 55, & 56

+

+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 PLATES 57 & 58

+

+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 PLATES 59 & 60.

+

+THE VARIOUS FORMS AND POSITIONS OF STRICTURES AND OTHER

+OBSTRUCTIONS OF THE URETHRA; FALSE PASSAGES; ENLARGEMENTS

+AND DEFORMITIES OF THE PROSTATE.

+

+General remarks. Different forms of the organic stricture. Coexistence

+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.

+

+

+COMMENTARY ON PLATES 61 & 62

+

+DEFORMITIES 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 PLATES 63 & 64

+

+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 PLATES 65 & 66.

+

+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 PLATES 67 & 68.

+

+THE SURGICAL DISSECTION OF THE ANTERIOR CRURAL REGION;

+THE ANKLES AND THE FOOT.

+

+Varieties of the anterior and posterior tibial and the peronaeal

+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 permanent

+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 reference 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.

+

+[End Table of Contents]

+

+

+

+COMMENTARY ON PLATES 1 & 2.

+

+THE FORM OF THE THORACIC CAVITY, AND THE POSITION OF THE LUNGS,

+HEART, AND LARGER BLOODVESSELS.

+

+In the human body there does not exist any such space as cavity,

+properly so called. Every space is occupied by its contents. The

+thoracic space is completely filled by its viscera, which, in mass, take

+a perfect cast or model of its interior. The thoracic viscera lie so

+closely to one another, that they respectively 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. The thoracic apparatus causes

+no vacuum by the acts of either contraction or dilatation. Neither do

+the lungs or the heart. When any organ, by its process of growth, or by

+its own functional act, forces a space for itself, it immediately

+inhabits that space entirely at the expense of neighbouring organs. When

+the heart dilates, the pulmonary space contracts; and when the thoracic

+space increases, general space diminishes in the same ratio.

+

+The mechanism of the functions of respiration and circulation consists,

+during the life of the animal, in a constant oscillatory nisus to

+produce a vacuum which it never establishes. These vital forces of the

+respiratory and circulatory organs, so characteristic of the higher

+classes of animals, are opposed to the general forces of surrounding

+nature. The former vainly strive to make exception to the irrevocable

+law, that "nature abhors a vacuum." This act of opposition between both

+forces constitutes the respiratory act, and thus the respiratory

+thoracic being (like a vibrating pendulum) manifests respiratory motion,

+not as an effort of volition originating solely with itself, but

+according to the measure of the force of either law; as entity is

+relationary, so is functionality likewise. The being is functional by

+relationship; and just as a pendulum is functional, by reason of the

+counteraction of two opposing forces,--viz., the force of motion and the

+force of gravity,--so is a thoracic cavity (considering it as a

+mechanical apparatus) functional by two opposing forces--the vital force

+and the surrounding physical force. The inspiration of thoracic space is

+the expiration of general space, and reciprocally.

+

+The thoracic space is a symmetrical enclosure originally, which

+aftercoming necessities modify and distort in some degree. The spaces

+occupied by the opposite lungs in the adult body do not exactly

+correspond as to capacity, O O, Plate 1. Neither is the cardiac space, A

+E G D, Plate 1, which is traversed by the common median line,

+symmetrical. The asymmetry of the lungs is mainly owing to the form and

+position of the heart; for this organ inclines towards the left thoracic

+side. The left lung is less in capacity than the right, by so much space

+as the heart occupies in the left pulmonary side. The general form of

+the thorax is that of a cone, I I N N, Plate 1, bicleft through its

+perpendicular axis, H M. The line of bicleavage is exactly median, and

+passes through the centre of the sternum in front, and the centres of

+the dorsal vertebral behind. Between the dorsal vertebral and the

+sternum, the line of median cleavage is maintained and sketched out in

+membrane. This membranous middle is formed by the adjacent sides of the

+opposite pleural or enveloping bags in which the lungs are enclosed. The

+heart, A, Plate 1, is developed between these two pleural sacs, F F, and

+separates them from each other to a distance corresponding to its own

+size. The adjacent sides of the two pleural sacs are central to the

+thorax, and form that space which is called mediastinum; the heart is

+located in this mediastinum, U E, Plate 1. The extent of the thoracic

+region ranges perpendicularly from the root of the neck, Q, Plate 1, to

+the roof of the abdomen--viz., the diaphragm, P, transversely from the

+ribs of one side, I N, Plate 1, to those of the other, and

+antero-posteriorly from the sternum, H M, to the vertebral column. All

+this space is pulmonary, except the cardiac or median space, which, in

+addition to the heart, A, Plate 1, and great bloodvessels, G C B,

+contains the oesophagus, bronchi, &c. The ribs are the true enclosures

+of thoracic space, and, generally, in mammalian forms, they fail or

+degenerate at that region of the trunk which is not pulmonary or

+respiratory. In human anatomy, a teleological reason is given for

+this--namely, that of the ribs being mechanically subservient to the

+function of respiration alone. But the transcendental anatomists

+interpret this fact otherwise, and refer it to the operation of a higher

+law of formation.

+

+The capacity of the thorax is influenced by the capacity of the abdomen

+and its contents. In order to admit of full inspiration and pulmonary

+expansion, the abdominal viscera recede in the same ratio as the lungs

+dilate. The diaphragm, P P, Plate 1, or transverse musculo-membranous

+partition which divides the pulmonary and alimentary cavities, is, by

+virtue of its situation, as mechanically subservient to the abdomen as

+to the thorax. And under general notice, it will appear that even the

+abdominal muscles are as directly related to the respiratory act as

+those of the thorax. The connexion between functions is as intimate and

+indissoluble as the connexion between organs in the same body. There can

+be no more striking proof of the divinity of design than by such

+revelations as anatomical science everywhere manifests in facts such as

+this--viz., that each organ serves in most cases a double, and in many a

+triple purpose, in the animal economy.

+

+The apex of the lung projects into the root of the neck, even to a

+higher level, Q, Plate 1, than that occupied by the sternal end of the

+clavicle, K. If the point of a sword were pushed through the neck above

+the clavicle, at K, Plate 1, it would penetrate the apex of the right

+lung, where the subclavian artery, Q, Plate 1, arches over it. In

+connexion with this fact, I may mention it as very probable that the

+bruit, or continuous murmur which we hear through the stethoscope, in

+chlorotic females, is caused by the pulsation of the subclavian artery

+against the top of the lung. The stays or girdle which braces the loins

+of most women prevents the expansion of the thoracic apparatus,

+naturally attained by the descent of the diaphragm; and hence, no doubt,

+the lung will distend inordinately above towards the neck. It is an

+interesting fact for those anatomists who study the higher

+generalizations of their science, that at those very localities--viz.,

+the neck and loins, where the lungs by their own natural effort are

+prone to extend themselves in forced inspiration--happen the "anomalous"

+creations of cervical and lumbar ribs. The subclavian artery is

+occasionally complicated by the presence of these costal appendages.

+

+If the body be transfixed through any one of the intercostal spaces, the

+instrument will surely wound some part of the lung. If the thorax be

+pierced from any point whatever, provided the instrument be directed

+towards a common centre, A, Plate 1, the lung will suffer lesion; for

+the heart is, almost completely, in the healthy living body, enveloped

+in the lungs. So true is it that all the costal region (the asternal as

+well as the sternal) is a pulmonary enclosure, that any instrument which

+pierces intercostal space must wound the lung.

+

+As the sternal ribs degenerate into the "false" asternal or incomplete

+ribs from before, obliquely backward down to the last dorsal vertebra,

+so the thoracic space takes form. The lungs range through a much larger

+space, therefore, posteriorly than they do anteriorly.

+

+The form of the thorax, in relation to that of the abdomen, may be

+learned from the fact that a gunshot, which shall enter a little below

+N, Plate 1, and, after traversing the body transversely, shall pass out

+at a corresponding point at the opposite side, would open the thorax and

+the abdomen into a common cavity; for it would pierce the thorax at N,

+the arching diaphragm at the level of M, and thereat enter the belly;

+then it would enter the thorax again at P, and make exit below N,

+opposite. If a cutting instrument were passed horizontally from before

+backward, a little below M, it would first open the abdomen, then pierce

+the arching diaphragm, and pass into the thorax, opposite the ninth or

+eighth dorsal vertebra.

+

+The outward form or superficies masks in some degree the form of the

+interior. The width of the thorax above does not exceed the diameter

+between the points I I, of Plate 1, or the points W W, of Plate 2. If we

+make percussion directly from before backwards at any place external to

+I, Plate 1, we do not render the lung vibrative. The diameters between I

+I and N N, Plate 1, are not equal; and these measures will indicate the

+form of the thorax in the living body, between the shoulders above and

+the loins below.

+

+The position of the heart in the thorax varies somewhat with several

+bodies. The size of the heart, even in a state of perfect health, varies

+also in subjects of corresponding ages, a condition which is often

+mistaken for pathological. For the most part, its form occupies a space

+ranging from two or three lines right of the right side of the sternum

+to the middle of the shafts of the fifth and sixth ribs of the left

+side. In general, the length of the osseous sternum gives the exact

+perpendicular range of the heart, together with its great vessels.

+

+The aorta, C, Plates 1 and 2, is behind the upper half of the sternum,

+from which it is separated by the pericardium, D, Plate 1, the thin edge

+of the lung, and the mediastinal pleurae, U E, Plate 1, &c. If the heart

+be injected from the abdominal aorta, the aortal arch will flatten

+against the sternum. Pulmonary space would not be opened by a

+penetrating instrument passed into the root of the neck in the median

+line above the sternum, at L, Plate 1. But the apices of both lungs

+would be wounded if the same instrument entered deeply on either side of

+this median line at K K. An instrument which would pierce the sternum

+opposite the insertion of the second, third, or fourth costal cartilage,

+from H downwards, would transfix some part of the arch of the aorta, C,

+Plate 1. The same instrument, if pushed horizontally backward through

+the second, third, or fourth interspaces of the costal cartilages close

+to the sternum, would wound, on the right of the sternal line, the vena

+cava superior, G, Plate 1; on the left, the pulmonary artery, B, and

+the descending thoracic aorta. In the healthy living body, the thoracic

+sounds heard in percussion, or by means of the stethoscope, will vary

+according to the locality operated upon, in consequence of the variable

+thickness of those structures (muscular and osseous, &c.,) which invest

+the thoracic walls. Uniformity of sound must, owing to these facts, be

+as materially interrupted, as it certainly is, in consequence of the

+variable contents of the cavity. The variability of the healthy thoracic

+sounds will, therefore, be too often likely to be mistaken for that of

+disease, if we forget to admit these facts, as instanced in the former

+state. Considering the form of the thoracic space in reference to the

+general form of the trunk of the living body, I see reason to doubt

+whether the practitioner can by any boasted delicacy of manipulation,

+detect an abnormal state of the pulmonary organs by percussion, or the

+use of the stethoscope, applied at those regions which he terms

+coracoid, scapulary, subclavian, &c., if the line of his examination be

+directed from before backwards. The scapula, covered by thick carneous

+masses, does not lie in the living body directly upon the

+osseous-thorax, neither does the clavicle. As all antero-posterior

+examination in reference to the lungs external to the points, I I,

+between the shoulders cannot, in fact, concern the pulmonary organs, so

+it cannot be diagnostic of their state either in health or disease. The

+difficulties which oppose the practitioner's examination of the state of

+the thoracic contents are already numerous enough, independent of those

+which may arise from unanatomical investigation.

+

+

+DESCRIPTION OF PLATES 1 & 2.

+

+PLATE 1.

+

+A.   Right ventricle 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

+     bloodvessels.

+

+E.   Mediastinal pleura, forming a second investment for the heart,

+     bloodvessels, &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.

+

+I I. First ribs.

+

+K K. Sternal ends of the clavicles.

+

+L.   Upper end of sternum.

+

+M.   Lower end of sternum.

+

+N N. Fifth ribs.

+

+O O. Collapsed lungs.

+

+P P. Arching diaphragm.

+

+Q.   Subclavian artery.

+

+R.   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.

+

+

+[Illustration: Upper body, showing internal organs of neck and chest.]

+Plate 1

+

+

+PLATE 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 mammae.

+

+Z.   Lower end of sternum.

+

+

+[Illustration: Upper body, showing internal organs of neck and chest.]

+Plate 2

+

+

+

+COMMENTARY ON PLATES 3 & 4.

+

+THE SURGICAL FORM OF THE SUPERFICIAL CERVICAL AND FACIAL

+REGIONS, AND THE RELATIVE POSITION OF THE PRINCIPAL

+BLOOD-VESSELS, NERVES, &c.

+

+When the neck is extended in surgical position, as seen in Plates 3 and

+4, its general outline assumes a quadrilateral shape, approaching to a

+square. The sides of this square are formed anteriorly by the line

+ranging from the mental symphysis to the top of the sternum, and

+posteriorly by a line drawn between the occiput and shoulder. The

+superior side of this cervical square is drawn by the horizontal ramus

+of the lower maxilla, and the inferior side by the horizontal line of

+the clavicle. This square space, R 16, 8, 6, Plate 4, is halved by a

+diagonal line, drawn by the sterno-cleido-mastoid muscle B, which cuts

+the square into two triangles. In the anterior triangle, F 16, 6, Plate

+4, is located the superficial common carotid artery, C, and its

+branches, D, with accompanying nerves. In the posterior triangle, 9, 8,

+6, Plate 4, is placed the superficial subclavian artery, A, its

+branches, L M, and the brachial plexus of nerves, I. Both these

+triangles and their contents are completely sheathed by that thin

+scarf-like muscle, named platysma myoides, A A, Plate 3, the fibres of

+which traverse the neck slantingly in a line, O A, of diagonal direction

+opposite to and secant of that of the sterno-mastoid muscle.

+

+When the skin and subcutaneous adipose membrane are removed by careful

+dissection from the cervical region, certain structures are exposed,

+which, even in the undissected neck, projected on the superficies, and

+are the unerring guides to the localities of the blood-vessels and

+nerves, &c. In Plate 4, the top of the sternum, 6; the clavicle, 7; the

+"Pomum Adami," 1; the lower maxilla at V; the hyoid bone, Z; the

+sterno-cleido-mastoid muscle, B; and the clavicular portion of the

+trapezius muscle, 8; will readily be felt or otherwise recognised

+through the skin, &c. When these several points are well considered in

+their relation to one another, they will correctly determine the

+relative locality of those structures--the blood-vessels, nerves, &c.,

+which mainly concern the surgical operation.

+

+The middle point, between 7, the clavicle, and 6, the sternum, of Plate

+4, is marked by a small triangular space occurring between the

+clavicular and sternal divisions of the sterno-cleido-mastoid muscle.

+This space marks the situation (very generally) of the bifurcation of

+the innominate artery into the subclavian and common carotid arteries of

+the right side; a penetrating instrument would, if passed into this

+space at an inch depth, pierce first the root of the internal jugular

+vein, and under it, but somewhat internal, the root of either of these

+great arterial vessels, and would wound the right vagus nerve, as it

+traverses this region. For some extent after the subclavian and carotid

+vessels separate from their main common trunk, they lie concealed

+beneath the sterno-mastoid muscle, B, Plate 4, and still deeper beneath

+the sternal origins of the sterno-hyoid muscle, 5, and sterno-thyroid

+muscle, some of whose fibres are traceable at the intervals. The

+omo-hyoid muscle and the deep cervical fascia, as will be presently seen,

+conceal these vessels also.

+

+The subclavian artery, A, Plate 4, first appears superficial to the

+above-named muscles of the cervical region just at the point where,

+passing from behind the scalenus muscle, N, Plate 4, which also conceals

+it, it sinks behind the clavicle. The exact locality of the artery in

+this part of its course would be indicated by a finger's breadth

+external to the clavicular attachment of the sterno-mastoid muscle. The

+artery passes beneath the clavicle at the middle of this bone, a point

+which is indicated in most subjects by that cellular interval occurring

+between the clavicular origins of the deltoid and great pectoral

+muscles.

+

+The posterior cervical triangle, 9, 8, 7, Plate 4, in which the

+subclavian artery is situated, is again subdivided by the muscle

+omo-hyoid into two lesser regions, each of which assumes somewhat of a

+triangular shape. The lower one of these embraces the vessel, A, and

+those nerves of the brachial plexus, I, which are in contact with it.

+The posterior belly of the omo-hyoid muscle, K, and the anterior

+scalenus muscle, N, form the sides and apex of this lesser triangular

+space, while the horizontal clavicle forms its base. This region of the

+subclavian artery is well defined in the necks of most subjects,

+especially when the muscles are put in action. In lean but muscular

+bodies, it is possible to feel the projection of the anterior scalenus

+muscle under the skin, external to the sterno-mastoid. The form of the

+omo-hyoid is also to be distinguished in the like bodies. But in all

+subjects may be readily recognised that hollow which occurs above the

+clavicle, and between the trapezius, 8, and the sterno cleido-mastoid, 7

+B, in the centre of which hollow the artery lies.

+

+The contents of the larger posterior cervical triangle, formed by B, the

+sterno-mastoid before; 9, the splenius; and 8, the trapezius behind,

+and by the clavicle below, are the following mentioned structures--viz.,

+A, the subclavian artery, in the third part of its course, as it emerges

+from behind N, the scalenus anticus; L, the transversalis colli artery,

+a branch of the thyroid axis, which will be found to cross the

+subclavian vessel at this region; I, the brachial plexus of nerves,

+which lie external to and above the vessel; H, the external jugular

+vein, which sometimes, in conjunction with a plexus of veins coming from

+behind the trapezius muscle, entirely conceals the artery; M, the

+posterior scapular artery, a branch of the subclavian, given off from

+the vessel after it has passed from behind the scalenus muscle; O,

+numerous lymphatic glands; P, superficial descending branches of the

+cervical plexus of nerves; and Q, ascending superficial branches of the

+same plexus. All these structures, except some of the lymphatic glands,

+are concealed by the platysma myoides A, as seen in Plate 3, and beneath

+this by the cervical fascia, which latter shall be hereafter more

+clearly represented.

+

+In somewhat the same mode as the posterior half of the omo-hyoid

+subdivides the larger posterior triangle into two of lesser dimensions,

+the anterior half of the same muscle divides the anterior triangle into

+two of smaller capacity.

+

+The great anterior triangle, which is marked as that space inclosed

+within the points, 6, the top of the sternum, the mental symphysis and

+the angle of the maxilla; and whose sides are marked by the median line

+of the neck before, the sterno-mastoid behind, and the ramus of the jaw

+above, contains C, the common carotid artery, becoming superficial from

+beneath the sterno-mastoid muscle, and dividing into E, the internal

+carotid, and D, the external carotid. The anterior jugular vein, 3, also

+occupies this region below; while some venous branches, which join the

+external and internal jugular veins, traverse it in all directions, and

+present obstacles to the operator from their meshy plexiform arrangement

+yielding, when divided, a profuse haemorrhage.

+

+The precise locality at which the common carotid appears from under the

+sterno-mastoid muscle is, in almost all instances, opposite to the

+thyroid cartilage. At this place, if an incision, dividing the skin,

+platysma and some superficial branches of nerves, be made along the

+anterior border of the sterno-mastoid muscle, and this latter be turned

+a little aside, a process of cervical fascia, and beneath it the sheath

+of the carotid artery, will successionally disclose themselves. In many

+bodies, however, some degree of careful search requires to be made prior

+to the full exposure of the vessel in its sheath, in consequence of a

+considerable quantity of adipose tissue, some lymphatic glands, and many

+small veins lying in the immediate vicinity of the carotid artery and

+internal jugular vein. This latter vessel, though usually lying

+completely concealed by the sterno-mastoid muscle, is frequently to be

+seen projecting from under its fore part. In emaciated bodies, where the

+sterno-mastoid presents wasted proportions, it will, in consequence,

+leave both the main blood-vessels uncovered at this locality in the

+neck.

+

+The common carotid artery ascends the cervical region almost

+perpendicularly from opposite the sterno-clavicular articulation to the

+greater cornu of the os hyoides. For the greater part of this extent it

+is covered by the sterno-mastoid muscle; but as this latter takes an

+oblique course backwards to its insertion into the mastoid process,

+while the main blood-vessel dividing into branches still ascends in its

+original direction, so is it that the artery becomes uncovered by the

+muscle. Even the root of the internal carotid, E, may be readily reached

+at this place, where it lies on the same plane as the external carotid,

+but concealed in great part by the internal jugular vein. It would be

+possible, while relaxing the sterno-mastoid muscle, to compress either

+the common carotid artery or its main branches against the cervical

+vertebral column, if pressure were made in a direction backwards and

+inwards. The facial artery V, which springs from the external carotid,

+D, may be compressed against the horizontal ramus of the lower jaw-bone

+at the anterior border of the masseter muscle. The temporal artery, as

+it ascends over the root of the zygoma, may be compressed effectually

+against this bony point.

+

+The external jugular vein, H, Plate 4, as it descends the neck from the

+angle of the jaw obliquely backwards over the sterno-mastoid muscle, may

+be easily compressed and opened in any part of its course. This vein

+courses downwards upon the neck in relation to that branch of the

+superficial cervical plexus, named auricularis magnus nerve, Q, Plate 4,

+G, Plate 3. The nerve is generally situated behind the vein, to which it

+lies sometimes in close proximity, and is liable, therefore, to be

+accidentally injured in the performance of phlebotomy upon the external

+jugular vein. The coats of the external jugular vein, E, Plate 3, are

+said to hold connexion with some of the fibres of the platysma-myoides

+muscle, A A, Plate 3, and that therefore, if the vessel be divided

+transversely, the two orifices will remain patent for a time.

+

+The position of the carotid artery protects the vessel, in some degree,

+against the suicidal act, as generally attempted. The depth of the

+incision necessary to reach the main blood-vessels from the fore part of

+the neck is so considerable that the wound seldom effects more than the

+opening of some part of the larynx. The ossified condition of the

+thyroid and cricoid parts of the laryngeal apparatus affords a

+protection to the vessels. The more oblique the incision happens to be,

+the greater probability is there that the wound is comparatively

+superficial, owing to the circumstance of the instrument having

+encountered one or more parts of the hyo-laryngeal range; but woeful

+chance sometimes directs the weapon horizontally through that membranous

+interval between the thyroid and hyoid pieces, in which case, as also in

+that where the laryngeal pieces persist permanently cartilaginous, the

+resistance to the cutting instrument is much less.

+

+The anatomical position of the parotid, H, Plate 3, and submaxillary

+glands, W, Plate 4, is so important, that their extirpation, while in a

+state of disease, will almost unavoidably concern other principal

+structures. Whether the diseased parotid gland itself or a lymphatic

+body lying in connexion with it, be the subject of operation, it seldom

+happens that the temporo-maxillary branch of the external carotid, F,

+escapes the knife. But an accident, much more liable to occur, and one

+which produces a great inconvenience afterwards to the subject, is that

+of dividing the portio-dura nerve, S, Plate 4, at its exit from the

+stylo-mastoid foramen, the consequence being that almost all the muscles

+of facial expression become paralyzed. The masseter, L, Plate 3,

+pterygoid, buccinator, 15, Plate 4, and the facial fibres of the

+platysma muscles, A O, Plate 3, still, however, preserve their power, as

+these structures are innervated from a different source. The orbicularis

+oculi muscle, which is principally supplied by the portio-dura nerve, is

+paralyzed, though it still retains a partial power of contraction, owing

+to the anatomical fact that some terminal twigs of the third or motor

+pair of nerves of the orbit branch into this muscle.

+

+The facial artery, V, and the facial vein, U, Plate 4, are in close

+connexion with the submaxillary gland. Oftentimes they traverse the

+substance of it. The lingual nerve and artery lie in some part of their

+course immediately beneath the gland. The former two are generally

+divided when the gland is excised; the latter two are liable to be

+wounded in the same operation.

+

+

+DESCRIPTION OF PLATES 3 & 4.

+

+PLATE 3.

+

+A A A. 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 post triangle.

+

+E. External jugular vein.

+

+F. Occipital artery, close to which are seen some branches of the

+   occipitalis 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.

+

+

+

+[Illustration: Right side of the head, showing blood vessels, muscles

+and other internal organs. ]

+Plate 3

+

+

+

+PLATE 4.

+

+A.  Subclavian artery passing beneath the clavicle, where it is crossed

+    by some blood-vessels and nerves.

+

+B.  Sternal attachment of the sterno-mastoid muscle, marking the

+    situation 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.

+

+G.  Temporal artery and temporal 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.  Brachial 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 pair of cerebral nerves.

+

+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 oculi muscle.

+

+14. Zygomaticus major muscle.

+

+15. Buccinator muscle.

+

+16. Depressor anguli oris muscle.

+

+(Page 16)

+

+

+[Illustration: Right side of the head, showing blood vessels, muscles

+and other internal organs. ]

+Plate 4

+

+

+

+COMMENTARY ON PLATES 5 & 6.

+

+THE SURGICAL FORM OF THE DEEP CERVICAL AND FACIAL REGIONS, AND

+THE RELATIVE POSITION OF THE PRINCIPAL BLOODVESSELS AND

+NERVES, &c.

+

+While the human cervix is still extended in surgical position, its

+deeper anatomical relations, viewed as a whole, preserve the

+quadrilateral form. But as it is necessary to remove the

+sterno-cleido-mastoid muscle, in order to expose the entire range of the

+greater bloodvessels and nerves, so the diagonal which that muscle

+forms, as seen in Plates 3 and 4, disappears, and thus both the cervical

+triangles are thrown into one common region. Although, however, the

+sterno-mastoid muscle be removed, as seen in Plate 5, still the great

+bloodvessels and nerves themselves will be observed to divide the

+cervical square diagonally, as they ascend the neck from the

+sterno-clavicular articulation to the ear.

+

+The diagonal of every square figure is the junction line of the opposite

+triangles which form the square. The cervical square being indicated as

+that space which lies within the mastoid process and the top of the

+sternum--the symphysis of the lower maxilla and the top of the shoulder,

+it will be seen, in Plate 5, that the line which the common carotid and

+internal jugular vein occupy in the neck, is the diagonal; and hence the

+junction line of the two surgical triangles.

+

+The general course of the common carotid artery and internal jugular

+vein is, therefore, obliquely backwards and upwards through the diagonal

+of the cervical square, and passing, as it were, from the point of one

+angle of the square to that of the opposite--viz., from the

+sterno-clavicular junction to the masto-maxillary space; and, taking the

+anterior triangle of the cervical square to be that space included

+within the points marked H 8 A, Plate 5, it will be seen that the common

+carotid artery ranges along the posterior side of this anterior

+triangle. Again: taking the points 5 Z Y to mark the posterior triangle

+of the cervical square, so will it be seen that the internal jugular

+vein and the common carotid artery, with the vagus nerve between them,

+range the anterior side of this posterior triangle, while the subclavian

+artery, Q, passes through the centre of the inferior side of the

+posterior triangle, that is, under the middle of the shaft of the

+clavicle.

+

+The main blood vessels (apparently according to original design) will be

+found always to occupy the centre of the animal fabric, and to seek

+deep-seated protection under cover of the osseous skeleton. The

+vertebrae of the neck, like those of the back and loins, support the

+principal vessels. Even in the limbs the large bloodvessels range

+alongside the protective shafts of the bones. The skeletal points are

+therefore the safest guides to the precise localities of the

+bloodvessels, and such points are always within the easy recognition of

+touch and sight.

+

+Close behind the right sterno-clavicular articulation, but separated

+from it by the sternal insertions of the thin ribbon-like muscles named

+sterno-hyoid and thyroid, together with the cervical fascia, is situated

+the brachio-cephalic or innominate artery, A B, Plates 5 and 6, having

+at its outer side the internal jugular division of the brachio-cephalic

+vein, W K, Plate 5. Between these vessels lies the vagus nerve, E, Plate

+6, N, Plate 5. The common carotid artery, internal jugular vein, and

+vagus nerve, hold in respect to each other the same relationship in the

+neck, as far upwards as the angle of the jaw. While we view the general

+lateral outline of the neck, we find that, in the same measure as the

+blood vessels ascend from the thorax to the skull, they recede from the

+fore-part of the root of the neck to the angle of the jaw, whereby a

+much greater interval occurs between them and the mental symphysis, or

+the apex of the thyroid cartilage, than happens between them and the top

+of the sternum, as they lie at the root of the neck. This variation as

+to the width of the interval between the vessels and fore-part of the

+neck, in these two situations, is owing to two causes, 1st, the somewhat

+oblique course taken by the vessels from below upwards; 2dly, the

+projecting development of the adult lower jaw-bone, and also of the

+laryngeal apparatus, which latter organ, as it grows to larger

+proportions in the male than in the female, will cause the interval at

+this place to be much greater in the one than the other. In the infant,

+the larynx is of such small size, as scarcely to stand out beyond the

+level of the vessels, viewed laterally.

+

+The internal jugular vein is for almost its entire length covered by the

+sterno-mastoid muscle, and by that layer of the cervical aponeurosis

+which lies between the vessels and the muscle. The two vessels, K C,

+Plate 5, with the vagus nerve, are enclosed in a common sheath of

+cellular membrane, which sends processes between them so as to isolate

+the structures in some degree from one another.

+

+The trunk of the common carotid artery is in close proximity to the

+vagus nerve, this latter lying at the vessel's posterior side. The

+internal jugular vein, which sometimes lies upon and covering the

+carotid, will be found in general separated from it for a little space.

+Opposite the os hyoides, the internal jugular vein lies closer to the

+common carotid than it does farther down towards the root of the neck.

+Opposite to the sterno-clavicular articulation, the internal jugular

+vein will be seen separated from the common carotid for an interval of

+an inch and more in width, and at this interval appears the root of the

+subclavian artery, B, Plates 5 and 6, giving off its primary branches,

+viz., the thyroid axis, D, the vertebral and internal mammary arteries,

+at the first part of its course.

+

+The length of the common carotid artery varies, of course, according to

+the place where the innominate artery below divides, and also according

+to that place whereat the common carotid itself divides into internal

+and external carotids. In general, the length of the common carotid is

+considerable, and ranges between the sterno-clavicular articulation and

+the level of the os hyoides; throughout the whole of this length, it

+seldom or never happens that a large arterial branch is given off from

+the vessel, and the operation of ligaturing the common carotid is

+therefore much more likely to answer the results required of that

+proceeding than can be expected from the ligature of any part of the

+subclavian artery which gives off large arterial branches from every

+part of its course.

+

+The sympathetic nerve, R, Plate 6, is as close to the carotid artery

+behind, as the vagus nerve, N, Plate 5, and is as much endangered in

+ligaturing this vessel. The branch of the ninth nerve, E, Plate 5,

+(descendens noni,) lies upon the common carotid, itself or its sheath,

+and is likely to be included in the ligature oftener than we are aware

+of.

+

+The trunk of the external carotid, D, Plate 5, is in all cases very

+short, and in many bodies can scarcely be said to exist, in consequence

+of the thyroid, lingual, facial, temporal, and occipital branches,

+springing directly from almost the same point at which the common

+carotid gives off the internal carotid artery. The internal carotid is

+certainly the continuation of the common arterial trunk, while the

+vessel named external carotid is only a series of its branches. If the

+greater size of the internal carotid artery, compared to that of the

+external carotid, be not sufficient to prove that the former is the

+proper continuation of the common carotid, a fact may be drawn from

+comparative philosophy which will put the question beyond doubt,

+namely--that as the common carotid follows the line of the cervical

+vertebrae, just as the aorta follows that of the vertebrae of the trunk,

+so does the internal carotid follow the line of the cephalic vertebrae.

+I liken, therefore, those branches of the so-called external carotid to

+be, as it were, the visceral arteries of the face and neck. It would be

+quite possible to demonstrate this point of analogy, were this the place

+for analogical reasoning.

+

+The common carotid, or the internal, may be compressed against the

+rectus capitis anticus major muscle, 13, Plate 6, as it lies on the

+fore-part of the vertebral column. The internal maxillary artery, 16,

+Plate 6, and the facial artery, G, Plate 5, are those vessels which

+bleed when the lower maxilla is amputated. In this operation, the

+temporal artery, 15, Plate 6, will hardly escape being divided also, it

+lies in such close proximity to the neck and condyle of the jaw-bone.

+

+The subclavian artery, B Q, Plate 5, traverses the root of the neck, in

+an arched direction from the sterno-clavicular articulation to the

+middle of the shaft of the clavicle, beneath which it passes, being

+destined for the arm. In general, this vessel rises to a level

+considerably above the clavicle; and all that portion of the arching

+course which it makes at this situation over the first rib has become

+the subject of operation. The middle of this arching subclavian artery

+is (by as much as the thickness of the scalenus muscle, X, Plate 5)

+deeper situated than either extremity of the arch of this vessel, and

+deeper also than any part of the common carotid, by the same fact. So

+many branches spring from all parts of the arch of the subclavian

+artery, that the operation of ligaturing this vessel is less successful

+than the same operation exercised on others.

+

+The structures which lie in connexion with the arch of the subclavian

+also render the operation of tying the vessel an anxious task. It is

+crossed and recrossed at all points by large veins, important nerves,

+and by its own principal branches. The vagus nerve, S E, Plate 6,

+crosses it at B, its root; external to which place the large internal

+jugular vein, K, Plate 5, lies upon it; external to this latter, the

+scalenus muscle, X, Plate 5, with the phrenic nerve lying upon the

+muscle, binds it fixedly to the first rib; more external still, the

+common trunk of the external jugular and shoulder veins, U, Plate 5, lie

+upon the vessel, and it is in the immediate vicinity of the great

+brachial plexus of nerves, P P, which pass down along its humeral

+border, many branches of the same plexus sometimes crossing it

+anteriorly.

+

+The depth at which the middle of the subclavian artery lies may be

+learned by the space which those structures, beneath which it passes,

+necessarily occupy. The clavicle at its sternal end is round and thick,

+where it gives attachment to the sterno-cleido-mastoid muscle. The root

+of the internal jugular vein, when injected, will be seen to occupy

+considerable space behind the clavicle; and the anterior scalenus muscle

+is substantial and fleshy. The united spaces occupied by these

+structures give the depth of the subclavian artery in the middle part of

+its course.

+

+The length of the subclavian artery between its point of branching from

+the innominate and that where it gives off its first branches varies in

+different bodies, but is seldom so extensive as to assure the operator

+of the ultimate success of the process of ligaturing the vessel. Above

+and below D, Plate 6, the thyroid axis, come off the vertebral and

+internal mammary arteries internal and anterior to the scalenus muscle.

+External and posterior to the scalenus, a large vessel, the post

+scapular, G, Plate 6, R, Plate 5, arises. If an aneurism attack any part

+of this subclavian arch, it must be in close connexion with some one of

+these branches. If a ligature is to be applied to any part of the arch,

+it will seldom happen that it can be placed farther than half an inch

+from some of these principal collateral branches.

+

+When the shoulder is depressed, the clavicle follows it, and the

+subclavian artery will be more exposed and more easily reached than if

+the shoulder be elevated, as this latter movement raises the clavicle

+over the locality of the vessel. Dupuytren alludes practically to the

+different depths of the subclavian artery in subjects with short necks

+and high shoulders, and those with long necks and pendent shoulders.

+When the clavicle is depressed to the fullest extent, if then the

+sterno-cleido-mastoid and scalenus muscles be relaxed by inclining the

+head and neck towards the artery, I believe it may be possible to arrest

+the flow of blood through the artery by compressing it against the first

+rib, and this position will also facilitate the operation of ligaturing

+the vessel.

+

+The subclavian vein, W, Plate 5, is removed to some distance from the

+artery, Q, Plate 5. The width of the scalenus muscle, X, separates the

+vein from the artery. An instance is recorded by Blandin in which the

+vein passed in company with the artery under the scalenus muscle.

+

+

+DESCRIPTION OF PLATES 5 & 6.

+

+PLATE 5.

+

+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-glossus 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 post scapular and external jugular veins, which enter

+    the subclavian vein by a common trunk.

+

+V.  Post-half of the omo-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.

+

+6.  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.

+

+

+[Illustration: Right side of the head and neck, showing blood vessels,

+muscles and other internal organs.]

+Plate 5

+

+

+

+PLATE 6.

+

+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.  Post 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 omo-hyoid 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 pair of cerebral nerves.

+

+18. Gustatory branch of fifth pair of nerves.

+

+19. External pterygoid muscle.

+

+20. Internal pterygoid muscle.

+

+21. Temporal muscle cut to show the deep temporal branches of fifth pair

+    of nerves.

+

+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.

+

+

+[Illustration: Right side of the head and neck, showing blood vessels,

+muscles and other internal organs.]

+Plate 6

+

+

+

+COMMENTARY ON PLATES 7 & 8.

+

+THE SURGICAL DISSECTION OF THE SUBCLAVIAN AND CAROTID REGIONS,

+THE RELATIVE ANATOMY OF THEIR CONTENTS.

+

+

+A perfect knowledge of the relative anatomy of any of the surgical

+regions of the body must include an acquaintance with the superposition

+of parts contained in each region, as well as the plane relationship of

+organs which hold the same level in each layer or anatomical stratum.

+The dissections in Plates 7 and 8 exhibit both these modes of relation.

+A portion of each of those superficial layers, which it was necessary to

+divide, in order to expose a deeper organ, has been left holding its

+natural level. Thus the order of superposition taken by the integument,

+the fasciae, the muscles, bones, veins, nerves, and arteries, which

+occupy both the surgical triangles of the neck, will be readily

+recognised in the opposite Plates.

+

+The depth of a bloodvessel or other organ from surface will vary for

+many reasons, even though the same parts in the natural order of

+superposition shall overlie the whole length of the vessel or organ

+which we make search for. The principal of those reasons are:--1st, that

+the stratified organs themselves vary in thickness at several places;

+2d, that the organ or vessel which we seek will itself incline to

+surface from deeper levels occupied elsewhere; 3d, that the normal

+undulations of surface will vary the depth of the particular vessels,

+&c.; and 4th, that the natural mobility of the superimposed parts will

+allow them to change place in some measure, and consequently influence

+the relative position of the object of search. On this account it is

+that the surgical anatomist chooses to give a fixed position to the

+subject about to be operated on, in order to reduce the number of these

+difficulties as much as possible.

+

+In Plate 7 will be seen the surgical relationship of parts lying in the

+vicinity of the common carotid artery, at the point of its bifurcation

+into external and internal carotids. At this locality, the vessel will

+be found, in general, subjacent to the following mentioned structures,

+numbered from the superficies to its own level--viz., the common

+integument and subcutaneous adipose membrane, which will vary in

+thickness in several individuals; next, the platysma myoides muscle, F

+L, which is identified with the superficial fascia, investing the outer

+surface of the sterno-mastoid muscle; next, the deeper layer of the same

+fascia, R S., which passes beneath the sterno-mastoid muscle, but over

+the sheath of the vessels; and next, the sheath of the vessels, Q, which

+invests them and isolates them from adjacent structures. Though the

+vessel lies deeper than the level of the sterno-mastoid muscle at this

+locality, yet it is not covered by the muscle in the same manner, as it

+is lower down in the neck. At this place, therefore, though the actual

+depth of the artery from surface will be the same, whether it be covered

+or uncovered by the sterno-mastoid muscle, still we know that the

+locality of the vessel relative to the parts actually superimposed will

+vary accordingly. This observation will apply to the situation and

+relative position of all the other vessels as well. Other occurrences

+will vary the relations of the artery in regard to superjacent

+structures, though the actual depth of the vessel from surface may be

+the same. If the internal jugular vein covers the carotid artery, as it

+sometimes does, or if a plexus of veins, gathering from the fore-part of

+the neck or face, overlie the vessel, or if a chain of lymphatic bodies

+be arranged upon it, as is frequently the case, the knowledge of such

+occurrences will guard the judgment against being led into error by the

+conventionalities of the descriptive method of anatomists. The normal

+relative anatomy of the bloodvessels is taken by anatomists to be the

+more frequent disposition of their main trunks and branches, considered

+per se, and in connexion with neighbouring parts. But it will be seen by

+this avowal that those vessels are liable to many various conditions;

+and such is the case, in fact. No anatomist can pronounce with exactness

+the precise figure of vessels or other organs while they lie concealed

+beneath the surface. An approach to truth is all that the best

+experience can boast of. The form and relations of the carotid vessels

+of Plate 7 may or may not be the same as those concealed beneath the

+same region of Plate 8, at the point R.

+

+The motions of the head upon the neck, or of the neck upon the trunk,

+will influence the relative position of the vessels A C B, of Plate 7,

+and therefore we take a fixed surgical position, in the expectation of

+finding that the carotid artery projects from under the anterior border

+of the upper third of the sterno-mastoid muscle, opposite the upper

+border of the thyroid cartilage; at this situation of the vessels, viz.,

+R, Plate 8, opposite O, the thyroid projection, is in general to be

+found the anatomical relation of the vessels as they appear dissected in

+Plate 7. Of these vessels, the main trunks are less liable to anomalous

+character than the minor branches.

+

+The relative position of the subclavian artery is as liable to be

+influenced by the motions of the clavicle on the sternum, as that of the

+carotid is by the motions of the lower jaw-bone on the skull, or by the

+larynx, in its own motions at the fore-part of the neck. It becomes as

+necessary, therefore, in the performance of surgical operations upon the

+subclavian artery, to fix the clavicle by depressing it, as in Plate 8,

+as it is to give fixity to the lower maxilla and larynx, in the position

+of Plate 7, when the carotid is the subject of operation.

+

+The same named structures, but different as to their parts, will be

+found to overlie the subclavian artery as are found to conceal the

+carotid artery. The skin, the fascia, and platysma muscle, the

+sterno-cleido-mastoid muscle, the deep layer of the cervical fascia,

+&c., cover both vessels. One additional muscle binds down the subclavian

+artery, viz., the scalenus anticus. The omo-hyoid relates to both

+vessels, the anterior division to the carotid, the posterior to the

+subclavian.

+

+The carotid artery lies uncovered by the sterno-mastoid muscle, opposite

+to the upper border of the thyroid cartilage, or the hyoid bone; and the

+subclavian artery emerges from under cover of a different part of the

+same muscle, opposite the middle of the clavicle. These points of

+relationship to the skeletal parts can be ascertained by the touch, in

+both instances, even in the undissected body. The thyroid point, O, of

+Plate 8, indicates the line, R N, which the carotid artery traverses in

+the same figure, along the anterior border of the sterno-mastoid muscle,

+as seen in the dissected region of Plate 7. The mid-point of the

+clavicle, U, Plate 7, and the top of the sternum in the same figure,

+will, while the eye follows the arching line, Z X T V, indicate with

+correctness the arching course of the subclavian, such as is represented

+in the dissection of that vessel, B, Plate 8.

+

+The subclavian artery has no special sheath, properly so called; but the

+deep layer of the cervical fascia, P, Plate 8, which passes under A, the

+clavicular portion of the sterno-mastoid muscle, and becomes of

+considerable thickness and density, sheaths over the vessel in this

+region of its course.

+

+A very complex condition of the veins which join the external jugular at

+this part of the course of the subclavian artery is now and then to be

+found overlying that vessel. If the hemorrhage consequent upon the

+opening of these veins, or that of the external jugular, be so profuse

+as to impede the operation of ligaturing the subclavian artery, it may

+in some measure be arrested by compressing them against the resisting

+parts adjacent, when the operator, feeling for D, the scalenus muscle,

+and the first rib to which it is attached, cannot fail to alight upon

+the main artery itself, B, Plate 8.

+

+The middle of the shaft of the clavicle is a much safer guide to the

+vessel than are the muscles which contribute to form this posterior

+triangle of the neck, in which the subclavian vessel is located. The

+form or position of the clavicle in the depressed condition of the

+shoulder, as seen in Plate 8, is invariable; whereas that of the

+trapezius and sterno-mastoid muscles is inconstant, these muscles being

+found to stand at unequal intervals from each other in several bodies.

+The space between the insertions of both these muscles is indefinite,

+and may vary in degrees of width from the whole length of the clavicle

+to half an inch; or, as in some instances, leaving no interval whatever.

+The position of the omo-hyoid muscle will not be accounted a sure guide

+to the locality of the subclavian artery, since, in fact, it varies

+considerably as to its relationship with that vessel. The tense cords of

+the brachial plexus of nerves, F, Plate 8, which will be found, for the

+most part, ranging along the acromial border of the artery, are a much

+surer guide to the vessel.

+

+On comparing the subclavian artery, at B, Plate 8, with the common

+carotid artery, at A, Plate 7, I believe that the former will be found

+to exhibit, on the whole a greater constancy in respect to the

+following-mentioned condition--viz., a single main arterial trunk arches

+over the first rib to pass beneath the middle of the clavicle, while the

+carotid artery opposite the thyroid piece of the larynx is by no means

+constantly single as a common carotid trunk. The place of division of

+the common carotid is not definite, and, therefore, the precise

+situation in the upper two-thirds of the neck, where it may present as a

+single main vessel, cannot be predicted with certainty in the

+undissected body. There is no other main artery of the body more liable

+to variation than that known as external carotid. It is subject to as

+many changes of character in respect to the place of its branching from

+the common carotid, and also in regard to the number of its own

+branches, as any of the lesser arteries of the system. It is but as an

+aggregate of the branches of that main arterial trunk which ranges from

+the carotid foramen of the temporal bone to the aorta; and, as a branch

+of a larger vessel, it is, therefore, liable to spring from various

+places of the principal trunk, just as we find to be the case with all

+the other minor branches of the larger arteries. Its name, external

+carotid, is as unfittingly applied to it, in comparison with the vessel

+from which it springs, as the name external subclavian would be if

+applied to the thyroid axis of the larger subclavian vessel. The

+nomenclature of surgical anatomy does not, however, court a

+philosophical inquiry into that propriety of speech which comparative

+science demands, nor is it supposed to be necessary in a practical point

+of view.

+

+It will, however, sound more euphoneously with reason, and at the same

+time, I believe, be found not altogether unrelated to the useful, if,

+when such conditions as the "anomalies of form" present themselves, we

+can advance an interpretation of the same, in addition to the dry record

+of them as isolated facts. Comparative anatomy, which alone can furnish

+these interpretations, will therefore prove to be no alien to the

+practical, while it may lend explanation to those bizarreries which

+impede the way of the anthropotomist. All the anomalies of form, both as

+regards the vascular, the muscular, and the osseous systems of the human

+body, are analyzed by comparison through the animal series. Numerous

+cases are on record of the subclavian artery being found complicated

+with supernumerary ribs jutting from the 5th, 6th, or 7th cervical

+vertebrae. [Footnote] To these I shall add another, in respect of the

+carotid arteries--viz., that I have found them complicated with an

+osseous shaft of bone, taking place of the stylo-hyoid ligament, a

+condition which obtains permanently in the ruminant and other classes of

+mammals.

+

+[Footnote: I have given an explanation of these facts in my work on

+Comparative Osteology and the Archetype Skeleton, to which, and also to

+Professor Owen's work, entitled Homologies of the Vertebrate Skeleton, I

+refer the reader.]

+

+

+DESCRIPTION OF PLATES 7 & 8.

+

+PLATE 7.

+

+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

+   insertions of sterno-cleido-mastoid muscle.

+

+Z. Projection of the sternal portion of the sterno-cleido-mastoid

+   muscle.

+

+

+[Illustration: Right side of the head and neck, showing blood vessels,

+muscles and other internal organs.]

+Plate 7

+

+

+

+PLATE 8.

+

+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. Post-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.

+

+

+[Illustration: Right side of the head and neck, showing blood vessels,

+muscles and other internal organs.]

+Plate 8

+

+

+

+COMMENTARY ON PLATES 9 & 10.

+

+THE SURGICAL DISSECTION OF THE STERNO-CLAVICULAR OR TRACHEAL

+REGION, AND THE RELATIVE POSITION OF ITS MAIN BLOODVESSELS,

+NERVES, &c.

+

+The law of symmetry governs the development of all structures which

+compose the human body; and all organized beings throughout the animal

+kingdom are produced in obedience to this law. The general median line

+of the human body is characterized as the point of fusion of the two

+sides; and all structures or organs which range this common centre are

+either symmetrically azygos, or symmetrically duplex. The azygos organ

+presents as a symmetrical unity, and the duplex organ as a symmetrical

+duality. The surgical anatomist takes a studious observation of this law

+of symmetry; and knowing it to be one of general and almost

+unexceptional occurrence, he practises according to its manifestation.

+

+The vascular as well as the osseous skeleton displays the law of

+symmetry; but while the osseous system offers no exception to this law,

+the vascular system offers one which, in a surgical point of view, is of

+considerable importance--namely, that behind the right sterno-clavicular

+articulation, C, Plate 9, is found the artery, A, named innominate, this

+being the common trunk of the right common carotid and subclavian

+vessels; while on the left side, behind the left sterno-clavicular

+junction, Q, Plate 10, the two vessels (subclavian, B, and carotid, A,)

+spring separately from the aortic arch. This fact of asymmetrical

+arrangement in the arterial trunks at the fore part of the root of the

+neck is not, however, of invariable occurrence; on the contrary,

+numerous instances are observed where the arteries in question, on the

+right side as well as the left, arise separately from the aorta; and

+thus Nature reverts to the original condition of perfect symmetry as

+governing the development of even the vascular skeleton. And not

+unfrequently, as if to invite us to the inquiry whether a separate

+origin of the four vessels (subclavian and carotid) from the aorta, or a

+double innominate condition of the vessels, were the original form with

+Nature, we find her also presenting this latter arrangement of them. An

+innominate or common aortic origin may happen for the carotid and

+subclavian arteries of the left side, as well as the right. Hence,

+therefore, while experience may arm the judgment with a general rule,

+such generality should not render us unmindful of the possible

+exception.

+

+When, as in Plate 9, A, the innominate artery rises to a level with C,

+the right sterno-clavicular junction, and when at this place it

+bifurcates, having on its left side, D, the trachea, and on its right

+side, B, the root of the internal jugular vein, together with a, the

+vagus nerve, the arterial vessel is said to be of normal character, and

+holding a normal position relative to adjacent organs. When, as in Plate

+10, A, the common carotid, and B, the subclavian artery, rise separately

+from the aortic arch to a level with Q, the left sterno-clavicular

+articulation, the vessels having M, the trachea, to their inner side,

+and  C D, the junction of the internal jugular and subclavian veins, to

+their outer side, with b, the left vagus nerve, between them, then the

+arterial vessels are accounted as being of normal character, and as

+holding a normal relative position. Every exception to this condition of

+A, Plate 9, or to that of A B, Plate 10, is said to be abnormal or

+peculiar, and merely because the disposition of the vessels, as seen in

+Plates 9 and 10, is taken to be general or of more frequent occurrence.

+

+Now, though it is not my present purpose to burden this subject of

+regional anatomy with any lengthy inquiry into the comparative meaning

+of the facts, why a common innominate trunk should occur on the right of

+the median line, while separate arterial trunks for the carotid and

+subclavian arteries should spring from the aorta on the left of this

+mid-line, thus making a remarkable exception to the rule of symmetry

+which characterizes all the arterial vessels elsewhere, still I cannot

+but regard this exceptional fact of asymmetry as in itself expressing a

+question by no means foreign to the interests of the practical.

+

+In the abstract or general survey of all those peculiarities of length

+to which the innominate artery, A, Plate 9, is subject, I here lay it

+down as a proposition, that they occur as graduated phases of the

+bicleavage of this innominate trunk from the level of A, to the aortic

+arch, in which latter phasis the aorta gives a separate origin to the

+carotid and subclavian vessels of the right side as well as the left. On

+the other hand, I observe that the peculiarities to the normal separate

+condition of A and B, the carotid and subclavian arteries of Plate 10,

+display, in the relationary aggregate, a phasial gradation of A and B

+joining into a common trunk union, in which state we then find the aorta

+giving origin to a right and left innominate artery. Between these two

+forms of development--viz., that where the four vessels spring

+separately from the aortic arch, and that where two innominate or

+brachio-cephalic arteries arise from the same--may be read all the sum

+of variation to which these vessels are liable. It is true that there

+are some states of these vessels which cannot be said to be naturally

+embraced in the above generalization; but though I doubt not that these

+might be encompassed in a higher generalization; still, for all

+practical ends, the lesser general rule is all-sufficient.

+

+In many instances, the innominate artery, A, Plate 9, is of such

+extraordinary length, that it rises considerably (for an inch, or even

+more) above the level of C, the sternal end of the clavicle. In other

+cases, the innominate artery bifurcates soon after it leaves the first

+part of the aortic arch; and between these extremes as to length, the

+vessel varies infinitesimally.

+

+The innominate artery lies closer behind the right sterno-clavicular

+junction than the left carotid or subclavian arteries lie in relation to

+the left sterno-clavicular articulation; and this difference of depth

+between the vessel of the right side and those of the left is mainly

+owing to the form and direction of the aortic arch from which they take

+origin. The aortic arch ranges, not alone transversely, but also from

+before backward, and to the left side of the dorsal spine; and

+consequently, as the innominate artery, A, Plate 9, springs from the

+first or fore part of the aorta, while the left carotid and subclavian

+arteries arise from the second and deeper part of its arch, the vessels

+of both sides rising into the neck perpendicularly from the root in the

+thorax, will still, in the cervical region, manifest a considerable

+difference as to antero-posterior depth. The depth of the left

+subclavian artery, B, Plate 10, from cervical surface, is even greater

+than that of the left common carotid, A, Plate 10, and this latter, at

+its root in the aortic arch, is deeper than the innominate artery. Both

+common carotids, A A, Plates 9 and 10, hold nearly the same

+antero-posterior depth on either side of the trachea, M, Plate 10, and

+D, Plate 9. Although the relative depth of the arterial vessels on both

+sides of the trachea is different, still they are covered by an equal

+number of identical structures, taking the same order of superposition.

+

+On either side of the episternal cervical pit, which, even in the

+undissected body of male or female, infant or adult, is always a

+well-marked surgical feature, may be readily recognised the converging

+sternal attachments of the sterno-mastoid muscles, L G, Plate 10; and

+midway between these symmetrical muscular prominences in the neck, but

+holding a deeper level than them, is situated that part of the trachea

+which is generally the subject of the operation of tracheotomy. The

+relative anatomy of the trachea, M, Plate 10, D, Plate 9, at this

+situation requires therefore to be carefully considered. The trachea is

+said to incline rather to the right side of the median line; but perhaps

+this observation would be more true to nature if it were accompanied by

+the remark, that this seeming inclination to the right side is owing to

+the fact, that the innominate artery, A, Plate 9, lies obliquely over

+its fore part, near the sternum. However this may be, it certainly will

+be the safer step in the operation to regard the median position of the

+trachea as fixed, than to encroach upon the locality of the carotid

+vessels; and to make the incision longitudinally and exactly through the

+median line, while the neck is extended backwards, and the chin made to

+correspond with the line of incision. And when the operator takes into

+consideration the situation of the vessel A, Plate 9, and A, Plate 10,

+at this region of the neck, he will at once own to the necessity of

+opening the trachea, D, Plate 9, M, Plate 10, at a situation nearer the

+larynx than the point marked in the figures. The course taken by the

+common carotid arteries is, in respect to the trachea, divergent from

+below upwards; and as these vessels will consequently be found to stand

+wider apart at the level of K, I, Plate 10, than they do at the level of

+M, Plate 10, so the farther upwards from the sternum we choose the point

+at which to open the trachea, the less likely are we to endanger the

+great arterial vessels.

+

+In addition to the fact, that the carotid arteries at an inch above the

+sternum lie nearer the median line than they do higher up in the neck,

+it should always be remembered, that the trachea itself is situated much

+deeper at the point M, Plate 10, D, Plate 9, than it is opposite the

+points F and K of the same figures. The laryngo-tracheal line is, in the

+lateral view of the neck, downwards and backwards, and therefore it will

+be found always at a considerable depth from cervical surface, as it

+passes behind the first bone of the sternum, midway between both

+sterno-mastoid muscles.

+

+In the operation of tracheotomy, the cutting instrument divides the

+following named structures as they lie beneath the common integument: If

+the incision be made directly upon the median line, the muscles F,

+sterno-hyoid, and E, sterno-thyroid, Plate 9, are not necessarily

+divided, as these structures and their fellows hold a somewhat lateral

+position opposite to each other. Beneath these muscles and above them,

+thus encasing them, the cervical fascia, f f, Plate 10, is required to

+be divided, in order to expose the trachea. Beneath f f the cervical

+fascia, will next be felt the rounded bilobed mass of the thyroid body,

+lying on the forepart of the trachea; above the thyroid body, the

+cricoid and some tracheal cartilaginous rings will be felt; and since

+the thyroid body varies much as to bulk in several individuals of the

+same and different sexes, as also from a consideration that its

+substance is traversed by large arterial and venous vessels, it will be

+therefore preferable to open the trachea above it, than through it or

+below it.

+

+On the forepart of the tracheal median line, either superficial to, or

+deeper than, the cervical fascia, the tracheotomist occasionally meets

+with a chain of lymphatic glands or a plexus of veins, which latter,

+when divided, will trammel the operation by the copious haemorrhage

+which all veins at this region of the neck are prone to supply, owing to

+their direct communication with the main venous trunks of the heart; and

+not unfrequently the inferior thyroid artery overlies the trachea at the

+point D, Plate 9, when this thyroid vessel arises directly from the arch

+of the aorta, between the roots of the innominate and left common

+carotid, or when it springs from the innominate itself. The inferior

+thyroid vein, sometimes single and sometimes double, overlies the

+trachea at the point D, Plate 9, when this vein opens into the left

+innominate venous trunk, as this latter crosses over the root of the

+main arteries springing from the aorta.

+

+Laryngotomy is, anatomically considered, a far less dangerous operation

+than tracheotomy, for the above-named reasons; and the former should

+always be preferred when particular circumstances do not render the

+latter operation absolutely necessary. In addition to the fact, that the

+carotid arteries lie farther apart from each other and from the median

+place--viz., the crico-thyroid interval, which is the seat of

+laryngotomy--than they do lower down on either side of the trachea, it

+should also be noticed that the tracheal tube being more moveable than

+the larynx, is hence more liable to swerve from the cutting instrument,

+and implicate the vessels. Tracheotomy on the infant is a far more

+anxious proceeding than the same operation performed on the adult;

+because the trachea in the infant's body lies more closely within the

+embrace of the carotid arteries, is less in diameter, shorter, and more

+mobile than in the adult body.

+

+The episternal or interclavicular region is a locality traversed by so

+many vitally important structures gathered together in a very limited

+space, that all operations which concern this region require more steady

+caution and anatomical knowledge than most surgeons are bold enough to

+test their possession of. The reader will (on comparing Plates 9 and 10)

+be enabled to take account of those structures which it is necessary to

+divide in the operation required for ligaturing the innominate artery,

+A, Plate 9, or either of those main arterial vessels (the right common

+carotid and subclavian) which spring from it; and he will also observe

+that, although the same number and kind of structures overlie the

+carotid and subclavian vessels, A B, of the left side, Plate 10, still,

+that these vessels themselves, in consequence of their separate

+condition, will materially influence the like operation in respect to

+them. An aneurism occurring in the first part of the course of the right

+subclavian artery, at the locality a, Plate 9, will lie so close to the

+origin of the right common carotid as to require a ligature to be passed

+around the innominate common trunk, thus cutting off the flow of blood

+from both vessels; whereas an aneurism implicating either the left

+common carotid at the point A, or the left subclavian artery at the

+point B, does not, of course, require that both vessels should be

+included in the same ligature. There seems to be, therefore, a greater

+probability of effectually treating an aneurism of the left

+brachio-cephalic vessels by ligature than attaches to those of the right

+side; for if space between collateral branches, and also a lesser

+caliber of arterial trunk, be advantages, allowing the ligature to hold

+more firmly, then the vessels of the left side of the root of the neck

+manifest these advantages more frequently than those of the right, which

+spring from a common trunk. Whenever, therefore, the "peculiarity" of a

+separate aortic origin of the right carotid and subclavian arteries

+occurs, it is to be regarded more as a happy advantage than otherwise.

+

+

+DESCRIPTION OF PLATES 9 & 10.

+

+PLATE 9.

+

+A. Innominate artery, at its point of bifurcation.

+

+B. Right 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 the subclavian artery.

+

+b. Anterior jugular vein, piercing the cervical fascia to join the

+   subclavian vein.

+

+

+[Illustration: Neck and upper chest, showing blood vessels, muscles and

+other internal organs.]

+Plate 9

+

+

+PLATE 10.

+

+A. Common carotid artery of left side.

+

+B. Left subclavian artery, having b, 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 f f f, 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.

+

+

+[Illustration: Neck and upper chest, showing blood vessels, muscles and

+other internal organs.]

+Plate 10

+

+

+

+COMMENTARY ON PLATES 11 & 12.

+

+THE SURGICAL DISSECTION OF THE AXILLARY AND BRACHIAL REGIONS,

+DISPLAYING THE RELATIVE ORDER OF THEIR CONTAINED PARTS.

+

+All surgical regions have only artificial boundaries; and these, as

+might be expected, do not express the same meaning while viewed from

+more points than one. These very boundaries themselves, being moveable

+parts, must accordingly influence the relative position of the

+structures which they bound, and thus either include within or exclude

+from the particular region those structures wholly or in part which are

+said to be proper to it. Of this kind of conventional surgical boundary

+the moveable clavicle is an example; and the bloodvessels which it

+overarches manifest consequently neither termination nor origin except

+artificially from the fixed position which the bone, R, assumes, as in

+Plate 11, or c*, Plate 12. In this position of the arm in relation to

+the trunk, the subclavian artery, B, terminates at the point where,

+properly speaking, it first takes its name; and from this point to the

+posterior fold of the axilla formed by the latissimus dorsi muscle, O,

+Plate 11, N, Plate 12, and the anterior fold formed by the great

+pectoral muscle, K, Plate 11, I, Plate 12, the continuation of the

+subclavian artery is named axillary. From the posterior fold of the

+axilla, O P, Plate 11, to the bend of the elbow, the same main vessels

+take the name of brachial.

+

+When the axillary space is cut into from the forepart through the great

+pectoral muscle, H K, Plate 11, and beneath this through the lesser

+pectoral muscle, L I, together with the fascial processes which invest

+these muscles anteriorly and posteriorly, the main bloodvessels and

+nerves which traverse this space are displayed, holding in general that

+relative position which they exhibit in Plate 11. These vessels, with

+their accompanying nerves, will be seen continued from those of the

+neck; and thus may be attained in one view a comparative estimate of the

+cervical and axillary regions, together with their line of union beneath

+the clavicle, c*, Plate 12, R, Plate 11, which serves to divide them

+surgically.

+

+In the neck, the subclavian artery, B, Plate 11, is seen to be separated

+from the subclavian vein, A, by the breadth of the anterior scalenus

+muscle, D, as the vessels arch over the first rib, F. In this region of

+the course of the vessels, the brachial plexus of nerves, C, ranges

+along the outer border of the artery, B, and is separated by the artery

+from the vein, A, as all three structures pass beneath the clavicle, R,

+and the subclavius muscle, E. From this latter point the vessels and

+nerves take the name axillary, and in this axillary region the relative

+position of the nerves and vessels to each other and to the adjacent

+organs is somewhat changed. For now in the axillary region the vein, a,

+is in direct contact with the artery, b, on the forepart and somewhat to

+the inner side of which the vein lies; while the nerves, D, d, Plate 12,

+embrace the artery in a mesh or plexus of chords, from which it is often

+difficult to extricate it, for the purpose of ligaturing, in the dead

+subject, much less the living. The axillary plexus of nerves well merits

+the name, for I have not found it in any two bodies assuming a similar

+order or arrangement. Perhaps the order in which branches spring from

+the brachial plexus that is most constantly met with is the one

+represented at D, Plate 12, where we find, on the outer border of B, the

+axillary artery, a nervous chord, d, giving off a thoracic branch to

+pass behind H, the lesser pectoral muscle, while the main chord itself,

+d, soon divides 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. Following that order of the nerves

+as they are shown in Plate 12, they may be enumerated from without

+inwards as follows:--the external or musculo-cutaneous, e; the two roots

+of the median, h;  the ulnar, f; the musculo-spiral, g; the circumflex,

+i; close to which are seen the origins of the internal cutaneous, the

+nerve of Wrisberg, some thoracic branches, and posteriorly the

+subscapular nerve not seen in this view of the parts.

+

+The branches which come off from the axillary artery are very variable

+both as to number and place of origin, but in general will be found

+certain branches which answer to the names thoracic, subscapular, and

+circumflex. These vessels, together with numerous smaller arteries,

+appear to be confined to no fixed point of origin, and on this account

+the place of election for passing a ligature around the main axillary

+artery sufficiently removed from collateral branches must be always

+doubtful. The subscapular artery, Q, Plate 12, is perhaps of all the

+other branches that one which manifests the most permanent character;

+its point of origin being in general opposite the interval between the

+latissimus and sub-scapular muscles, but I have seen it arise from all

+parts of the axillary main trunk. If it be required to give, in a

+history of the arteries, a full account of all the deviations from the

+so-called normal type to which these lesser branches here and elsewhere

+are subject, such account can scarcely be said to be called for in this

+place.

+

+The form of the axillary space is conical, while the arm is abducted

+from the side, and while the osseous and muscular structures remain

+entire. The apex of the cone is formed at the root of the neck beneath

+the clavicle, R, Plate 11, and the subclavious muscle, E, and between

+the coracoid process, L*, of the scapula and the serratus magnus muscle,

+as this lies upon the thoracic side; at this apex the subclavian

+vessels, A B, enter the axillary space. The base of the cone is below,

+looking towards the arm, and is formed in front by the pectoralis major,

+K H, and behind by the latissimus dorsi, O, and teres muscles, P,

+together with a dense thick fascia; at this base the axillary vessels, a

+b, pass out to the arm, and become the brachial vessels, a*b*. The

+anterior side of the cone is formed by the great pectoral muscle, H K,

+Plate 11, and the lesser pectoral, L I. The inner side is formed by the

+serratus magnus muscle, M, Plate 12, on the side of the thorax; the

+external side is formed by the scapular and humeral insertion of the

+subscapular muscle, the humerus and coraco-brachialis muscle; and the

+posterior side is formed by the latissimus dorsi, the teres and body of

+the subscapular muscle.

+

+In this axillary region is contained a complicated mass of bloodvessels,

+nerves, and lymphatic glands, surrounded by a large quantity of loose

+cellular membrane and adipose tissue. All the arterial branches here

+found are given off from the axillary artery; and the numerous veins

+which accompany these branches enter the axillary vein. Nerves from

+other sources besides those of the axillary plexus traverse the axillary

+space; such nerves, for example, as those named intercosto-humeral, seen

+lying on the latissimus tendon, O, Plate 11. The vein named cephalic, S,

+enters the axillary space at that cellular interval occurring between

+the clavicular origin of the deltoid muscle, G, and the humeral

+attachment of the pectoralis major, H, which interval marks the place of

+incision for tying the axillary artery.

+

+The general course of the main vessels through the axillary space would

+be indicated with sufficient accuracy by a line drawn from the middle of

+the clavicle, R R, Plate 11, to the inner border of the biceps muscle,

+N. In this direction of the axillary vessels, the coracoid process, L*,

+from which arises the tendon of the pectoralis minor muscle, L, is to be

+taken as a sure guide to the place of the artery, b, which passes, in

+general, close to the inner side of this bony process. Even in the

+undissected body the coracoid process may be felt as a fixed resisting

+point at that cellular interval between the clavicular attachments of

+the deltoid and great pectoral muscles. Whatever necessity shall require

+a ligature to be placed around the axillary in preference to the

+subclavian artery, must, of course, be determined by the particular

+case; but certain it is that the main artery, at the place B, a little

+above the clavicle, will always be found freer and more isolated from

+its accompanying nerves and vein, and also more easily reached, owing to

+its comparatively superficial situation, than when this vessel has

+become axillary. The incision required to be made, in order to reach the

+axillary artery, b, from the forepart, through the skin, both pectoral

+muscles, and different layers of fasciae, must be very deep, especially

+in muscular, well-conditioned bodies; and even when the level of the

+vessel is gained, it will be found much complicated by its own branches,

+some of which overlie it, as also by the plexus of nerves, D, Plate 12,

+which embraces it on all sides, while the large axillary vein, a, Plate

+11, nearly conceals it in front. This vein in Plate 11 is drawn somewhat

+apart from the artery.

+

+Sometimes the axillary artery is double, in consequence of its high

+division into brachial branches. But as this peculiarity of premature

+division never takes place so high up as where the vessel, B, Plate 11,

+overarches the first rib, F, this circumstance should also have some

+weight with the operator.

+

+When we view the relative position of the subclavian vessels, A B, Plate

+11, to the clavicle, R, we can readily understand why a fracture of the

+middle of this bone through that arch which it forms over the vessels,

+should interfere with the free circulation of the blood which these

+vessels supply to the arm. When the clavicle is severed at its middle,

+the natural arch which the bone forms over the vessels and nerves is

+lost, and the free moving broken ends of the bone will be acted on in

+opposing directions by the various muscles attached to its sternal and

+scapular extremities. The outer fragment follows more freely than the

+inner piece the action of the muscles; but, most of all, the weight of

+the unsupported shoulder and arm causes the displacement to which the

+outer fragment is liable. The subclavius muscle, E, like the pronator

+quadratus muscle of the forearm, serves rather to further the

+displacement of the broken ends of the bone than to hold them in situ.

+

+If the head of the humerus be dislocated forwards beneath L, Plate 11,

+the coracoid attachment of the pectoralis minor muscle, it must press

+out of their proper place and put tensely upon the stretch the axillary

+vessels and plexus of nerves. So large and resistent a body as the head

+of the humerus displaced forwards, and taking the natural position of

+these vessels and nerves, will accordingly be attended with other

+symptoms--such as obstructed circulation and pain or partial paralysis,

+besides those physical signs by which we distinguish the presence of it

+as a new body in its abnormal situation.

+

+When the main vessels and nerves pass from the axillary space to the

+inner side of the arm, they become comparatively superficial in this

+latter situation. The inner border of the biceps muscle is taken as a

+guide to the place of the brachial artery for the whole extent of its

+course in the arm. In plate 11, the artery, b*, is seen in company with

+the median nerve, which lies on its fore part, and with the veins called

+comites winding round it and passing with it and the nerve beneath the

+fascia which encases in a fold of itself all three structures in a

+common sheath. Though the axillary vein is in close contact with the

+axillary artery and nerves, yet the basilic vein, d*, the most

+considerable of those vessels which form the axillary vein, is separated

+from the brachial artery by the fascia. The basilic vein, however,

+overlies the brachial artery to its inner side, and is most commonly

+attended by the internal cutaneous nerve, seen lying upon it in Plate

+11, as also by that other cutaneous branch of the brachial plexus, named

+the nerve of Wrisberg. If a longitudinal incision in the course of the

+brachial artery be made (avoiding the basilic vein) through the

+integument down to the fascia of the arm, and the latter structure be

+slit open on the director, the artery will be exposed, having the median

+nerve lying on its outer side in the upper third of the arm, and passing

+to its inner side towards the bend of the elbow, as at b*, Plate 12. The

+superior and inferior profunda arteries, seen springing above and below

+the point b, Plate 12, are those vessels of most importance which are

+given off from the brachial artery, but the situation of their origin is

+very various. The ulnar nerve, f, lies close to the inner side of the

+main arterial trunk, as this latter leaves the axilla, but from this

+place to the inner condyle, Q, behind which the ulnar nerve passes into

+the forearm, the nerve and artery become gradually more and more

+separated from each other in their descent. The musculo-spiral nerve, g,

+winds under the brachial artery at the middle of the arm, but as this

+nerve passes deep between the short and long heads of the triceps

+muscle, P, and behind the humerus to gain the outer aspect of the limb,

+a little care will suffice for avoiding the inclusion of it in the

+ligature.

+

+The brachial artery may be so effectually compressed by the fingers on

+the tourniquet, against the humerus in any part of its course through

+the arm, as to stop pulsation at the wrist.

+

+The tourniquet is a less manageable and not more certain compressor of

+the arterial trunk than is the hand of an intelligent assistant. At

+every region of the course of an artery where the tourniquet is

+applicable, a sufficient compression by the hand is also attainable with

+greater ease to the patient; and the hand may compress the vessel at

+certain regions where the tourniquet would be of little or no use, or

+attended with inconvenience, as in the locality of the subclavian

+artery, passing over the first rib, or the femoral artery, passing over

+the pubic bone, or the carotid vessels in the neighbourhood of the

+trachea, as they lie on the fore part of the cervical spinal column.

+

+

+DESCRIPTION OF PLATES 11 & 12.

+

+PLATE 11.

+

+A. Subclavian vein, crossed by a branch of the brachial plexus given to

+   the subclavius muscle; a, the axillary vein; a *, the basilic vein,

+   having the internal cutaneous nerve lying on it.

+

+B. Subclavian artery, lying on F, the first rib; b, the axillary artery;

+   b *, the brachial artery, accompanied by the median nerve and venae

+   comites.

+

+C. Brachial plexus of nerves; c*, 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 R. 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.

+

+

+

+[Illustration: Right arm and upper chest, showing blood vessels, muscles

+and other internal organs.]

+Plate 11

+

+

+PLATE 12.

+

+A. Axillary vein, cut and tied; a, the basilic vein, cut.

+

+B. Axillary artery; b, brachial artery, in the upper part of its course,

+   having h, the median nerve, lying rather to its outer side; b*, 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 d is a branch on the coracoid

+   border of the axillary artery; e, the musculo-cutaneous nerve, piercing

+   the coraco-brachialis muscle; f, the ulnar nerve; g, musculo-spiral

+   nerve; h, the median nerve; i, 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.

+

+

+[Illustration: Right arm, showing blood vessels, muscles and other

+internal organs.]

+Plate 12

+

+

+

+COMMENTARY ON PLATES 13 & 14.

+THE SURGICAL FORM OF THE MALE AND FEMALE AXILLAE COMPARED.

+

+Certain characteristic features mark those differences which are to be

+found in all corresponding regions of both sexes. Though the male and

+female bodies, in all their regions, are anatomically homologous or

+similar at basis, yet the constituent and corresponding organs of each

+are gently diversified by the plus or minus condition, the more or the

+less, which the development of certain organs exhibits; and this

+diversity, viewed in the aggregate, constitutes the sexual difference.

+That diversity which defines the sexual character of beings of the same

+species, is but a link in that extended chain of differential gradation

+which marks its progress through the whole animal kingdom. The female

+breast is a plus glandular organ, situated, pendent, in that very

+position where, in a male body, the unevolved mamma is still

+rudimentarily manifested.

+

+The male and female axillae contain the same number and species of

+organs; and the difference by which the external configuration of both

+are marked mainly arises from the presence of the enlarged mammary

+gland, which, in the female, Plate 14, masks the natural outline of the

+pectoral muscle, E, whose axillary border is overhung by the gland; and

+thus this region derives its peculiarity of form, contrasted with that

+of the male subject.

+

+When the dissected axilla is viewed from below, the arm being raised,

+and extended from the side, its contained parts, laid deeply in their

+conical recess, are sufficiently exposed, at the same time that the

+proper boundaries of the axillary cavity are maintained. In this point

+of view from which the axillary vessels are now seen, their relative

+position, in respect to the thorax and the arm, are best displayed. The

+thickness of that fleshy anterior boundary formed by both pectoral

+muscles, E F, Plate 13, will be marked as considerable; and the depth at

+which these muscles conceal the vessels, A B, in the front aspect of the

+thoracico-humeral interval, will prepare the surgeon for the

+difficulties he is to encounter when proceeding to ligature the axillary

+artery at the incision made through the anterior or pectoral wall of

+this axillary space.

+

+The bloodvessels of the axilla follow the motions of the arm; and

+according to the position assumed by the arm, these vessels describe

+various curves, and lie 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 curve from the clavicle at the point

+K, Plate 14, 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 described, in reference

+to the thorax, from the point 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 in their passage to the inner side of the arm. The vessels may be

+readily compressed against the upper third of the humerus by the finger,

+passed into the axilla, and still more effectually if the arm be raised,

+as this motion will rotate the tuberous head of the humerus downwards

+against them.

+

+The vessels and nerves of the axilla are bound together by a fibrous

+sheath derived from the membrane called costo-coracoid; and the base or

+humeral outlet of this axillary space, described by the muscles C, K, E,

+G, Plate 13, is closed by a part of the fascial membrane, g, extended

+across from the pectoral muscle, E, to the latissimus dorsi tendon, K.

+In the natural position of the vessels at that region of their course

+represented in the Plates, the vein A overlies 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 is drawn a

+little apart from them.

+

+The axillary space gives lodgment to numerous lymphatic glands, which

+are either directly suspended from the main artery, or from its

+principal branches, by smaller branches, destined to supply them. These

+glands are more numerous in the female axilla, Plate 14, than in the

+male, Plate 13, and while they seem to be, as it were, indiscriminately

+scattered here and there through this region, we observe the greater

+number of them to be gathered together along the axillary side of the

+great pectoral muscle; at which situation, h, in the diseased condition

+of the female breast, they will be felt to form hard, nodulated masses,

+which frequently extend as far up through the axillary space as the root

+of the neck, involving the glands of this latter region also in the

+disease.

+

+The contractile motions of the pectoral muscle, E, of the male body,

+Plate 13, are during life readily distinguishable; and that boundary

+which it furnishes to the axillary region is well defined; but in the

+female form, Plate 14, the general contour of the muscle E, while in

+motion, is concealed by the hemispherical mammary gland, F, which,

+surrounded by its proper capsule, lies loosely pendent from the fore

+part of the muscle, to which, in the healthy state of the organ, it is

+connected only by free-moving bonds of lax cellular membrane. The

+motions of the shoulder upon the trunk do not influence the position of

+the female mammary gland, for the pectoral muscle acts freely beneath

+it; but when a scirrhus or other malignant growth involves the mammary

+organ, and this latter contracts, by the morbid mass, a close adhesion

+to the muscle, then these motions are performed with pain and

+difficulty.

+

+When it is required to excise the diseased female breast, (supposing the

+disease to be confined to the structure of the gland itself,) the

+operation may be performed confidently and without difficulty, in so far

+as the seat of operation does not involve the immediate presence of any

+important nerves or bloodvessels. But when the disease has extended to

+the axillary glands, the extirpation of these (as they lie in such close

+proximity to the great axillary vessels and their principal branches)

+requires cautious dissection. It has more than once happened to eminent

+surgeons, that in searching for and dissecting out these diseased

+axillary glands, H, h, Plate 14, the main artery has been wounded.

+

+As the coracoid process points to the situation of the artery in the

+axilla, so the coraco-brachialis muscle, C, marks the exact locality of

+the vessel as it emerges from this region; the artery ranges along the

+inner margin of both the process and the muscle, which latter, in fleshy

+bodies, sometimes overhangs and conceals it. When the vessel has passed

+the insertion of the coraco-brachialis, it becomes situated at the inner

+side of the biceps, which also partly overlaps it, as it now lies on the

+forepart of the brachialis  anticus. As the general course of the

+artery, from where it leaves the axilla to the bend of the elbow, is one

+of winding from the inner side to the forepart of the limb, so should

+compression of the vessel, when necessary, be directed in reference to

+the bone accordingly--viz., in the upper or axillary region of the arm,

+from within outwards, and in the lower part of the arm, from before

+backwards.

+

+All incised, lacerated, or contused wounds of the arm and shoulder,

+happening by pike, bayonet, sabre, bullet, mace, or arrow, on the outer

+aspect of the limb, are (provided the weapon has not broken the bones)

+less likely to implicate the great arteries, veins, and nerves. These

+instruments encountering the inner or axillary aspect of the member,

+will of course be more likely to involve the vessels and nerves in the

+wound. In severe compound fractures of the humerus occurring from force

+applied at the external side of the limb, the brachial vessels and

+nerves have been occasionally lacerated by the sharp jagged ends of the

+broken bone,--a circumstance which calls for immediate amputation of the

+member.

+

+The axilla becomes very frequently the seat of morbid growths, which,

+when they happen to be situated beneath the dense axillary fascia, and

+have attained to a large size, will press upon the vessels and nerves of

+this region, and cause very great inconvenience. Adipose and other kind

+of tumours occurring in the axilla beneath the fascia, and in close

+contact with the main vessels, have been known to obstruct these vessels

+to such a degree, as to require the collateral or anastomatic

+circulation to be set up for the support; of the limb. When abscesses

+take place in the axilla, beneath the fascia, it is this structure which

+will prevent the matter from pointing; and it is required, therefore, to

+lay this fascia freely open by a timely incision. The accompanying

+Plates will indicate the proper direction in which such incision should

+be made, so as to avoid the vessels A, B. When the limb is abducted from

+the side, the main vessels and nerves take their position parallel with

+the axis of the arm. 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 shall be required to bear forcibly

+against the axillary region. While we know that the locality of the main

+vessels and nerves is that very situation upon which a pad or fulcrum

+presses, when placed in the axilla for securing the reduction of

+fractures of the clavicle, the neck of the humerus, or scapula, so

+should this member of the fracture apparatus be adapted, as well to

+obviate this pressure upon these structures, as to give the needful

+support to the limb in reference to the clavicle, &c. The habitual use,

+for weeks or more, of a hard, resisting fulcrum in the axilla, must act

+in some degree like the pad of a tourniquet, arresting the flow of a

+vigorous circulation, which is so essential to the speedy union of all

+lesions of bones. And it should never be lost sight of, that all

+grievously coercive apparatus, which incommode the suffering patient,

+under treatment, are those very instruments which impede the curative

+process of Nature herself.

+

+The anatomical mechanism of the human body, considered as a whole, or

+divisible into regions, forms a study so closely bearing upon practice,

+that the surgeon, if he be not also a mechanician, and fully capable of

+making his anatomical knowledge suit with the common principles of

+mechanics, while devising methods for furthering the efforts, of Nature

+curatively, may be said to have studied anatomy to little or no purpose.

+The shoulder apparatus, when studied through the principle of mechanics,

+derives an interest of practical import which all the laboured

+description of the schools could never supply to it, except when

+illustrating this principle.

+

+The disposal of the muscular around the osseous elements of the shoulder

+apparatus, forms a study for the surgeon as well in the abnormal

+condition of these parts, as in their normal arrangement; for in

+practice he discovers that that very mechanical principle upon which

+both orders of structures (the osseous and muscular) are grouped

+together for normal articular action, becomes, when the parts are

+deranged by fracture or, other accident, the chief cause whereby

+rearrangement is prevented, and the process of reunion obstructed. When

+a fracture happens in the shaft of the humerus, above or below the

+insertions of the pectoral and latissimus dorsi muscles, these are the

+very agents which when the bone possessed its integrity rendered it

+functionally fitting, and which, now that the bone is severed, produce

+the displacement of the lower fragment from the upper one. To counteract

+this source of derangement, the surgeon becomes the mechanician, and

+now, for the first time, he recognises the necessity of the study of

+topographical anatomy.

+

+When a bone is fractured, or dislocated to a false position and retained

+there by the muscular force, the surgeon counteracts this force upon

+mechanical principle; but while he puts this principle in operation, he

+also acknowledges to the paramount necessity of ministering to the ease

+of Nature as much as shall be consistent with the effectual use of the

+remedial agent; and in the present state of knowledge, it is owned, that

+that apparatus is most efficient which simply serves both objects, the

+one no less than the other. And, assuming this to be the principle which

+should always guide us in our treatment of fractures and dislocations, I

+shall not hesitate to say, that the pad acting as a fulcrum in the

+axilla, or the perineal band bearing as a counterextending force upon

+the groin (the suffering body of the patient being, in both instances,

+subjected for weeks together to the grievous pressure and irritation of

+these members of the apparatus), do not serve both objects, and only one

+incompletely; I say incompletely, for out of every six fractures of

+either clavicle or thigh-bone, I believe that, as the result of our

+treatment by the present forms of mechanical contrivances, there would

+not be found three cases of coaptation of the broken ends of the bone so

+complete as to do credit to the surgeon. The most pliant and portable of

+all forms of apparatus which constitute the hospital armamentaria, is

+the judgment; and this cannot give its approval to any plan of

+instrument which takes effect only at the expense of the patient.

+

+

+DESCRIPTION OF PLATES 13 & 14.

+

+PLATE 13.

+

+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; b, basilic

+   vein, forming, with a, 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 g, the axillary fascia, and

+   perforated, 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.

+

+

+[Illustration: Arm and chest, showing blood vessels, muscles and other

+internal organs.]

+Plate 13

+

+

+PLATE 14.

+

+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.

+

+

+[Illustration: Arm and chest, showing blood vessels, muscles and other

+internal organs.]

+Plate 14

+

+

+

+COMMENTARY ON PLATES 15 & 16.

+

+THE SURGICAL DISSECTION OF THE BEND OF THE ELBOW

+AND THE FOREARM, SHOWING THE RELATIVE POSITION

+OF THE ARTERIES, VEINS, NERVES, &c.

+

+The farther the surgical region happens to be removed from the centre of

+the body, the less likely is it that all accidents or operations which

+involve such regions will concern 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, the 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 the 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 from 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 every surgical region becomes a study of more or

+less interest to the surgeon, according to the degree of importance

+attaching to the organs contained, or according to the frequency of such

+accidents as are liable to occur in each. The bend of the elbow is a

+region of anatomical importance, owing to the fact of its giving passage

+to C, Plate 15, the main artery of the limb, and also because in it are

+located the veins D, B, E, F, which are frequently the subject of

+operation. The anatomy of this region becomes, therefore, important;

+forasmuch as the operation which is intended to concern the veins alone,

+may also, by accident, include the main arterial vessel which they

+overlie. The nerves, which are seen to accompany the veins

+superficially, as well as that which accompanies the more

+deeply-situated artery, are, for the same reason, required to be known.

+

+The course of the brachial artery along the inner border of the biceps

+muscle is comparatively superficial, from the point where it leaves the

+axilla to the bend of the elbow. In the whole of this course it is

+covered by the fascia of the arm, which serves to isolate it from the

+superficial basilic vein, B, and the internal cutaneous nerve, both of

+which nevertheless overlie the artery. The median nerve, d, Plate 15,

+accompanies the artery in its proper sheath, which is a duplication of

+the common fascia; and in this sheath are also situated the venae

+comites, making frequent loops around the artery. The median nerve

+itself, D, Plate 16, takes a direct course down the arm; and the

+different relative positions which this nerve holds in reference to the

+artery, C, at the upper end, the middle, and the lower end of the arm,

+occur mainly in consequence of the undulating character of the vessel

+itself.

+

+When it is required to ligature the artery in the middle of the arm, the

+median nerve will be found, in general, at its outer side, between it

+and the biceps; but as the course of the artery is from the inner side

+of the biceps to the middle of the bend of the elbow, so we find it

+passing under the nerve to gain this locality, C, Plate 16, where the

+median nerve, D, then becomes situated at the inner side of the vessel.

+The median nerve, thus found to be differently situated in reference to

+the brachial artery, at the upper, the middle, and the lower part of the

+arm, is (with these facts always held in memory) taken as the guide to

+that vessel. An incision made of sufficient length (an inch and a half,

+more or less) over the course of the artery, and to the outer side of

+the basilic vein, B, Plate 16, will divide the skin, subcutaneous

+adipose membrane, which varies much in thickness in several individuals,

+and will next expose the common fascial envelope of the arm. When this

+fascia is opened, by dividing it on the director, the artery becomes

+exposed; the median nerve is then to be separated from the side of the

+vessel by the probe or director, and, with the precaution of not

+including the venal comites, the ligature may now be passed around the

+vessel. In the lower third of the arm it is not likely that the operator

+will encounter the ulnar nerve, and mistake it for the median, since the

+former, d, Plate 16, is considerably removed from the vessel. If the

+incision be made precisely in the usual course of the brachial artery,

+the ulnar nerve will not show itself. It will be well, however, to bear

+in mind the possible occurrence of some of those anomalies to that

+normal relative position of the artery, the median, and the ulnar nerve,

+which the accompanying Plates represent.

+

+The median nerve, D, Plate 16, is sometimes found to lie beneath the

+artery in the middle and lower third of the arm. At other times it is

+found far removed to the inner side of the usual position of the vessel,

+and lying in close contact with the ulnar nerve, d. Or the brachial

+artery may take this latter position, while the median nerve stands

+alone at the position of D, Plate 16. Or both the main artery and the

+median nerve may course much to the inner side of the biceps muscle, A,

+Plate 16, while in the usual situation of the nerve and vessel there is

+only to be found a small arterial branch (the radial), which springs

+from the brachial, high up in the arm. Or the nerve and vessel may be

+lying concealed beneath a slip of the brachialis anticus muscle, E,

+Plate 16, in which case no appearance of them will be at all manifested

+through the usual place of incision made for the ligature of the

+brachial vessel. Or, lastly, there may be found more arteries than the

+single main brachial appearing at this place in the arm, and such

+condition of a plurality of vessels occurs in consequence of a high

+division of the brachial artery. Each of these variations from the

+normal type is more or less frequent; and though it certainly is of

+practical import to bear them in mind, still, as we never can foretell

+their occurrence by a superficial examination of the limb, or pronounce

+them to be present till we actually encounter them in operation, it is

+only when we find them that we commence to reason upon the facts; but

+even at this crisis the knowledge of their anatomy may prevent a

+confusion of ideas.

+

+That generalization of the facts of such anomalies as are liable to

+occur to the normal character of the brachial artery, represented in

+Plates 15 and 16, which appears to me as being most inclusive of all

+their various conditions, is this--viz., that the point of division into

+radial, ulnar, and interosseous, which F, Plate 16, usually marks, may

+take place at any part of the member between the bend of the elbow and

+the coracoid process in the axillary space.

+

+At the bend of the elbow, the brachial artery usually occupies the

+middle point between e, the inner condyle of the humerus and the

+external margin of the supinator radii longus muscle, G. The structures

+which overlie the arterial vessel, C, Plate 16, at this locality,

+numbering them from its own depth to the cutaneous surface, are these--

+viz., some adipose cellular membrane envelopes the vessel, as it lies on

+E, the brachialis anticus muscle, and between the two accompanying

+veins; at the inner side of the artery, but separated from it by a small

+interval occupied by one of the veins, is situated the median nerve d,

+Plate 15. Above all three structures is stretched that dense fibrous

+band of the fascia, H, Plate 16, which becomes incorporated with the

+common fascial covering of the forearm. Over this fascial process lies

+the median basilic vein, F B, Plate 15, accompanying which are seen some

+branches of the internal cutaneous nerve. The subcutaneous adipose

+tissue and common integument cover these latter. If it be required to

+ligature the artery at this locality, an incision two inches and a half

+in length, made along the course of the vessel, and avoiding the

+superficial veins, will expose the fascia; and this being next divided

+on the director, the artery will be exposed resting on the brachialis

+anticus, and between the biceps tendon and pronator teres muscle. As

+this latter muscle differs in width in several individuals, sometimes

+lying in close contact with the artery, and at other times leaving a

+considerable interval between the vessel and itself, its outer margin is

+not, therefore, to be taken as a sure guide to the artery. The inner

+border of the biceps indicates much more generally the situation of the

+vessel.

+

+The bend of the elbow being that locality where the operation of

+phlebotomy is generally performed, it is therefore required to take

+exact account of the structures which occupy this region, and more

+especially the relation which the superficial veins hold to the deeper

+seated artery. In Plate 15, the artery, C, is shown in its situation

+beneath the fascial aponeurosis, which comes off from the tendon of the

+biceps, a portion of which has been cut away; and the venous vessel, F

+B, which usually occupies the track of the artery, is pushed a little to

+the inner side. While opening any part of the vessel, F B, which

+overlies the artery, it is necessary to proceed with caution, as well

+because of the fact that between the artery, C, and the vein, F B, the

+fascia alone intervenes, as also because the ulnar artery is given off

+rather frequently from the main vessel at this situation, and passes

+superficial to the fascia and flexors of the forearm, to gain its usual

+position at K, Plate 15. I have met with a well marked example of this

+occurrence in the living subject.

+

+The cephalic vein, D, is accompanied by the external cutaneous nerve,

+which branches over the fascia on the outer border of the forearm. The

+basilic vein, B, is accompanied by the internal cutaneous nerve, which

+branches in a similar way over the fascia of the inner and fore part of

+the forearm. The numerous branches of both these nerves interlace with

+the superficial veins, and are liable to be cut when these veins are

+being punctured. Though the median basilic, F, and the basilic vein, B,

+are those generally chosen in the performance of the operation of

+bleeding, it will be seen, in Plate 15, that their contiguity to the

+artery necessarily demands more care and precision in that operation

+executed upon them, than if D, the cephalic vein, far removed as it is

+from the course of the artery, were the seat of phlebotomy.

+

+As it is required, in order to distend the superficial veins, D, B, F,

+that a band should be passed around the limb at some locality between

+them and the heart, so that they may yield a free flow of blood on

+puncture, a moderate pressure will be all that is needful for that end.

+It is a fact worthy of notice, that the excessive pressure of the

+ligaturing band around the limb at A B, Plate 15, will produce the same

+effect upon the veins near F, as if the pressure were defective, for in

+the former case the ligature will obstruct the flow of blood through the

+artery; and the vein, F, will hence be undistended by the recurrent

+blood, just as when, in the latter case, the ligature, making too feeble

+a pressure on the vein, B, will not obstruct its current in that degree

+necessary to distend the vessel, F.

+

+Whichever be the vein chosen for phlebotomy at the bend of the elbow, it

+will be seen, from an examination of Plates 15 and 16, that the opening

+may be made with most advantage according to the longitudinal axis of

+the vessel; for the vessel while being cut open in this direction, is

+less likely to swerve from the point of the lancet than if it were to be

+incised across, which latter mode is also far more liable to implicate

+the artery. Besides, as the nerves course along the veins from above

+downwards--making, with each other, and with the vessels, but very acute

+angles--all incisions made longitudinally in these vessels, will not be

+so likely to divide any of these nerves as when the instrument is

+directed to cut crossways.

+

+The brachial artery usually divides, at the bend of the elbow, into the

+radial, the ulnar, and the interosseous branches. The point F, Plate 16,

+is the common place of division, and this will be seen in the Plate to

+be somewhat below the level of the inner condyle, e. From that place,

+where the radial and ulnar arteries spring, these vessels traverse the

+forearm, in general under cover of the muscles and fascia, but

+occasionally superficial to both these structures. The radial artery, F

+N, Plate 16, takes a comparatively 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

+Plate 16, at the outer side of the vessel. The supinator radii longus

+muscle in general overlaps, with its inner border, both the radial

+artery and nerve. At the situation of the radial pulse, I, Plate 15, the

+artery is not accompanied by the nerve, for this latter will be seen, in

+plate 16, to pass outward, under the tendon of the supinator muscle, to

+the integuments.

+

+The ulnar artery, whose origin is seen near F, Plate 16, 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, Plate 16, 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 and ligatured 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, Plate 16, is the guide to the

+radial artery; and the outer margin of the flexor carpi ulnaris muscle,

+K, Plate 16, indicates the locality of the ulnar artery. Both arteries,

+I, K, Plate 15, 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 over the track of

+the vessels, through the skin and the fascia, will readily expose each.

+

+Whenever circumstances may 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, Plate 16, the course of the vessel may be 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. The line of incision will 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 mid-place in the wrist at Q. The ulnar

+nerve, d, Plate 16, passing behind the inner condyle, e, does not come

+into connexion with the ulnar artery until both arrive at the place O.

+It will, however, be considered an awkward proceeding 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 arteries happen to be completely divided

+in a wound, both ends of the vessel will bleed alike, in consequence of

+the free anastomosis of both arteries in the hand.

+

+

+DESCRIPTION OF PLATES 15 & 16.

+

+PLATE 15.

+

+A. Fascia covering the biceps muscle.

+

+B. Basilic vein, with the internal cutaneous nerve.

+

+C. Brachial artery, with the venae 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.

+

+

+[Illustration: Right arm, showing blood vessels, muscles and other

+internal organs.]

+Plate 15

+

+

+PLATE 16.

+

+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 artery.

+

+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. Lower end of ulnar artery, in company with the ulnar nerve.

+

+T. Pisiform bone.

+

+U. Extensor metacarpi pollicis.

+

+

+[Illustration: Right arm, showing blood vessels, muscles and other

+internal organs.]

+Plate 16

+

+

+

+COMMENTARY ON PLATES 17, 18, & 19.

+

+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 blood vessels 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, Plate 17, occupies (as its name indicates) the radial

+border of the forepart of the wrist, and the ulnar artery, C, Plate 17,

+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, Plate 17, at the wrist, is not accompanied by the

+radial nerve; for this nerve, C, Plate 19, passes from the side of the

+artery, at a position, C, Plate 19, varying from one to two or more

+inches above the wrist, to gain the dorsal aspect of the hand. The ulnar

+artery, C, Plate 17, is attended by the ulnar nerve, D, in the wrist,

+and both these pass in company to the palm. The ulnar nerve, D E, lies

+on the ulnar 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, Plate 17, through the

+integument, and this incision will expose the fascia, which forms a

+common investment for all the structures at this region. When this

+fascia has been cautiously slit open on the director, the vessels will

+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, Plate 18, 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, Plate 19, forms the deep palmar arch E, Plate 18. This deep palmar

+arch lies close upon the forepart 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,

+Plate 19. The deep palmar arch, E, Plate 18, inosculates with a branch

+of the ulnar artery, I, Plate 18, whilst its dorsal interosseal

+branches, Plate 19, communicate freely with the dorsal carpal arch,

+which is formed by a branch of the radial artery E, Plate 19, and the

+terminal branch of the posterior interosseous vessel.

+

+The ulnar artery, C, Plate 17, 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 superficial palmar

+arch, F. From this arch arise three or four branches of considerable

+size, which are destined to supply the fingers. A little above 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, b b, and ulnar nerves, e e. The superficial 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, Plate 18, which passes between the muscles of the little

+finger to join the deep arch beneath the long flexor tendons. 2nd, by

+the branch (superficialis volae) which springs from the radial artery,

+A, Plate 17, and crosses the muscles of the ball of the thumb, to join

+the terminal branch of the superficial arch, F, Plate 17. 3rd, by

+another terminal branch of the superficial arch, which joins the

+arteries of the thumb, derived from the radial vessel, as seen at e,

+Plate 18.

+

+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

+haemorrhage occasioned by a wound of either of them. It will be at once

+seen, that when a haemorrhage takes place from any of these larger

+vessels of the hand, the bleeding will 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, viz.,

+that though in the arm these arteries are separate, in the hand their

+communication renders them as one.

+

+If a haemorrhage 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 F, Plate 17, bleeds, and in order to arrest

+that bleeding we tie the vessel C, Plate 17, still the vessel F will

+continue to bleed, in consequence of its communication with the vessel

+E, Plate 18, by the branch 1, Plate 18, and other branches above

+mentioned. If E, Plate 18, bleeds, a ligature applied to the vessel A,

+Plate 18, will 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

+Plates 17 and 19.

+

+Any considerable haemorrhage, therefore, which may be caused by a wound

+of the superficial or deep palmar arches, or their branches, and which

+we are unable to arrest by compression, applied directly to the patent

+orifices of the vessel, will in general require that a ligature be

+applied to both the radial and ulnar arteries at the wrist; and it

+occasionally happens that even this proceeding will not stop the flow of

+blood, for the interosseous arteries, which also communicate with the

+vessels of the hand, may still maintain the current of circulation

+through them. These interosseous arteries being branches of the ulnar

+artery, and being given off 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

+all probability 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 difficulty

+which occasionally presents itself, as to the arrest of haemorrhage from

+the vessels of the hand. In addition to these facts he will do well to

+remember some other arrangements of these vessels, which are liable to

+occur; and upon these I shall offer a few observations.

+

+While I view 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 having 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 measure 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 individually liable.

+

+Again, as the single brachial artery divides into the three arteries 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 palmar 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 when

+this latter fails (for fail it will, sometimes,) we then reasonably

+arrive at the conclusion 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 as 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, viz., that they

+communicate with each other in the hand. Hence, therefore, it becomes

+evident, 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 two great hazards. It is also true

+that to tie the main brachial artery for a haemorrhage of anyone 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 vessels 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 particular, there can be none attending the following rule of

+conduct, viz., that in all cases of haemorrhage, caused by wounds of the

+vessels of the upper limb, we should, if at all practicable, endeavour

+to stop the flow of blood from the divided vessels in the wound itself,

+by ligature or otherwise; and both ends of the divided 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, F, Plate 17, 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, Plates 17 and 18. All deep incisions

+made in the median line of the forepart of the wrist are liable to wound

+the median nerve B, Plate 17. When the thumb, together with its

+metacarpal bone, is being amputated, the radial artery E, Plate 19,

+which winds round near the head of that bone, may be wounded. It is

+possible, by careful dissection, to perform this operation without

+dividing the radial vessel.

+

+

+DESCRIPTION OF PLATES 17, 18, & 19.

+

+PLATE 17.

+

+A. Radial artery.

+

+B. Median nerve; b b b b, its branches to the thumb and fingers.

+

+C. Ulnar artery, forming F, the superficial palmar arch.

+

+D. Ulnar nerve; E e e, 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 muscle of the little finger.

+

+M. Flexor brevis pollicis muscle.

+

+N. Abductor pollicis muscle.

+

+OOOO. 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; P P P, their digital

+   prolongations.

+

+T. Tendon of flexor carpi ulnaris.

+

+U. Union of the digital arteries at the tip of the finger.

+

+

+

+[Illustration: Right hand, showing blood vessels, muscles and other

+internal organs.]

+Plate 17

+

+

+

+PLATE 18.

+

+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 off e, 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; h, 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

+   lumbricales muscles cut and turned down.

+

+O. Tendon of flexor pollicis longus.

+

+P. Carpal end of the metacarpal bone of the thumb.

+

+

+[Illustration: Left hand, showing blood vessels, muscles and other

+internal organs.]

+Plate 18

+

+

+

+PLATE 19.

+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.

+

+

+[Illustration: Right hand, showing blood vessels, muscles and other

+internal organs.]

+Plate 19

+

+

+

+COMMENTARY  ON PLATES 20 & 21.

+

+THE RELATIVE POSITION OF THE CRANIAL,

+NASAL, ORAL, AND PHARYNGEAL CAVITIES, &c.

+

+On making a section (vertically through the median line) of the

+cranio-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 anatomists,

+that the facial apparatus manifests in reference to the cranial

+structures the same general relations which the hyoid apparatus bears to

+the cervical vertebrae, and that these relations are similar to those

+which the thoracic apparatus bears to the dorsal vertebrae. To this

+anatomical fact I shall 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, Plate 20, is continuous with the spinal

+canal C. The osseous envelope of the brain, called calvarium, 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 foramina 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 vertebrae, 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 likewise by that

+continuity apparent between all compartments of the 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 undefended

+condition, is liable to fracture. When the cranium is fractured, in

+consequence of force applied to its anterior or posterior surfaces, A or

+B, Plate 20, 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,

+while 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, while 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 will follow 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 will take effect at the

+junction of the spine with the cranial base, whilst the resisting force

+will 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 where 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 all hollow

+forms, receive the vibratory influence of force externally applied. The

+brain receives the concussion of the force applied to its osseous

+envelope; and when this latter happens to be fractured, the danger to

+life is not in proportion to the extent of the fracture here, any more

+than elsewhere in the skeleton fabric, but is solely in proportion to

+the amount 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 protuberance,

+B, within 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, Plate 21, 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 partition

+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, Plate 20, 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 likewise.

+All structures situated on either side of the median line are similar.

+And the structure which occupies the median line is itself double, or

+duality fused into symmetrical unity. The osseous nasal septum is

+composed of two laminae laid side by side. The spongy bones, X W, are

+attached to the outer wall of the nasal fossa, and are situated one

+above the other. These bones are three in number, the uppermost is the

+smallest. The outer wall of each naris is grooved by three fossae,

+called meatuses, and these are situated between 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 maxillary 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 which lines all parts of the nasal fossa almost completely

+fills this cavity. When polypi or other growths occupy the nasal fossae,

+they must gain room at the expense of neighbouring parts. The nasal duct

+may have a bent probe introduced 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 lower spongy bone, W, at which locality

+the duct opens. An instrument of sufficient length, when introduced into

+the nostrils in the same direction, will, if passed backwards through

+the posterior nares, reach the opening of the Eustachian tube, 8.

+

+While the jaws are closed, the tongue, R, Plate 20, occupies the oral

+cavity almost completely. When the jaws are opened they form a cavity

+between them equal in capacity to the degree at which they are sundered

+from each other. The back of the pharynx can be seen when the jaws are

+widely opened if the tongue be depressed, as R, Plate 20. The hard

+palate, U, which forms the roof of the mouth, is extended further

+backwards by the soft palate, V, which hangs as the loose velum of the

+throat between the nasal fossae above and the fauces below. Between the

+velum palati, V, and the root of the tongue, we may readily discern,

+when the jaws are open, two ridges of arching form, 5, 6, on either side

+of the fauces. These prominent arches and their fellows are named the

+pillars of the fauces. The anterior pillar, 5, is formed by the

+submucous palato-glossus muscle; the posterior pillar, 6, is formed by

+the palato-pharyngeus muscle. Between these pillars, 5 and 6, is

+situated the tonsil, S, beneath the mucous membrane. When the tonsils of

+opposite sides become inflamed and suppurate, an incision may be made

+into either gland without much chance of wounding the internal carotid

+artery; for, in fact, this vessel lies somewhat removed from it behind.

+In Plate 21, that point of the superior constrictor of the pharynx,

+marked D, indicates the situation of the tonsil gland; and a

+considerable interval will be seen to exist between D and the internal

+carotid vessel F.

+

+If the head be thrown backwards the nasal and oral cavities will look

+almost vertically towards the pharyngeal pouch. When the juggler is

+about to "swallow the sword," he throws the head back so as to bring the

+mouth and fauces in a straight line with 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 whom

+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 below the epiglottis, 9, as when

+they are being passed into the oesophagus by the mouth. The glottis may

+be always avoided by keeping the point of the instrument pressing

+against the back of the pharynx during its passage downwards.

+

+When in suspended animation we endeavour to inflate the lungs through

+the nose or mouth, we should press the larynx, 10, 11,12, backwards

+against the vertebral column, so as to close the oesophageal tube.

+

+

+DESCRIPTION OF PLATES 20 & 21.

+

+PLATE 20.

+

+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.

+

+I I*. Seventh cervical vertebra.

+

+K K*. First rib surrounding the upper part of the pleural sac.

+

+L L*. Subclavian artery of the right side overlying the pleural sac.

+

+M M*. Right subclavian vein.

+

+N. Right common carotid artery cut at its origin.

+

+O. Trachea.

+

+P. Thyroid body.

+

+Q. Oesophagus.

+

+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.

+

+

+[Illustration: Head and neck, in section, from front to back; showing

+blood vessels, muscles and other internal organs.]

+Plate 20

+

+

+PLATE 21.

+

+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 F, 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.

+

+

+

+

+[Illustration: Head and neck, showing blood vessels, muscles and other

+internal organs.]

+Plate 21

+

+

+

+COMMENTARY ON PLATE 22.

+

+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, (considering this body morphologically,) results,

+simply, from the circumstance 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

+mammalia 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 thoracico-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 occupied 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 22, the two lungs, D D*, whilst in

+their ordinary expanded state, may be said to range over all 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

+lungs. 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 expanded within

+it. The increase in thoracic space is attained, laterally, by the

+expansion of the ribs, C I; 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 all the

+ribs on each side to each other; and by the ascent of the diaphragm. The

+expansion of the lungs around the heart would compress this organ, were

+it not that the costal sides yield 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 all 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

+walls are dilatable by the muscular effort; and, therefore, between the

+extremes of inspiration and expiration, the lungs still 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 respiratory act

+ceases--the lungs become immovable, and the thoracic walls are (so far

+as the motions of respiration are concerned) rendered immovable also.

+The muscles of respiration cannot, therefore, 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 still further proof of this in the

+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 effect is produced as when the

+external air was admitted through an opening in the side.

+

+When serous or purulent effusion takes place within the cavity of the

+pleura, the capacity of the lung becomes lessened according to the

+quantity of the effusion. 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 difference between the thoracic

+walls externally, even when a considerable quantity of either serum,

+pus, or air, occupies the pleural sacs.

+

+In the healthy state of the thoracic organs, a sound characteristic of

+the presence of the lung adjacent to the walls of the thorax may be

+elicited by percussion, or heard during the respiratory act through the

+stethoscope, over all that costal space ranging anteriorly between B,

+the first rib, and I K, the eight 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 effused 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 respiratory murmur at that locality which the fluid

+occupies. Fluid, when effused into the pleural sac, will of course

+gravitate; and its position will vary according to the position of the

+patient. The sitting or standing posture will therefore suit best for

+the examination of the thorax in reference to the presence of fluid.

+

+Though the lungs are closely applied to the costal sides at all 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 downwards 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 effused 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 hydro-pericardium 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 line 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 pneumothorax 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 hollow

+sound on percussion, whilst, by the ear or stethoscope applied 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 different

+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, I I*, is the greatest. The perpendicular depth of the thorax,

+measured anteriorly, ranges from A, the top of the sternum, to F, 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 respiratory murmur over all 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 yielded a 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.

+

+Owing to the conical form of the thoracic space, the apex of which is

+measured by the first ribs, B B*, and the basis by I I*, it will be seen

+that if percussion be made directly from before, backwards, 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 axillae, 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 expiration.

+Percussion, when made over the surface of the angle of the right side,

+discovers the presence of the liver, G G*. When made over the median

+line, 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 wholly.

+

+Beneath the umbilicus, N, and on either side of it as far outwards as

+the lower asternal ribs, K L, thus ranging the abdominal parietes

+transversely, percussion discovers the transverse colon, O, P, O*. 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 where 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 22, 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 liver, G, and

+the stomach, M, below. These latter organs, although occupying abdominal

+space, rise to a considerable height behind K L, the asternal ribs, a

+fact which should be borne in mind when percussing the walls of the

+thorax and abdomen at this region.

+

+

+DESCRIPTION OF PLATE 22.

+

+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.

+

+I I*. 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.

+

+OO*. 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.

+

+

+[Illustration: Chest and abdomen, showing bones, blood vessels, muscles

+and other internal organs.]

+Plate 22

+

+

+

+COMMENTARY ON PLATE 23.

+

+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 proportion 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 precedence 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 individuals 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 23, 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

+corresponding 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 muffles 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, O, 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 suspensory ligaments--it must happen

+that the diaphragm while descending and ascending in the motions of

+inspiration and expiration will 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 fills 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 abdomen relax during every inspiration, and

+thus this cavity 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 the

+lungs on either side of it. As the expanding lungs force the diaphragm

+downwards, the heart follows it, and all the abdominal viscera yield

+place to the descending thoracic contents. In strong muscular efforts

+the diaphragm plays an important part, for, previously 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 contracting 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 herniae of

+various kinds are produced. The most common situations of abdominal

+herniae are at the inguinal regions, towards which the intestines, T T,

+naturally gravitate; and at these situations the abdominal parietes are

+weak and membranous.

+

+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 situation. The

+liver occupies the whole depth of the right hypochondrium; 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 caecum, 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 will 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 will 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 cardiac 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, R,

+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 all, 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 thoracic organs to have full and easy play in the

+respiratory movements 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 apparatus remains underanged,

+the motor powers perform their functions 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 efforts

+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,

+will 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, will equally obstruct the breathing; and though the

+situation of the accumulated air is in fact anatomically different in

+both cases, yet the effect produced is similar. Interlobular pressure

+and interpleural pressure result in the same thing, viz., the permanent

+retention of the air external to the pulmonary cells, which, in the

+former case, are collapsed individually; 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 will,

+in the same manner as the distended pleural sac, depress the diaphragm

+and render the thoracic muscles inoperative. The foregoing observations

+have been made in reference to the effect of wounds of the thorax, the

+proper treatment of which will be obviously suggested by our knowledge

+of the state of the contained organs which have suffered lesion.

+

+

+

+DESCRIPTION OF PLATE 23.

+

+A. Upper end of the sternum.

+

+B B.* First pair of ribs.

+

+C C.* 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 nerve on its outer border.

+

+I I*. Right and left lungs collapsed, and turned outwards, to show the

+      heart's outline.

+

+K K*. 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 superficial 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 coeliac axis dividing into the coronary, splenic and hepatic

+   arteries.

+

+Q. Inferior vena cava.

+

+R. The spleen.

+

+S S* S**. 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.

+

+S***. Ascending colon in the right iliac region.

+

+T. Convolutions of the small intestines distended with air.

+

+

+[Illustration: Chest and abdomen, showing bones, blood vessels, muscles

+and other internal organs.]

+Plate 23

+

+

+

+COMMENTARY ON PLATE 24.

+

+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 wholly 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 still 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 vertebral column. In Plate 26 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 obliterated ductus arteriosus joins it. See

+Plates 12 & 26.

+

+The pulmonary artery, B, Plates 1 & 2, 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 derangement 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 of the thorax. As the

+arch of the aorta is directed from before backwards--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 must 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 vertebrae, 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 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, H H*; the

+thoracic duct, L; the oesophagus, I; the superior vena cava, H, Plate

+26, or wholly obliterate either of the vagi nerves. The aneurism of the

+arch of the aorta may cause suffocation 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 considerable caliber; but at

+this inaccessible situation, they seldom or never call for surgical

+interference. As the intercostal arteries pass outwards, traversing the

+intercostal spaces with their accompanying 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 perform

+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 sometimes 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 vertebrae, and on arriving

+opposite 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, pancreas, 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 skill 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, R, 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

+derangement, 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 blood vessels

+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 liver 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 liver. When the liver is inflamed, we

+account for the gastric irritation, either from the inflammation having

+extended to the neighbouring stomach, or by this latter organ being

+affected by "reflex action." The hepatic cough is caused by the like

+phenomena disturbing the diaphragm, N, with which the liver, P, lies in

+close contact.

+

+When large biliary concretions form in S, the gallbladder, or in the

+hepatic duct, Nature, failing in her efforts to discharge them through

+the common bile-duct, into the duodenum, T, sets up inflammation 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, becomes 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 sufficient time

+be allowed for Nature to establish the adhesive inflammation, 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.

+

+

+DESCRIPTION OF PLATE 24.

+

+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. Oesophagus.

+

+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.

+

+

+[Illustration: Chest and abdomen, showing bones, blood vessels, muscles

+and other internal organs.]

+Plate 24

+

+

+

+COMMENTARY ON PLATE 25.

+

+THE RELATION OF THE PRINCIPAL BLOODVESSELS OF THE THORAX AND

+ABDOMEN TO THE OSSEOUS SKELETON, ETC.

+

+The arterial system of vessels assumes, in all cases, somewhat of the

+character of the forms upon which they are distributed, or of the organs

+which they supply. This mode of distribution becomes the more apparent,

+according as we rise from particulars to take a view of the whole. With

+the same ease that any piece of the osseous fabric, taken separately,

+may be known, so may any one artery, taken apart from the rest, be

+distinguished as to the place which it occupied, and the organs which it

+supplied in the economy. The vascular skeleton, whether taken as a whole

+or in parts, exhibits characteristics as apparent as are those of the

+osseous skeleton itself. The main bloodvessel, A B 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 25, viewed as a whole, we find that as the vertebral column

+stands central to the osseous skeleton, so does the aorta, A B C, take

+the centre of the arterial skeleton. As the ribs jut symmetrically from

+either side of the vertebral column, so do the intercostal arteries

+follow 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 extremities 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

+25, are represented in what is called their normal character--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 recall 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 will 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 arteries, 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 arteries, 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 26, exactly correspond to each

+other, and to the common iliac veins, S T; 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 25, is

+a brachia-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 uniformity.

+The separate condition of the vessels I K, notwithstanding the frequency

+of the occurrence of such, may be considered as a special variation from

+the original type.

+

+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 F, 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 vertebrae, 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 following

+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 25,--it varies not only its own length,

+but also that of the vessels H 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, still 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 considerably

+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 H

+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 affect 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.[Footnote]

+

+[Footnote: 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 25, 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--"Rara

+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 (Handbuch der Mensch Anat.), Soemmerring (De

+Corp. Hum Fabrica), Boyer (Tr. d'Anat.), and Mr. Harrison (Surg. Anal.

+of Art.), to be the most frequent. Tiedemann figures this variety

+amongst others (Tabulae 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 (Anal. 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 tam integralibus quam partibus;

+illae enim sunt, quae naturam uniunt, et constituere 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.)]

+

+The difference between the perpendicular range of the anterior and

+posterior walls of the thoracic cavity may be estimated on a reference

+to Plate 25, in which the xyphoid cartilage, E, joined to the seventh

+pair of ribs, bounds its anterior wall below, while F, 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

+ranges 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 cristae 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 cristae of the iliac bones. The

+kidneys lie on the fore part of the quadratus lumborum and psoae

+muscles. They are sometimes found to have descended as low as the iliac

+fossae, 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 all 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

+circulation 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 pubic. The lumbar, the

+gluteal, and the circumflex ilii arteries, also communicate around the

+hip-bone. The same vessels would serve to carryon 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.

+

+

+DESCRIPTION OF PLATE 25.

+

+A. The arch of the aorta.

+

+B B. The descending thoracic part of the aorta, giving off b b, the

+     intercostal 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.

+

+f f.  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.

+

+

+[Illustration: Chest and abdomen, showing bones, blood vessels, muscles

+and other internal organs.]

+Plate 25

+

+

+

+COMMENTARY ON PLATE 26.

+

+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 described 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 constant 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 effects 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 concern 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 still the superficies is so moulded upon the

+deeper situated structures, that we are induced to study it as a map,

+which discourses of all 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 processes 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 off 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 includes 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 all 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 compartment 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 22. If the thorax be

+deeply penetrated at any part of this region, the instrument will wound

+either the lung or the heart, according to the situation of the wound.

+But when fluid becomes effused in any considerable quantity within the

+pleural sac, it occupies space between the lung and the thoracic walls;

+and the fluid compresses 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. Therefore, 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 possibility 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 22. 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 area of pericardial

+surface will be exposed and brought into immediate 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 be

+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 hydragogue

+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 the patient this position, and of choosing some point within the

+line P Z, for the place whereat to make the opening, 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 form 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 whichever 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 displaces the intestines on its own side; and the sac lies

+in contact with the neighbouring abdominal parietes; nor will 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 puncturing 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 viscera on that

+side, we should recollect 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 caecum 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, P Z; and

+as to this place, we prefer it to all 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 gravitates in large

+quantity, and in immediate contact with the abdominal 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 mesenteric bond allows.

+

+If the ovarian dropsy form a considerable tumour in the abdomen, it may

+be readily reached by the trocar and cannula penetrating the line P Z.

+And thus we 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 wound the urinary bladder, which, when

+distended, rises considerably above the pubic symphysis.

+

+Amongst the many mechanical obstructions which, by impeding the

+circulation, give rise to dropsical effusion, are the following:--An

+aneurismal tumour of the aorta, A, or the innominate artery, [Footnote

+1] F, 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, owing to an obstruction 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.

+Tuberculous 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. [Footnote 2] An abscess or

+other tumour of the liver may, by pressing on the vena portae, cause

+serous effusion into the peritonaeal 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.

+

+[Footnote 1: 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.]

+

+[Footnote 2: 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 26.

+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 position, 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.]

+

+

+DESCRIPTION OF PLATE 26.

+

+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 brachia-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. Oesophagus.

+

+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 connection 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 the anterior superior iliac spinous processes.

+

+9, 10. Situations of the coracoid processes.

+

+11, 12. Right and left hypochondriac regions.

+

+

+[Illustration: Chest and abdomen, showing bones, blood vessels, muscles

+and other internal organs.]

+Plate 26

+

+

+

+COMMENTARY ON PLATE 27.

+

+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 condition of it as being

+the seat of hernial, 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 a useless detail

+of trifling evidence. And it would seem that nothing can more directly

+tend to this simplification, 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 herniae which are described as being proper to either region,

+occur in such close connexion as at times to render it very difficult to

+distinguish between them.

+

+The human species is, of all others, most subject to hernial 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 all times, subject the abdominal parietes 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

+depending 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 D 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 aperture, which transmits the thyroid vessels; and at

+the greater sacrosciatic notch, through which the gluteal vessels pass;

+and all regions of the abdominal walls may give exit to intestinal

+protrusion in consequence of malformations, disease, or injury. But as

+the more frequent varieties of herniae are those which traverse the

+localities, A, D, E, and as these, fortunately, are the most manageable

+under the care of the surgical anatomist, we proceed to examine the

+structures concerned in their occurrence.

+

+A direct opening from within outwards does not exist in the walls of the

+abdomen; and anatomy demonstrates to us the fact, that where the

+spermatic cord, D F, and the femoral vessels, pass from the abdomen to

+the external parts, they carry with them a covering of the several

+layers of structures, both muscular and membranous, which they encounter

+in their passage. The inguinal and crural forms of herniae which follow

+the passages made by the spermatic cord, and the crural vessels, must

+necessarily carry with them the like investments, and these are what

+constitute the coverings of the herniae themselves.

+

+The groin in its undissected state is marked by certain elevations and

+depressions which indicate the general relations of the subcutaneous

+parts. The abdomen is separated from the thigh by an undulating grooved

+line, extending from C*, the point of the iliac bone, to B, the

+symphysis pubis This line or fold of the groin coincides exactly with

+the situation of that fibrous band of the external oblique muscle named

+Poupart's ligament. From below the middle of this abdomino-femoral

+groove, C B, another curved line, D, b, springs, and courses obliquely,

+inwards and downwards, between the upper part of the thigh and the

+pubis, to terminate in the scrotum. The external border of this line

+indicates the course of the spermatic cord, D F, which can be readily

+felt beneath the skin. In all subjects, however gross or emaciated they

+may happen to be, these two lines are readily distinguishable, and as

+they bear relations to the several kinds of rupture taking place in

+these parts, the surgeon should consider them with keen regard. A

+comparison of the two sides of the figure, PLATE 27, will show that the

+spermatic cord, D F, and Poupart's ligament, C B, determine the shape of

+the inguino-femoral region. When the integument with the subcutaneous

+adipose tissue is removed from the inguino-femoral region, we expose

+that common investing membrane called the superficial fascia. This

+fascia, a a a, stretches over the lower part of the abdomen and the

+upper part of the thigh. It becomes intimately attached to Poupart's

+ligament along the ilio-pubic line, C B; it invests the spermatic cord,

+as shown at b, and descends into the scrotum, so as to encase this part.

+Where this superficial fascia overlies the saphenous opening, E, of the

+fascia lata, it assumes a "cribriform" character, owing to its being

+pierced by numerous lymphatic vessels and some veins. As this

+superficial fascia invests all parts of the inguino-femoral region, as

+it forms an envelope for the spermatic cord, D F, and sheathes over the

+saphenous opening, E, it must follow of course that wherever the hernial

+protrusion takes place in this region, whether at D, or F, or E, or

+adjacent parts, this membrane forms the external subcutaneous covering

+of the bowel.

+

+There is another circumstance respecting the form and attachments of the

+superficial fascia, which, in a pathological point of view, is worthy of

+notice--viz., that owing to the fact of its enveloping the scrotum,

+penis, spermatic cord, and abdominal parietes, whilst it becomes firmly

+attached to Poupart's ligament along the abdomino-femoral fold, B C, it

+isolates these parts, in some degree, from the thigh; and when urine

+happens to be from any cause extravasated through this abdominal-scrotal

+bag of the superficial fascia, the thighs do not in general participate

+in the inflammation superinduced upon such accident.

+

+The spermatic cord, D, emerges from the abdomen and becomes definable

+through the fibres of the sheathing tendon of the external oblique

+muscle, H, at a point midway between the extremities of the ilio-pubic

+line or fold. In some cases, this place, whereat the cord first

+manifests itself in the groin, lies nearer the pubic symphysis; but

+however much it may vary in this particular, we may safely regard the

+femoro-pubic fold, D, b, as containing the cord, and also that the place

+where this fold meets the iliopubic line, C B, at the point D, marks the

+exit of the cord from the abdomen.

+

+The spermatic cord does not actually pierce the sheathing tendon of the

+external oblique muscle at the point D, and there does not, in fact,

+exist naturally such an opening as the "external abdominal ring," for

+the cord carries with it a production of the tendon of the external

+oblique muscle, and this has been named by surgical anatomists the

+"intercolumnar fascia," [Footnote] the "spermatic fascia." The fibres of

+this spermatic fascia are seen at D F, crossing the cord obliquely, and

+encasing it. This covering of the cord lies beneath the spermatic

+envelope formed by, a b, the superficial fascia; and when a hernial

+protrusion descends through the cord, both these investing membranes

+form the two outermost envelopes for the intestine in its new and

+abnormal situation.

+

+[Footnote: On referring to the works of Sir Astley Cooper, Hesselbach,

+Scarpa, and, others, I find attempts made to establish a distinction

+between what is called the "intercolumnar fascia" and the "spermatic

+fascia," and just as if these were structures separable from each other

+or from the aponeurotic sheath of the external oblique muscle. I find,

+in like manner, in these and other works, a tediously-laboured account

+of the superficial fascia, as being divisible into two layers of

+membrane, and that this has given rise to considerable difference of

+opinion as to whether or not we should regard the deeper layer as being

+a production of the fascia lata, ascending from the thigh to the

+abdomen, or rather of the membrane of the abdomen descending to the

+thigh, &c. These and such like considerations I omit to discuss here;

+for, with all proper deference to the high authority of the authors

+cited, I dare to maintain, that, in a practical point of view, they arc

+absolutely of no moment, and in a purely scientific view, they are, so

+far as regards the substance of the truth which they would reveal,

+wholly beneath the notice of the rational mind. The practitioner who

+would arm his judgment with the knowledge of a broad fact or principle,

+should not allow his serious attention to be diverted by a pursuit after

+any such useless and trifling details, for not only are they unallied to

+the stern requirements of surgical skill, but they serve to degrade it

+from the rank and roll of the sciences. Whilst operating for the

+reduction of inguinal hernia by the "taxis" or the bistoury, who is

+there that feels anxiety concerning the origin or the distinctiveness of

+the "spermatic fascia?" Or, knowing it to be present, who concerns

+himself about the better propriety of naming it "tunica vaginalis

+communis," "tunique fibreuse du cordon spermatique," "fascia

+cremasterica," or "tunica aponeurotica?"]

+

+The close relations which the cord, D F, bears to the saphenous opening,

+E, of the fascia lata, should be closely considered, forasmuch as when

+an oblique inguinal hernia descends from D to F, it approaches the

+situation of the saphenous opening, E, which is the seat of the femoral

+or crural hernia, and both varieties of hernia may hence be confounded.

+But with a moderate degree of judgment, based upon the habit of

+referring the anatomy to the surface, such error may always be avoided.

+This important subject shall be more fully treated of further on.

+

+The superficial bloodvessels of the inguino-femoral region are, e e,

+the saphenous vein, which, ascending from the inner side of the leg and

+thigh, pierces the saphenous opening, E, to unite with the femoral vein.

+The saphenous vein, previously to entering the saphenous opening,

+receives the epigastric vein, i, the external circumflex ilii vein, h,

+and another venous branch, d, coming from the fore part of the thigh. In

+the living body the course of the distended saphenous vein may be traced

+beneath the skin, and easily avoided in surgical operations upon the

+parts contained in this region. Small branches of the femoral artery

+pierce the fascia lata, and accompany these superficial veins. Both

+these orders of vessels are generally divided in the operation required

+for the reduction of either the inguinal or the femoral strangulated

+hernia; but they are, for the most part, unimportant in size. Some

+branches of nerves, such as, k, the external cutaneous, which is given

+off from the lumbar nerves, and, f, the middle cutaneous, which is

+derived from the crural nerve, pierce the fascia lata, and appear upon

+the external side and middle of the thigh.

+

+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 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 27, with practical advantage. The umbilicus, A, indicates pretty

+generally the level at which the aorta bifurcates on the forepart of the

+lumbar vertebrae. 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 vertebrae bear forward 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,

+transversely, from these points, and through B, it would penetrate the

+aorta at its bifurcation. The line A B coincides with the linea alba.

+The oblique lines, A D, A D,* indicate the course of the iliac vessels.

+The point D 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 where the

+spermatic cord enters the abdomen. The direct line drawn between D and G

+marks the course of the femoral artery, and this ranges along the outer

+border, E, of the saphenous opening.

+

+

+DESCRIPTION OF PLATE 27.

+

+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.

+

+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 lying near Poupart's ligament.

+

+d. A common venous trunk, formed by branches from the thigh and abdomen,

+   and joining--

+

+e e. The saphenous vein.

+

+f.  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 branches of nerves from the lumbar plexus.

+

+

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+PLATE 27

+

+

+

+COMMENTARY ON PLATES 28 & 29.

+

+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 D,

+together with the facts, that corresponding 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, will 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 herniae.

+

+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, quae sensim in aponeurosin mutata, ac cum tendineis

+hujus musculi partibus unita, externe ac anteriore parte abdomen tegit;

+finem vero nullibi habere perspicuum 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

+obteguntur." (Icones Herniarum.)

+

+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. Where the superficial

+fascia, after encasing the cord, descends into the scrotum, it is also

+devoid of the fatty tissu.

+

+By the removal of the superficial fascia and glands we expose the

+aponeurosis of the external oblique muscle, A a, Pl. 28, (constituting

+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 protrusions,

+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, Pl. 28, 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 herniae occur

+immediately above the line, C D, while the femoral varieties of herniae

+take place below this line. The herniae of the inguinal triangle are,

+therefore, distinguishable from those of the femoral triangle by a

+reference to the line, 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, B C D, Pl. 28.

+The fleshy fibres of the muscle, A, after forming the lateral wall 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 becomes relaxed in the same degree as it

+does when we flex the thigh upon the abdomen. The utmost degree of

+relaxation 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, Pl.

+28, 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 this bone. The lower band identifies itself with

+Poupart's ligament. 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

+abdominal 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, Pl. 29.

+

+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 pendulous as far

+outwards as the point E, Pl. 28, 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 Pl. 28, the cord, K, 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 Pl. 29, 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,  Pl. 28,

+together with its spermatic elongation, E, we expose the internal

+oblique, F E, Pl. 29, 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 h, 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 (Recherches anatomiques

+sur les Hernies de l'Abdomen) first demonstrated the correctness of this

+idea.

+

+The oblique and serial arrangement of the muscular fibres of the

+internal oblique, F, Pl. 29, 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, e, 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 muscular 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, H, Pl. 28, 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, Pl.

+28; 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, Pl. 28, 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, therefore, below the iliac part, and in this way passes outwards

+beneath the sheath of the femoral vessels, K I, Pl. 29. These two

+divisions of the fascia lata, although separated above, are united and

+continuous 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 h, Pl. 28. Through this opening, the saphena vein, O, Pl.

+29, 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 h, Pl. 28, with its "upper and lower cornua," and its "falciform

+process," or edge, h, exists naturally. Nor need we be surprised,

+therefore, that so accurate an observer as Soemmering (de Corporis

+Humani 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, Pl. 29, the iliac part, H h, blends by its

+falciform margin with the superficial fascia, and also with N n, the

+sheath of the femoral vessels. The so-called 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 h, Pl. 28, the

+dense falciform process, h, 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 cribriform fascia covers it; and the upper

+end of the saphena vein, M, passes beneath its lower border. The upper

+cornu, h, Pl. 29, 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, Pl. 28, 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.

+

+

+DESCRIPTION OF THE FIGURES OF PLATES 28 & 29.

+

+PLATE 28.

+

+A. The 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.

+

+F G. See Plate 29.

+

+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.

+

+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.

+

+N. A tributary vein coming from the fore part of the thigh.

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+Plate 28

+

+

+PLATE 29.

+

+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; e, 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; f, 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.

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+Plate 29

+

+

+

+COMMENTARY ON PLATES 30 & 31.

+

+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, F,

+Pl. 30. 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 E 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 f, is named

+the "conjoined tendon."

+

+The conjoined tendon, f, Plates 30 and 31, 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 well 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, Plate 30,

+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 h, 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, Plate 30, which at a subsequent period are

+converted into a cremaster, entirely occupy the space L h. 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 h, 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 h; the meaning of

+which is, that the cremasteric 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 E F, just in the same

+way as the testicle does in the foetus. (Cloquet.)

+

+From the above-mentioned facts, viewed comparatively, it seems that the

+following inferences may be legitimately drawn:--1st, that the space L h

+does not naturally exist devoid of a muscular covering; 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 h, Plate 30--K k,

+Plate 31. This fascia or membrane affords a general lining to the

+abdominal walls, 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 fascia 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 with those other fibrous

+structures which envelope serous cavities. The transversalis fascia

+supports externally the peritonaeum, 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 which lie external to those sacs are pierced by the

+vessels which course between them and the serous membranes, and afford

+sheaths or envelopes for these vessels in their passage from the

+interior to the external parts. The sheath, H h, Plates 30 and 31, which

+surrounds the spermatic vessels, and the sheath, R, Plate 31, which

+envelopes the crural vessels, are elongations of the fascia

+transversalis.

+

+In the groin, the transversalis fascia, K k, Plate 31, presents, in

+general, so dense a texture as to offer considerable resistance to

+visceral pressure. Here it is stretched between the transverse muscle,

+F, Plate 31, 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 with f, the

+conjoined tendon, thereby fencing the external abdominal ring.

+Immediately above the middle of Poupart's ligament, this membrane, at

+the point marked h, Plate 30, is pouched into a canal-shaped elongation,

+which 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,

+when 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 Plates 30 and 31.

+

+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

+dwell upon them. The sheath of the femoral vessels is also

+funnel-shaped, and surrounds 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, Plate 30, is separated from the falciform

+margin, S s, 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 particularly noticed

+when considering the anatomy of crural hernia.

+

+Beneath the fascia transversalis is found the subserous 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 (sull' 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 peritoneal tunica vaginalis--a

+structure which will be considered in connexion with congenital herniae.

+

+By removing the subserous cellular tissue, we lay bare the peritonaeum,

+which forms the eighth layer of the inguinal region. Upon it the

+epigastric and spermatic vessels are seen to rest. These vessels course

+between the fascia transversalis and the peritonaeum. The internal ring

+which is formed in the fascia, K h, 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 with the general serous cavity; and

+here it must be evident that before the bowel, which is situated

+immediately behind the peritonaeum, I, can be received into the canal, H

+h, it must either rupture that membrane, or elongate it in the form of a

+sac.

+

+The exact position which the epigastric, L, Plate 31, and spermatic

+vessels, 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 herniae which 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 wall 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 which have been already made respecting the several

+layers of structures found in the groin, I endeavoured 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, whilst the

+innermost layer consisted of the transversalis fascia elongated into the

+fascia spermatica interna, or sheath. The peritonaeum, which forms the

+eighth layer of the groin, was seen to be drawn across the internal ring

+of this canal above in such a way as to close it completely, whilst all

+the other layers, seven in number, were described as being continued

+over the spermatic vessels in the form of funnel-shaped investments, as

+far down 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 individuals,

+I omit to mention the scale of measurements drawn up by some eminent

+surgeons, with 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 oblique 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 herniae than others.

+

+

+DESCRIPTION OF THE FIGURES OF PLATES 30 & 31.

+

+PLATE 30.

+

+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, with e, the conjoined

+   tendon.

+

+G. The rectus muscle enclosed in its sheath.

+

+H. The fascia spermatica interna covering the cord; h, its funnel-shaped

+   extremity.

+

+I, K, L, M. See Plate 31.

+

+N. The femoral artery; n, 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 the fascia lata.

+

+V. The iliac portion attached to Poupart's ligament.

+

+W. The lower part of the iliacus muscle.

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+PLATE 30

+

+

+PLATE 31.

+

+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; f, 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

+     external ring.

+

+I. The peritonaeum closing the internal ring.

+

+K. The fascia transversalis; k, its pubic part.

+

+L. The epigastric artery and veins.

+

+M. The spermatic artery, veins, and vas deferens bending round the

+   epigastric artery at the internal ring; m, 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.

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+Plate 31

+

+

+

+COMMENTARY ON PLATES 32, 33, & 34.

+

+THE DISSECTION OF THE OBLIQUE OR EXTERNAL AND

+THE DIRECT OR INTERNAL INGUINAL HERNIAE.

+

+The order in which 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

+peritonaeum, and from this membrane the intestine, when about to

+protrude, derives its first covering. This covering constitutes 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 caecum 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 allow 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 blood vessels and nerves of the abdomen lie external to the

+peritonaeum. Those vessels which traverse the abdomen on their way to

+the external organs course outside the peritonaeum; and at the places

+where they enter the abdominal parietes, the membrane is reflected from

+them. This disposition of the peritonaeum in respect to the spermatic

+and iliac vessels is exhibited in Plate 32.

+

+The part of the peritonaeum 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 herniae 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

+which are the weakest.

+

+The inner surface of the groin is divided into two pouches or fossae, by

+an intervening crescentic fold of the peritonaeum, which corresponds

+with the situation of the epigastric vessels. This fold is formed by the

+epigastric vessels and the umbilical ligament, which, being tenser and

+shorter than the peritonaeum, thereby cause this membrane to project.

+The outer fossa represents a triangular space, the apex of which is

+below, at P; the base being formed by the fibres of the transverse

+muscle above; the inner side by the epigastric artery; and the outer

+side by Poupart's ligament. The apex of this inverted triangle is

+opposite the internal ring. The inner fossa is bounded by the epigastric

+artery externally; by the margin of the rectus muscle internally; and by

+the os pubis and inner end of Poupart's ligament inferiorly. The inner

+fossa is opposite the external abdominal ring, and is known as the

+triangle of Hesselbach.

+

+The two peritonaeal 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 fossae are named

+external and internal also, in reference to the same part.

+

+The external inguinal hernia, so called from its commencing in the outer

+peritonaeal fossa, on the outer side of the epigastric artery, takes a

+covering from the peritonaeum of this place, and pushes forward into the

+internal abdominal ring at the point marked P, Plate 32. In this place,

+the incipient hernia or bubonocele, covered by its sac, lies on the

+forepart 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 the spermatic

+vessels, anterior, while the protruded intestine itself is separated

+from actual contact with either of these vessels by its proper sac. The

+bubonocele, projecting through the internal ring at the situation marked

+F, (Plate 33,) 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

+obliquely inwards along the canal, traversing this canal with the

+spermatic vessels, which still lie behind it, and, lastly, makes its

+exit at the 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 oblique hernia. In this stage of the hernial protrusion, 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 actually in

+front of the epigastric artery, P, and this vessel is separated from the

+anterior wall of the canal, H h, 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 form a tumour of the size and in

+the situation of f g, 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 vessels through the inguinal canal, at length terminates

+in the scrotum.

+

+The external inguinal hernia having entered the canal, P, (Plate 32,) 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, still 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 R, Plate 32, internal to the epigastric artery,

+and forces directly forwards through the external abdominal ring,

+carrying investments from each of such structures as it meets with in

+this locality of the groin. As the external ring, H, Plate 34, is

+opposite the inner peritonaeal fossa, Q R, Plate 32, this hernia, which

+protrudes thus immediately from behind forwards, is also named direct.

+In this way these two varieties of hernia, (the external, Plate 33, and

+the internal, Plate 34,) though commencing in different situations, P

+and R, Plate 32, within the abdomen, arrive at the same place--viz., the

+external ring, H, Plates 33 and 34. The coverings of the internal

+hernia, Plate 34, 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

+peritonaeum, 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

+common 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. [Footnote]

+

+[Footnote: 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 constantly 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 adverso 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 involucro adeo inhaerent, ut pro lubitu musculum

+(membranam) efformare queas unde magnam illam inter anatomicos

+discrepantiam ortam conjicio." (Camper. Icones Herniarum.)]

+

+The variety in the number of investments of the internal inguinal hernia

+(especially as regards the presence or absence of the conjoined tendon

+and cremaster) appears to me to be dependent, 1st, upon the position

+whereat this hernia occurs; 2nd, upon the state of the parts through

+which 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

+narrow, and removed from it nearer to the median line. At the external

+ring, H, (Plate 34,) the sac of this hernia, g, protrudes on the inner

+side of the spermatic vessels, f; 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, (Plate 34,) the investments, g f, of the

+direct hernia are not always distinct from those of the oblique hernia,

+g f, (Plate 33); 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, a priori, expect, from the

+anatomical disposition of the parts. But it is true, nevertheless, that

+the part where 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.

+

+

+DESCRIPTION OF THE FIGURES OF PLATES 32, 33, & 34.

+

+PLATE 32.

+

+A. That part of the ilium which abuts against the sacrum.

+

+B. The spine of the ischium.

+

+C. The tuberosity of the ischium.

+

+D. The symphysis pubis.

+

+E. Situation of the anterior superior iliac spine.

+

+F. Crest of the ilium.

+

+G. Iliacus muscle.

+

+H. Psoas magnus muscle supporting the spermatic vessels.

+

+I. Transversalis muscle.

+

+K. Termination of the sheath of the rectus muscle.

+

+L1 L2 L3. The iliac, transverse and pelvic portions of the transversalis

+          fascia.

+

+M M. The peritonaeum lining the groin.

+

+N. The epigastric vessels lying between the peritonaeum, M, and the

+   transversalis fascia, L2. O. The umbilical ligament.

+

+P. The neck of the sac of an external inguinal hernia formed before the

+   spermatic vessels.

+

+Q. An interval which occasionally occurs between the umbilical ligament

+   and the epigastric artery.

+

+R and Q. Situations where the direct inguinal hernia occurs when, as in

+         this case, the umbilical ligament crosses the space named the

+   internal 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 peritonaeum.

+

+V. External iliac artery covered by the peritonaeum.

+

+W. Internal iliac artery.

+

+X. Common iliac artery.

+

+

+[Illustration: Abdomen, showing bones, blood vessels, muscles

+and other internal organs.]

+Plate 32

+

+

+PLATE 33.--The External Inguinal Hernia.

+

+A. Anterior iliac spinous process.

+

+B. The umbilicus.

+

+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

+     external hernia; upon it are seen the cremasteric fibres.

+

+G g. The peritonaeal covering or sac of the external hernia within the

+     sheath.

+

+H. The external abdominal ring.

+

+I. The crista pubis.

+

+K k. The saphenous opening.

+

+L. The saphena vein.

+

+M. The femoral vein.

+

+N. The femoral artery; n, its profunda branch.

+

+O. The anterior crural nerve.

+

+P. The epigastric vessels overlaid by the neck of the hernia.

+

+Q Q. The sheath of the femoral vessels.

+

+R. The sartorius muscle.

+

+S. The iliacus muscle.

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+Plate 33

+

+

+PLATE 34.--The Internal Inguinal Hernia.

+

+The letters indicate the same parts as in Plate 33

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+Plate 34

+

+

+

+COMMENTARY ON PLATES 35, 36, 37, & 38.

+

+THE DISTINCTIVE DIAGNOSIS BETWEEN EXTERNAL AND INTERNAL

+INGUINAL HERNIAE, THE TAXIS, THE SEAT OF STRICTURE, AND THE OPERATION.

+

+A comparison of the relative position of these two varieties of herniae

+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 herniae 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, Plate 37, G, Plate 38, 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 still 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, Plate 36, it dilates

+considerably, and assumes the form of an oblong swelling, H, Plate 36,

+behind which the spermatic vessels are situated. When it has become

+scrotal, the cord will be found still on its posterior aspect, while the

+testicle itself occupies a situation directly below the swelling.

+

+The internal hernia, H, Plate 38, 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, unswollen. 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 hernia,) but is found to

+be placed either at its fore part or its outer side. This difference as

+to the relative position of the cord and testicle in both these forms of

+herniae, is accounted for under the supposition 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 hernia, for this also occasionally enters the canal. Both forms

+of inguinal herniae may exist at the same time on the same side: the

+external, G, Plate 38, 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 of hernia--a compound of the oblique and

+direct--while the parts remain still covered by the integuments, it must

+be difficult to tell its nature, or to distinguish any mark by which to

+diagnose the case from one of the external variety, H, Plate 36, which,

+on entering the canal at the internal ring, protrudes at the external

+ring. In both cases, the swelling produced in the groin must be exactly

+of the same size and shape. The epigastric artery in the case where the

+two herniae co-exist lies between them, holding in its usual position

+with 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 internal hernia, H, to assume

+its usual position with respect to the cord, Q. [Footnote]

+

+[Footnote: Cases of this double hernia (external and internal) have been

+met with by Wilmer, Arnaud, Sandifort, Richter, and others. A plurality

+of the same variety of hernia may also occur on the same side. A

+complete and incomplete external inguinal hernia existing in the one

+groin, is recorded by Mr. Aston Key in his edition of Sir Astley

+Cooper's work on Hernia. Sir Astley Cooper states his having met with

+three internal inguinal herniae in each inguinal region. (Ing. et

+Congenit. Hernire.) ]

+

+Returning, however, to the more frequent conditions of inguinal

+hernia--viz., those in which either the direct or the oblique variety

+occurs alone--it should be remembered that a hernia originally oblique,

+H, Plates 35 and 37, 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, Plate 35, opposite

+to the external ring, as at I, and thereby exhibit all the appearance of

+a hernia originally direct, I, Plate 37. In such a case, the epigastric

+artery, F, which lies on the outer side of the neck of a truly direct

+hernia, I, Plate 37, will be found to course on the inner side, G, of

+the neck of this false-seeming direct hernia, I, Plate 35.

+

+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

+forward, 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 backwards. Pressure made in this latter direction will 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 protruding bowel, the lower parts of the transversalis

+and internal oblique 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, Plate 37, or at the external ring, T, Plate 38; and

+according to the locality where this hernia enters the inguinal wall,

+the nature of its stricture will vary. If the hernia pass through a

+cleft in the conjoined tendon, f, Plate 38, this structure will

+constrict its neck all 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, will be constricted against the sharp resisting edge of

+the tendon. Again, if the hernia enter the inguinal wall 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 herniae, 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 per se, or independently of

+adjacent structures. The form of the sac of a hernia is influenced by

+the parts through which it passes, or which it pushes and elongates

+before itself. Its neck, H, Plate 37, 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, Plate 36, from the same cause.

+The neck of the sac of a direct hernia, I, Plate 37, 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 equal to the capacities of these

+outlets. But if these constricting outlets did not exist, the neck of

+the sac would 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 inflammation and undergoes chronic

+thickening--then, even though we liberate the stricture of the internal

+ring or the external, the neck of the sac will 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 necessity of opening the sac (a proceeding otherwise

+not only needless, but objectionable) and dividing 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 require that

+this should be opened, and the state of its contained parts examined,

+prior to the replacement of the bowel in the abdomen. If the bowel were

+adherent to the neck of the sac, we might, when trying to reduce it by

+the taxis, produce visceral invagination; 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 following 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 below the ring. The length of the incision will require to be

+varied according to circumstances, but its direction should be oblique

+with 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

+when the stricture is produced by either of the muscles which lie

+beneath the aponeurosis of the external 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 with 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 artery being situated on the inner side of the neck

+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 inwards 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, Plate 35, has been borne inwards to the place, G, where it

+still lies, internal to the neck of the sac, and since, moreover, it is

+very difficult 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 will be

+seen, however, on referring to Plates 32, 33, 34, 35, 36, 37, & 38, that

+an incision carried obliquely upwards towards the umbilicus would be

+much more likely to avoid the epigastric artery through all its varying

+relations.

+

+

+DESCRIPTION OF THE FIGURES OF PLATES 35, 36, 37, & 38.

+

+PLATE 35.

+

+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 peritonaeum lining the groin.

+

+E. The situation of the conjoined tendon resisting the further progress

+   of the external hernia gravitating inwards.

+

+F. A dotted line indicating the original situation of the epigastric

+   artery in the external hernia.

+

+G. The new position assumed by the epigastric artery borne inwards by

+   the weight of the old external hernia.

+

+H. The original situation of the neck of the sac of the external hernia.

+

+I. The new situation assumed by the neck of the sac of an old external

+   hernia which has gravitated inwards from 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.

+

+

+[Illustration: Abdomen, showing bone, blood vessels, muscles

+and other internal organs.]

+Plate 35

+

+

+PLATE 36.--AN ANTERIOR VIEW OF PLATE 35.

+

+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; f, the conjoined tendon.

+

+G. The transversalis fascia investing the upper part of the hernial sac;

+   g, the original situation of the epigastric artery internal to this

+   hernia; g*, the new situation of the artery pushed inwards.

+

+H. The hernial sac, invested by h, 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 P. Falciform margin of the saphenous opening.

+

+Q. See Plate 38.

+

+R. Sheath of the femoral vessels.

+

+S. Anterior crural nerve.

+

+T. The external ring.

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+Plate 36

+

+

+PLATE 37.

+

+All the letters except the following indicate the same parts as in Plate

+35.

+

+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.

+

+

+[Illustration: Abdomen, showing blood vessels, muscles

+and other internal organs.]

+Plate 37

+

+

+PLATE 38.--AN ANTERIOR VIEW OF PLATE 37.

+

+All the letters, with the exception of the following, refer to the same

+parts as in Plate 36.

+

+G. The funnel-shaped elongation of the fascia transversalis receiving g,

+   the sac of the external bubonocele.

+

+H. The sac of the internal inguinal hernia invested by h, the

+   transversalis fascia.

+

+Q. The spermatic vessels lying on the outer side of H, the direct

+   inguinal hernia.

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+Plate 38

+

+

+

+COMMENTARY ON PLATES 39 & 40.

+

+DEMONSTRATIONS OF THE NATURE OF CONGENITAL AND

+INFANTILE INGUINAL HERNIAE, AND OF HYDROCELE.

+

+PLATE 39. Fig. 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 abdominal 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 peritonaeal 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 bloodvessels. 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 peritonaeal 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.[Footnote]

+

+[Footnote:  Dr. Carpenter (Principles of Human Physiology) remarks, that

+"the cause of this descent is not very clear. It can scarcely be due

+merely, as some have supposed, to the contraction of the gubernaculum,

+since that does not contain any fibrous structure until after the

+lowering of the testis has commenced." Dr. Sharpey (Quain's Anatomy, 5th

+edition) observes, that "the office of the gubernaculum is yet

+imperfectly understood." The opinions of these two distinguished

+physiologists will doubtless be regarded as an impartial estimate of the

+results of the researches prosecuted in reference to these questions by

+Haller, Camper, Hunter, Arnaud, Lobstein, Meckel, Paletta, Wrisberg,

+Vicq d'Azyr, Brugnone, Tumiati, Seiler, Girardi, Cooper, Bell, Weber,

+Carus, Cloquet, Curling, and others. From my own observations, I am led

+to believe that no such muscular structure as a gubernaculum exists, and

+therefore that the descent of the testis is the effect of another cause.

+Leaving these matters, however, to the consideration of the

+physiologist, it is sufficient for the surgeon to know that the testis

+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. ]

+

+The general lining membrane of the foetal abdomen 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. [Footnote]  The testis in the loins has a covering from both

+membranes, and is still found to be enclosed by both, even when it has

+descended to the scrotum. The two coverings of fibro-serous structure

+which surrounded the testis in the loins become respectively the tunica

+albuginea and tunica vaginalis when the gland occupies the scrotal

+cavity.

+

+[Footnote: 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.) ]

+

+

+[Illustration: Abdomen and leg, showing blood vessels, muscles

+and other internal organs.]

+Plate 39--Figure 1

+

+

+PLATE 39, Fig. 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 d, is still

+continuous at the internal ring, 6 b. From this point downwards, to a

+level with the upper border of the testicle, the canal of communication

+between the scrotal cavity and the abdomen becomes 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 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 spermatic sheath, or

+infundibuliform fascia enclosing the remains of the serous canal,

+together with the spermatic vessels, &c.

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 39--Figure 2

+

+

+PLATE 39, Fig. 3.--The serous tunica vaginalis is separated from the

+peritonaeum.--When the testicle, 7, has descended to the scrotum, the

+serous tube or lining of the inguinal canal and cord, 6 b, 6 c, closes

+and degenerates into a simple cord, (infantile spermatic cord,) and

+thereby the peritonaeal 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 forming the fascia propria of

+an external inguinal hernia. The anterior 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 d, is now traceable as a distinct sac,[Footnote] 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.

+

+[Footnote: Mr. Owen states that the Chimpanzee alone, amongst brute

+animals, has the tunica vaginalis as a distinct sac.]

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 39--Figure 3

+

+

+PLATE 40, Fig. 1.--The abdomino-scrotal serous lining remains continuous

+at the internal ring, and a congenital hydrocele is formed.--When the

+serous spermatic tube, 6 b, 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 gravitate 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. [Footnote 1]  As long as the canal of

+communication, 6 b, 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 d, 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 puncture may be made with most safety in front of the

+scrotum. If ascites should form in an adult in whom the tunica vaginalis

+still communicates with the peritonaeal 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 disease, 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, Plate 39, is arrested in the inguinal canal,

+[Footnote 2] if pressure be made on this passage with a view of causing

+its closure, the testicle will be prevented from descending.

+

+[Footnote 1: 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 spermatic tube to close.]

+

+[Footnote 2: 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 "testi-conde;" the 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.]

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 40--Figure 1.

+

+

+PLATE 40, Fig. 2.--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 b, 6 c, may become

+adherent at intervals; and the intervening sacs of serous membrane

+continuing to secrete their proper fluid, will 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

+modes:--1st, if the serous tube close only at the internal ring, 6 a,

+while the lower part of it, 6 b, 6 c, remains pervious, and

+communicating with the tunica vaginalis, 6 d, a hydrocele will be 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 b, remains pervious, and the internal ring, 6 a, open, and

+communicating with the peritonaeal sac, a hydrocele of the cord will

+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.

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 40--Figure 2.

+

+

+PLATE 40, Fig. 3.--Hydrocele of the isolated tunica vaginalis.--When the

+serous spermatic tube, 6 b, 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 congenital hydrocele. [Footnote] 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

+distended, as it may be, in the latter form of the complaint.

+

+[Footnote: 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 inflammatory 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

+Anatomy;" Mr. Curling's "Treatise on Diseases of the Testis;" and also

+his article "Testicle," in the Cyclopaedia of Anatomy and Physiology.]

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 40--Figure 3.

+

+

+PLATE 40, Fig. 4.--The serous spermatic tube remaining pervious, a

+congenital 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 envelope 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

+affected 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.

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 40--Figure 4.

+

+

+PLATE 40, Fig. 5.--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 peritonaeum, 6 a, near the closed

+ring, 6 b, takes a distinct sac or investment from this membrane. This

+hernial sac, 6 e, will vary as to its position in regard to the tunica

+vaginalis, 6 d, according to the place whereat it dilates the

+peritonaeum 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 reception of the naked intestine. If

+in infantile hernia a hydrocele should form in the tunica vaginalis, the

+fluid will also distend the pervious serous spermatic tube, 6 c, as far

+up as the closed internal ring, 6 b, and will 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 still

+the consequence of original default.

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 40--Figure 5.

+

+

+PLATE 40, Fig. 6.--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. 6, Plate 40, with the infantile variety, Fig. 5, Plate 40, 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 remaining in part pervious in the infantile

+hernia; and on comparing Fig. 6, Plate 40, with the congenital variety,

+Fig. 4, Plate 40, 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. 4, 5, & 6,

+Plate 40, is owing to the variety in the anatomical circumstances under

+which these herniae have happened.

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 40--Figure 6.

+

+

+

+COMMENTARY ON PLATES 41 & 42.

+

+DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF INGUINAL HERNIAE IN GENERAL.

+

+PLATE 41, Fig. 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 peritonaeum at the point 1, or dilate this membrane before

+it in the form of a sac. [Footnote] If the peritonaeum at the 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 across the internal ring, it will, on

+entering the fibrous tube, (infundibuliform fascia,) be found invested

+by a sac of the peritonaeum, 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 peritonaeum at the point 1, then the naked intestine will

+lie in immediate contact with these vessels.

+

+[Footnote: 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 protruding bowel.]

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 41--Figure 1

+

+

+PLATE 41, Fig. 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 Fig, 1, Plate 41. But,

+as the serous tube through which the congenital hernia descends, still

+communicates with the tunica vaginalis, so will this form of hernia

+enter this tunic, and thereby become different to all other herniae,

+forasmuch as it will lie in immediate contact with the testicle.

+[Footnote]

+

+[Footnote: 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.]

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 41--Figure 2

+

+

+PLATE 41, Fig. 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, Plate 41, or that which is described in the note

+to Fig. 2, Plate 41; 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 Fig. 1, Plate 41. 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.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 41--Figure 3

+

+

+PLATE 41, Fig. 4.--If the serous spermatic tube, 11, be obliterated or

+closed at the internal ring, 1, thus cutting off communication with the

+general peritonaeal 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 peritonaeum, in order to form its sac anew, as stated of Fig.

+1, Plate 41. 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 peritonaeum 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 still 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 Fig.

+1, Plate 41.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 41--Figure 4

+

+PLATE 41, Fig. 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, till, 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.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 41--Figure 5

+

+

+PLATE 41, Fig. 6.--When the bowel dilates the peritonaeum 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, therefore, 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. [Footnote]

+

+

+[Footnote: 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.]

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 41--Figure 6

+

+

+PLATE 41. Fig. 7.--When an external inguinal hernia, 11, dilates and

+protrudes the peritonaeum from the closed internal ring, 1, and descends

+the inguinal canal and fibrous tube, 3, 3, it imitates, in most

+respects, the original descent of the testicle. The difference between

+both descents attaches alone to the mode in which they become covered by

+the serous membrane; for the testicle passes through the internal ring

+behind the inguinal peritonaeum, at the same time that it takes a

+duplicature of this membrane; whereas the bowel encounters this part of

+the peritonaeum from within, and in this mode becomes invested by it on

+all sides. This figure also represents the form and relative position of

+a hernia, as occurring in Figs. 1 and 3, 5, and 6, Plate 41.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 41--Figure 7

+

+

+PLATE 41, Fig. 8.--When the serous spermatic tube only closes at the

+internal ring, as seen at 1, Fig. 4, Plate 41, if a hernia afterwards

+pouch the peritonaeum at this part, and enter the inguinal canal, we

+shall then have the form of hernia, Fig. 8, Plate 41, termed infantile.

+Two serous sacs will be here found, one within the cord, 13, and

+communicating with the tunica vaginalis, the other, 11, containing the

+bowel, and being received by inversion into the upper extremity of the

+first. Thus the infantile serous canal, 13, receives the hernial sac,

+11. The inguinal canal and cord may become multicapsular, as in Fig. 8,

+from various causes, each capsule being a distinct serous membrane.

+First, independent of hernial formation, the original serous tube may

+become interruptedly obliterated, as in Plate 40, Fig. 2. Secondly,

+these sacs may persist to adult age, and have a hernial sac added to

+their number, whatever this may be. Thirdly, the original serous tube,

+13, Fig. 8, may persist, and after having received the hernial sac, 11,

+the bowel may have been reduced, leaving its sac behind it in the

+inguinal canal; the neck of this sac may have been obliterated by the

+pressure of a truss, a second hernia may protrude at the point 1, and

+this may be received into the first hernial sac in the same manner as

+the first was received into the original serous infantile tube. The

+possibility of these occurrences is self-evident, even if they were

+never as yet experienced. [Footnote]

+

+[Footnote: According to Mr. Lawrence and M. Cloquet, most of the serous

+cysts found around hernial tumours are ancient sacs obliterated at the

+neck, and adhering to the new swelling (opera cit.)]

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 41--Figure 8

+

+

+PLATE 42, Fig. 1.--The epigastric artery, 9, being covered by the fascia

+transversalis, can lend no support to the internal ring, 2, 2, nor to

+the tube prolonged from it. The herniary bowel may, therefore, dilate

+the peritonaeum immediately on the inner side of the artery, and enter

+the inguinal canal. In this way the hernia, 11, although situated

+internal to the epigastric artery, assumes an oblique course through the

+canal, and thus closely simulates the external variety of inguinal

+hernia, Fig. 7, Plate 41. If the hernia enter the canal, as represented

+in Fig. 1, Plate 42, it becomes invested by the same structures, and

+assumes the same position in respect to the spermatic vessels, as the

+external hernia.

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 42--Figure 1

+

+

+PLATE 42, Fig. 2.--The hernial sac, 11, which entered the ring of the

+fibrous tube, 2, 2, at a point immediately internal to the epigastric

+artery, 9, may, from having been at first oblique, as in Fig. 1, Plate

+42, assume a direct position. In this case, the ring of the fibrous

+tube, 2, 2, will be much widened; but the artery and spermatic vessels

+will remain in their normal position, being in no wise affected by the

+gravitating hernia. If the conjoined tendon, 6, be 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 hernia enters the mouth of the

+fibrous tube, then, of course, the cord will be found external. If the

+cord lie towards the pubes, apart from the vessel, the hernia may enter

+the fibrous tube between the cord, 10, and artery, 9. [Footnote:] It is

+impossible for any internal hernia to assume the congenital form,

+because the neck of the original serous spermatic tube, 11, Fig. 2,

+Plate 41, being external to the epigastric artery, 9, cannot be entered

+by the hernia, which originates internally to this vessel.

+

+[Footnote: M. Cloquet states that the umbilical cord is always found on

+the inner side of the external hernia. Its position varies in respect to

+the internal hernia, (op. cit. prop. 52.)]

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 42--Figure 2

+

+

+PLATE 42, Fig. 3.--Every internal hernia, which does not rupture the

+peritonaeum, carries forward a sac produced anew from this membrane,

+whether the hernia enter the inguinal canal or not. But this is not the

+case with respect to the fibrous membrane which forms the fascia

+propria. If the hernia enter the inguinal wall immediately on the inner

+side of the epigastric artery, Fig. 1, Plate 42, it passes direct into

+the ring of the fibrous tube, 2, 2, already prepared to receive it. But

+when the hernia, 11, Fig. 3, Plate 42, cleaves the conjoined tendon, 6,

+6, then the artery, 9, and the tube, 2, 2, remain in their usual

+position, while the bowel carries forward a new investment from the

+transversalis fascia, 5, 5. That part of the conjoined tendon which

+stands external to the hernia keeps the tube, 2, 2, in its proper place,

+and separates it from the fold of the fascia which invests the hernial

+sac. This is the only form in which an internal hernia can be said to be

+absolutely distinct from the inguinal canal and spermatic vessels. This

+hernia, when passing the external ring, 4, has the spermatic cord on its

+outer side.

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 42--Figure 3

+

+

+PLATE 42, Fig. 4.--The external hernia, from having been originally

+oblique, may assume the position of a hernia originally internal and

+direct. The change of place exhibited by this form of hernia does not

+imply a change either in its original investments or in its position

+with respect to the epigastric artery and spermatic vessels. The change

+is merely caused by the weight and gravitation of the hernial mass,

+which bends the epigastric artery, 9*, from its first position on the

+inner margin of the internal ring, 1, till it assumes the place 9. In

+consequence of this, the internal ring of the fascia transversalis, 2,

+2, is considerably widened, as it is also in Fig. 2, Plate 42. 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 hernia may

+disturb the order and relative position of the spermatic vessels; but

+these, as well as the hernia, still occupy the inguinal canal, and are

+invested by the spermatic fascia, 3, 3. When an internal hernia, Fig. 1,

+Plate 42, enters the inguinal canal, it also may descend the cord as far

+as the testicle, and assume in respect to this gland the same position

+as the external hernia. [Footnote]

+

+[Footnote: As the external hernia, Fig. 4, Plate 42, may displace the

+epigastric artery inwards, so may the internal hernia, Fig. 1, Plate 42,

+displace the artery outwards. Mr. Lawrence, Sir Astley Cooper, Scarpa,

+Hesselbach, and Langenbeck, state, however, that the internal hernia

+does not disturb the artery from its usual position three-fourths of an

+inch from the external ring.]

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 42--Figure 4

+

+

+PLATE 42, Figs. 5, 6, 7.--The form and position of the inguinal canal

+varies according to the sex and age of the individual. In early life,

+Fig. 6, the internal ring is situated nearly opposite to the external

+ring, 4. As the pelvis widens gradually in the advance to adult age,

+Fig. 5, the canal becomes oblique as to position. This obliquity is

+caused by a change of place, performed rather by the internal than the

+external ring. [Footnote] 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. 7,

+merely transmits the round ligament, 14, accounts anatomically for the

+fact, that this sex is less liable to the occurrence of rupture in this

+situation.

+

+[Footnote: M. Velpeau (Nouveaux Elemens de med. Operat.) states the

+length of the inguinal canal in a well-formed adult, measured from the

+internal to the external ring, to be 1-1/2 or 2 inches, and 3 inches

+including the rings; but that in some individuals the rings are placed

+nearly opposite; whilst in young subjects the two rings nearly always

+correspond. When, in company with these facts, we recollect how much the

+parts are liable to be disturbed in ruptures, it must be evident that

+their relative position cannot be exactly ascertained by measurement,

+from any given point whatever. The judgment alone must fix the general

+average.]

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 42--Figure 5

+

+

+[Illustration: Abdomen and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 42--Figure 6

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 42--Figure 7

+

+

+

+COMMENTARY ON PLATES 43 & 44.

+

+THE DISSECTION OF FEMORAL HERNIA, AND THE SEAT OF STRICTURE.

+

+Whilst all forms of inguinal herniae escape from the abdomen at places

+situated immediately above Poupart's ligament, the femoral hernia, G,

+Fig. 1, Plate 43, 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 herniae, 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 herniae 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 herniae, 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 herniae 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, Plate 43, extends between the

+anterior superior iliac spinous process and the pubic spine. It connects

+the aponeurosis of the external oblique muscle, D d, Fig. 2, Plate 44,

+with F, 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. 1, Plate 44, we find Gimbernat's

+ligament, R, a structure well known in connexion with femoral hernia.

+Gimbernat'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, corresponding 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. 1, Plate 44, 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 well be supposed to suffer pressure from the three together.

+

+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 f, of the femoral vessels, E F, Fig. 1, Plate 43, passes

+from beneath the middle of the femoral arch. In this situation, the

+iliac part of the fascia lata, F G, Fig. 2, Plate 44, covers the sheath.

+Its inner side is bounded by Gimbernat's ligament, R, Fig. 1, Plate 44,

+and 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, Plate 43, is occupied by the femoral artery; the middle one, F,

+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 of the saphenous opening, Gimbernat's ligament, and the

+conjoined 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 ends than

+elsewhere. The femoral sheath being broader above than below, whilst the

+vessels are of a 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, Plate 43, is, in the natural state of the

+parts, closed over by the peritonaeum, in the same manner as this

+membrane shuts the internal inguinal ring. There is, however,

+corresponding to each ring, a depression in the peritonaeal covering;

+and here it is that the bowel first forces the membrane and forms of

+this part its sac.

+

+On removing the peritonaeum 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 remove 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 peritonaeum. 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, Plate 43, 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 peritonaeum.

+

+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, Plate 43, 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, Plate 43, which passes close to the outer

+and upper border of, H, the femoral ring. This vessel occasionally gives

+off the obturator artery, which, when thus derived, will be found to

+pass towards the obturator foramen, in close connexion 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 instances, the vessel crosses the

+ring; a vein generally accompanies the artery. These peculiarities in

+the origin and course of the obturator 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 structures which have

+just now been enumerated as bounding this passage, 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, Plate 43, 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, Plate 43, of

+the canal itself. [Footnote 1] Its further progress through the

+saphenous opening, B F, Fig. 1, Plate 44, 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 opening. 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, [Footnote 2] 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 will have its three parts--neck, body, and fundus--forming nearly

+right angles with each other: its neck [Footnote 3] 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.

+

+[Footnote 1: 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.]

+

+[Footnote 2:  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!]

+

+[Footnote 3: The neck of the sac at the femoral ring lies very deep, in

+the undissected state of the parts (Lawrence).]

+

+The crural hernia is much more liable to suffer 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. [Footnote] This

+hernia suffers stricture of the passive kind always; for the dense

+fibrous bands in its neighbourhood compress it rather by withstanding

+the force of the herniary 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 increase in size and

+weight.

+

+[Footnote: Sir A. Cooper (Crural Hernia) is of opinion that the

+stricture is generally in the neck of the sheath. Mr. Lawrence remarks,

+"My own observations 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.)]

+

+

+DESCRIPTION OF THE FIGURES OF PLATES 43 & 44.

+

+PLATE 43.

+

+FIGURE 1.

+

+A. Anterior superior iliac spine.

+

+B. Iliacus muscle, cut.

+

+C. Anterior crural nerve, cut.

+

+D. Psoas muscle, cut.

+

+E. Femoral artery enclosed in e, its compartment of the femoral sheath.

+

+F. Femoral vein in its compartment, f, of the femoral sheath.

+

+G. The fascia propria of the hernia; g, the contained sac.

+

+H. Gimbernat's ligament.

+

+I. Round ligament of the uterus.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 43.--FIGURE 1.

+

+

+FIGURE 2.

+

+A. Anterior superior iliac spine.

+

+B. Symphysis pubis.

+

+C. Rectus abdominis muscle.

+

+D. Peritonaeum.

+

+E. Conjoined tendon.

+

+F. Epigastric artery.

+

+G* G. Positions of the obturator artery when given off from the

+      epigastric.

+

+H. Neck of the sac of the crural hernia.

+

+I. Round ligament of the uterus.

+

+K. External iliac vein.

+

+L. External iliac artery.

+

+M. Tendon of the psoas parvus muscle, resting on the psoas magnus.

+

+N. Iliacus muscle.

+

+O. Transversalis fascia.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 43.--FIGURE 2.

+

+

+PLATE 44.

+

+FIGURE 1.

+

+A. Anterior superior iliac spine.

+

+B. The crural hernia.

+

+C. Round ligament of the uterus.

+

+D. External oblique muscle; d, Fig. 2, its aponeurosis.

+

+E. Saphaena vein.

+

+F. Falciform process of the saphenous opening.

+

+G. Femoral artery in its sheath.

+

+H. Femoral vein in its sheath.

+

+I. Sartorius muscle.

+

+K. Internal oblique muscle; k, conjoined tendon.

+

+L L. Transversalis fascia.

+

+M. Epigastric artery.

+

+N. Peritonaeum.

+

+O. Anterior crural nerve.

+

+P. The hernia within the crural canal.

+

+Q Q. Femoral sheath.

+

+R. Gimbernat's ligament.

+

+

+FIGURE 2.

+

+The other letters refer to the same parts as seen in Fig. 1.

+

+G. Glands in the neighbourhood of Poupart's ligament.

+

+H. Glands in the neighbourhood of the saphenous opening.

+

+I. The sartorius muscle seen through its fascia.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 44.--FIGURE 1, 2.

+

+

+

+COMMENTARY ON PLATES 45 & 46.

+

+DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF FEMORAL HERNIA--

+ITS DIAGNOSIS, THE TAXIS, AND THE OPERATION.

+

+PLATE 45, Fig. 1.--The point, 3, from which an external inguinal hernia

+first progresses, and the part, 5, within which the femoral hernia

+begins to be 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

+hernial; and they are readily accounted for by the anatomical relations

+of the parts concerned.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 45.--FIGURE 1

+

+

+PLATE 45, Fig. 2.--There exists a very evident analogy between the

+canals through which both herniae 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.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 45.--FIGURE 2

+

+

+PLATE 45, Fig. 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, Plate 45. The

+epigastric artery always holds an intermediate position between both

+rings. The spermatic vessels in the inguinal tube, 3, 3, Fig. 2, Plate

+45, are represented by the round ligament in the female inguinal canal,

+Fig. 3, Plate 45. When the bowel is about to protrude at either of the

+rings, it first dilates the peritonaeum, which covers these openings.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 45.--FIGURE 3

+

+

+PLATE 45, Fig. 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 occupied by the

+psoas and iliacus muscles, and, moreover, as the abdominal fibrous

+membrane and its prolongation, the femoral sheath, closely embrace the

+vessels on their outer anterior and posterior 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 readily pass. The peritonaeum, 2, and crural septum,

+13, form at this place the only barrier against the protrusion of the

+bowel into the canal.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 45.--FIGURE 4

+

+

+PLATE 45, Fig. 5.--The hernia cannot freely enter the compartment, 10,

+occupied by the artery, neither can it enter the place 11, occupied 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 opposed by, 4,

+the conjoined tendon, and by, 8, Gimbernat's ligament. Neither will 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. [Footnote] The bowel, therefore, enters the femoral canal, 9,

+and herein it lies covered by its peritonaeal 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.

+

+[Footnote: The mode in which the femoral sheath, continued from the

+abdominal membrane, becomes simply applied to the sides of the vessels,

+renders it of course not impossible for a hernia to protrude into the

+sheath at any point of its abdominal entrance. Mr. Stanley and M.

+Cloquet have observed a femoral hernia external to the vessels.

+Hesselbach has also met 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.)]

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 45.--FIGURE 5

+

+

+PLATE 45, Fig. 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 still continuous with

+the fascia transversalis. When the hernia ruptures the saphenous side of

+the canal, the fascia propria is, of course, absent.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 45.--FIGURE 6

+

+

+PLATE 46, Fig. 1.--The anatomical circumstances which serve for the

+diagnosis of a femoral from an inguinal hernia may be best explained by

+viewing in contrast the respective positions assumed by both complaints.

+The direct hernia, 13, traverses the inguinal wall 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 herniae 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,

+will serve to indicate, by negative evidence, that it is not a femoral

+hernia.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 46.--FIGURE 1

+

+

+PLATE 46, Fig. 2.--When the inguinal and femoral herniae 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 swelling can

+scarcely be mistaken for an inguinal rupture, since, in addition to its

+being superficial to the aponeurosis which covers the inguinal canal,

+and also to the femoral arch, it may be withdrawn 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.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+PLATE 46.--FIGURE 2

+

+

+PLATE 46, Fig. 3.--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 will 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 correspond with this situation only,

+other circumstances, such as the constant 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, [Footnote] by rare occurrence, happen to loop round the inner

+side of the neck of the sac, supposing 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?

+

+[Footnote: 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 cadavres, 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 3-1/2, 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) in 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?]

+

+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 contained intestine

+suffer constriction throughout the whole length of the canal. [Footnote]

+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.

+

+[Footnote: "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 peritonaeal membranes where they lie within the

+circumference of the crural ring."--Morton (Surgical Anatomy of the

+Groin p. 148).]

+

+An incision commencing a little way 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 (superficial pubic, &c.)

+may be divided, and some lymphatic bodies exposed. On cautiously turning

+aside the incised adipose membrane contained between the two layers of

+the superficial fascia, the fascia propria, 9, Figs. 4, 5, Plate 46, 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 drawn outwards, so as to separate

+it from the inner wall of the crural canal, a director [Footnote] 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--viz., the falciform process, 6; the inner wall

+of the canal, which is continuous 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-sufficient 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.

+

+[Footnote: 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.]

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 46--Figure 3

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 46--Figure 4

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 46--Figure 5

+

+

+

+COMMENTARY ON PLATE 47.

+

+THE SURGICAL DISSECTION OF THE PRINCIPAL BLOODVESSELS AND

+NERVES OF THE ILIAC AND FEMORAL REGIONS.

+

+Through the groin, as through the axilla, the principal blood vessels

+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 overlooked, 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, transversely 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 drawn

+from the navel to a point, D, of the inguinal fold, midway 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 abdomen, 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

+sacra-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 consequence of the epigastric or circumflex

+iliac branches arising higher up or lower down 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

+generally 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 main

+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 O, 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 intestines, and

+are closely invested by the serous membrane. The origin of the vena

+cava, F, lies close to the right side 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 commencement 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, g, 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 peritonaeum, 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

+the genito-crural nerve, descend along the outer border of the iliac

+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 abdomen 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 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 membrane 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 of femoral.

+

+The femoral vessels, O N W, in the upper third of the thigh traverse a

+triangular space, the base of which is formed by Poupart's ligament, D,

+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 this place they lie

+imbedded in loose cellular and adipose tissue. The femoral vein, O, is

+on the same plane with the artery near Poupart'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 it

+may 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 these--the

+long saphenous nerve--enters the sheath and follows the artery as far as

+the opening in the great adductor tendon. The femoral artery, before it

+passes through this opening into the popliteal space, gives off its

+anastomatic branch. The profundus branch, N, springs from the outer side

+of the femoral artery usually at a distance of from one to two inches

+(seldom more) below Poupart's ligament, and soon subdivides. [Footnote]

+The femoral artery in a few instances has been found double.

+

+[Footnote: The ordinary length of each part of the main artery is stated

+on the authority of Mr. Quain. See "Anatomy of the Arteries," &c. ]

+

+The main artery of the lower limb may be exposed and tied in any part of

+its course from the aorta to the popliteal space. But the situation most

+eligible for performing such an operation depends of course upon

+circumstances, both anatomical and pathological. If an aneurism affect

+the popliteal part of the vessel, or if, from whatever cause arising, it

+be found expedient to tie the femoral above this part, the place best

+suited for the operation is that where the artery, W, first passes under

+cover of the sartorius muscle. [Footnote]  For, considering that the

+vessel gives off no important branch destined to supply any part of the

+thigh or leg between the profundus branch and those into which it

+divides below the popliteal space, the arrest to circulation will be the

+same in amount at whichever part of the vessel between these two points

+the ligature be applied. But since the vessel in the situation specified

+can be reached with greater facility here than elsewhere lower down; and

+since, moreover, a ligature applied to it here will be sufficiently

+removed from the profundus branch above, and the seat of disease below,

+to produce the desired result, the choice of the operator is determined

+accordingly. The steps of the operation performed at the situation W,

+where the artery 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 situation, 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.

+

+[Footnote: This is the situation chosen by Scarpa for arresting by

+ligature the circulation through the femoral artery in cases of

+popliteal aneurism. The reasons stated in the text are those which

+determine the surgeon to perform the operation in this place in

+preference to that (the lower third of the thigh) where Mr. Hunter first

+proposed to tie 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, (external and internal circumflex,

+&c.), arises as high up as Poupart's ligament, close to the origin of

+the epigastric and circumflex iliac. [Footnote]

+

+[Footnote: The main artery (Plate 47) has been exposed in the iliac and

+femoral regions with the object of showing the relation which its parts

+bear to each other and to the whole; all the other dissections have been

+made upon the same plan, the practical tendency of which will be

+illustrated when considering the subject of arterial anastomosis.]

+

+The external iliac part of the artery, G I, when requiring to be tied,

+may be reached in the following way: an incision, commencing above the

+anterior iliac spine, B, is to be carried inwards parallel 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 disturbing the peritonaeum more than

+is necessary. The skin and the three abdominal muscles having been

+successively incised, the fibrous transversalis fascia is next to be

+carefully divided, so as to expose the peritonaeum. This membrane is

+then to be gently raised by the fingers, from off the iliacus and psoas

+muscles as far inwards as the margin of the true pelvis where the artery

+lies. On raising the peritonaeum the spermatic vessels will be found

+adhering to it. The iliac artery itself is liable to be displaced by

+adhering to the serous membrane, when this is being detached from the

+inner side of the psoas muscle. [Footnote] The artery having been

+divested of its serous covering as far up as a point midway between I G,

+the epigastric and internal iliac branches, the ligature is to be passed

+around it in this place, as being equidistant from these two sources of

+disturbance. As the vein, K, lies close along the inner side of the

+artery, the point of the instrument should first be inserted between

+them, and passed from within outwards, in order to avoid wounding the

+vein. If an aneurism affect the upper end of the external iliac artery,

+it is proposed to tie the common iliac; but this is an operation of so

+serious a nature, that it can in this respect be exceeded only by tying

+the aorta itself. The common iliac artery is so situated, that it can as

+easily be reached from the groin upwards as from the side of the abdomen

+inwards, and in both directions the peritonaeum would have to be

+disturbed to an equal extent.

+

+[Footnote: The student, in operating upon the dead subject, is often

+puzzled to find that the iliac artery does not appear in its usual

+situation, unaware at the time that he has lifted the vessel in

+connexion with the peritonaeum. I have once seen a very distinguished

+surgeon, whilst performing this operation on the living body, at fault

+owing to the same cause.]

+

+DESCRIPTION OF PLATE 47.

+

+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.

+

+E E*. The right and left iliac muscles covered by the peritonaeum; the

+      external cutaneous nerve is seen through the membrane.

+

+F. The vena cava.

+

+G G*. The common iliac arteries giving off the internal iliac branches

+      on the sacro-iliac symphyses; g g, the right and left ureters.

+

+H H*. The right and left common iliac veins.

+

+I I*. The right and left external iliac arteries, each is crossed by the

+      circumflex ilii vein.

+

+K K *. 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; 0, the saphena vein.

+

+P. The anterior crural nerve.

+

+Q. The sartorius muscle, cut.

+

+S. The pectinaeus 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.

+

+

+[Illustration: Abdomen and leg, showing bone, blood vessels

+and other internal organs.]

+Plate 47.

+

+

+

+COMMENTARY ON PLATES 48 & 49.

+

+THE RELATIVE ANATOMY OF THE MALE PELVIC ORGANS.

+

+As the abdomen and pelvis form one general cavity, the organs contained

+in both regions are thereby intimately related. The viscera of the

+abdomen completely fill 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

+perinaeum 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

+perinaeum, 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

+perinaeal 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 perinaeal 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 relaxation 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" urinae, 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, Plate 49, (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 neighbouring 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 symphysis. 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 hypogastrium.

+

+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 intestines now gravitate upon

+it. When the body is recumbent, the bladder recedes somewhat from the

+pubes, and as the intestines 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 peritonaeum, 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 inadmissible, if indeed the necessity for it

+can now be conceived.

+

+By removing the os innominatum, A D, Plate 48, together with the

+internal obturator, and levator ani muscles, which arise from its inner

+side, we obtain a lateral view, Plate 49, 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 peritonaeum, are also now fully

+displayed. On tracing this membrane 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 forepart 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; 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 peritonaeum 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 peritonaeum 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 peritonaeum, forms 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 limit 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 anterior 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, D, 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 perinaeal 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, W C, 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 corresponding 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, forwards against the base of the bladder,

+and give to this part a degree of obliquity upwards and backwards, in

+respect to the perinaeum and anus. From the point where the prostate, V,

+lies in contact with the rectum, W, this latter curves downwards, and

+slightly backwards, to the anus, P. The prostate is situated at a

+distance of about an inch and a half or two inches from the anus--the

+distance varying according to whether the bladder and bowel be distended

+or not. [Footnote]

+

+[Footnote: 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 perinaeum, as it is termed, is frequently met with. This may be

+occasioned either by an unusual quantity of fat in the perinaeum, 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 prostate and bladder become situated higher in the

+pelvis than naturally, and consequently at a greater distance from the

+perinaeum."--On the Lateral Operation of Lithotomy.]

+

+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 circulation, produced from

+whatever cause, the bowel is liable to be affected with haemorrhoids or

+to assume a haemorrhagic tendency.

+

+The pudic artery, S s, is a branch of the internal iliac. It 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 small 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 perinaeum. At the place where the

+vessel re-enters the pelvis, it lies removed at an interval of an inch

+and a half from the perinaeum, 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 and bladder. The

+principal branches given off from the pudic artery of either side, are

+(1st), the inferior hemorrhoidal, to supply the lower end of the rectum;

+(2nd), the transverse and superficial perinaeal; (3rd), the artery of

+the bulb; (4th), that which enters the corpus cavernosum of the penis,

+N; and (5th), the dorsal artery of the penis. [Footnote] 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.

+

+[Footnote: The pudic artery, or some one of its branches, occasionally

+undergoes marked deviations from the ordinary course. In Mr. Quain's

+work, ("Anatomy of the Arteries,") a case is represented in which the

+artery of the bulb arose from the pudic as far back as the tuber ischii,

+and crossed the line of incision made in the lateral operation of

+lithotomy. In another figure is seen a vessel ("accessory pudic"),

+which, passing between the base of the bladder and the levator ani

+muscle, crosses in contact with the left lobe of the prostate.]

+

+

+DESCRIPTION OF PLATES 48 & 49.

+

+PLATE 48.

+

+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 peritonaeum.

+

+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; n, its artery.

+

+O. The urethra; o, the bulbus urethrae.

+

+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.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 48

+

+

+PLATE 49.

+

+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 peritonaeum; G *, its side,

+   not covered by the membrane.

+

+H H. The recto-vesical peritonaeal pouch,

+

+I. The vas deferens.

+

+K. The ureter.

+

+L. The vesicula seminalis.

+

+M, N, O, P, Q, R, S, T, U, refer to the same parts as in Plate 48.

+

+V. The prostate.

+

+W. The lower part of the rectum.

+

+X. The deep perinaeal fascia.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 49

+

+

+

+COMMENTARY ON PLATES 50 & 51.

+

+THE SURGICAL DISSECTION OF THE SUPERFICIAL STRUCTURES OF THE

+MALE PERINAEUM.

+

+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 all forms which are anomalous to either sex, may be interpreted

+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 perinaeum respectively

+into equal and similar sides. The umbilicus is a cicatrix formed after

+the metamorphosis of a median foetal structure--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 hypogastrium 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 process of union along the

+median line may err by a defect or omission, so may it, on the other

+hand, err by an excess of 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 perinaeum, the dissection of these parts has been

+conducted accordingly.

+

+By removing the skin and subjacent adipose membrane from the

+hypogastrium, we expose the superficial fascia. This membrane, E E E*,

+Fig. 1, Plate 50, 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. From 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 skin 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 together, form

+the median septum scroti, E, Fig. 2, Plate 50. In the perinaeum, Fig. 1,

+Plate 51, 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 perinaeal

+line the two sacs of which the membrane is composed 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 perinaeal

+fascia, and by this connexion separates the urethral from the anal

+spaces. The superficial fascia of the hypogastrium, the scrotum, and the

+perinaeum 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 ruptured,

+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 tunicae

+vaginales, which form the immediate coverings of the testicles, cannot

+be entered by the urine, as they are distinct sacs originally protruded

+from the abdomen. It is in consequence 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, D D, Fig. 2, Plate 50.

+While viewed in section, its two corpora cavernosa are seen to unite

+anteriorly, and by this union to form a septum "pectiniforme;"

+posteriorly they remain distinct and lateral, F F, Fig. 2, Plate 51,

+being attached to the ischio-pubic rami as the crura penis. The urethra,

+B, Fig. 2, Plate 50, 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. 1, 2, Plate 51, is that space which is bounded

+above by the arch of the pubes, behind by C, the os coccygis, and the

+lower borders of, I I, the glutaei muscles and sacro-sciatic ligaments,

+and laterally by D D, the ischiatic tuberosities. The osseous boundaries

+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,

+Plate 50, 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 depression formed between

+D D, the ischiatic tuberosities, and the double folds of the nates.

+

+The perinaeum, Fig. 3, Plate 50, 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, A D D, contains the urethra; the

+posterior space, D D C, contains the rectum. The central raphe, A B C,

+traverses both these spaces. The anterior or urethral space is (while

+viewed in reference to its osseous boundaries) 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 raphe 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 A B. Behind the point B, the sound or staff sinks

+deeper in the perinaeum 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, Plate 50, 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

+perinaeal 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 perinaeal

+centre, the line of incision, B E, Fig. 3, Plate 50, is carried

+obliquely from above downwards and outwards; but in cases where the

+tuberosity approaches the centre, the incision must necessarily be made

+more vertical. The posterior perinaeal space may be described on the

+surface by two lines drawn from D D, the ischiatic tuberosities, to C,

+the point of the coccyx, whilst the transverse line between D and D

+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 urinae, E,

+Fig. 2, Plate 51, which embraces the urethra, and the sphincter ani, B

+C, which surrounds the anus, H, 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. 1, Plate 51, is

+found a considerable quantity of granular adipose tissue, traversed by

+the inferior haemorrhoidal arteries and nerves-branches of the pudic

+artery and nerve.

+

+In front of the anus are seen two small muscles (transversae perinaei),

+G G, Fig. 2, Plate 51, 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 perinaeal spaces. Behind each muscle is found a small artery,

+crossing to the median line. The left transverse 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

+F, overlaying the crura penis. Between each muscle and the accelerator

+urinae, the superficialis perinaei artery and nerve course forwards to

+the scrotum, &c.

+

+The perinaeal muscles having been brought fully into view, Plate 52,

+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

+urinae, D, the erector penis, and E, the transverse muscle. Along the

+surface of this interval, the superficial perinaeal 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 membrane

+named the deep perinaeal 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 perinaeal space require to be

+removed, Fig. 1, Plate 53, in order to expose the urethra, B M, the crus

+penis, D, and the deep perinaeal fascia. The fascia will be now seen

+stretched across the subpubic triangular space, reaching from one

+ischio-pubic ramus to the other, whilst by its lower border,

+corresponding with the line of the transversae perinaei muscles, it

+becomes continuous with the superficial fascia, in the manner before

+described. The deep perinaeal fascia (triangular ligament) encloses

+between its two layers, C E, on either side of the urethra, the pudic

+artery, the artery of the bulb, Cowper's glands, and some muscular

+fibres occasionally to be met with, to which 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

+wounding 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 perinaeal space; the rectum occupies the middle in the

+posterior space. When either of these parts specially requires to be

+incised--the urethra for impassable stricture, &c., and the lower part

+of the rectum for fistula in ano--the operation may be performed

+without fear of inducing dangerous arterial haemorrhage. With the object

+of preserving from injury these important parts, deep incisions at, or

+approaching to, the middle line must be avoided. The outer

+(ischio-pubic) boundary of the perinaeum is the line along which the

+pudic artery passes. The anterior half 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 structures placed at the middle line, B M F,

+Fig. 2, Plate 52, and those in connexion with the left perinaeal

+boundary, D G L, 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 should be made through the left side of the

+perinaeum from a point midway between M, the bulb, and D, crus penis

+above, to a point, K, midway between the anus, F, and tuber ischii, G,

+below. As the upper end of this incision is commenced over the situation

+of the superficial perinaeal artery and the artery of the bulb, the

+knife 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, which parts, together with the

+membranous portion of the urethra, are still concealed by the deep

+perinaeal 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, will

+leave them untouched; but when the pudic artery, or some one of its

+branches, deviates from its ordinary course and crosses the line of

+incision, a serious haemorrhage will ensue, despite the anatomical

+knowledge of the most experienced operator. When it is requisite to

+divide the superficial 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 haemorrhoidal arteries and nerves converging

+towards the anus will be the more likely to escape being wounded.

+

+

+DESCRIPTION OF THE FIGURES OF PLATES 50 & 51.

+

+PLATE 50.

+

+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.

+

+F F. The spermatic cords.

+

+

+FIGURE 2.

+

+A. The umbilicus.

+

+B. The urethra.

+

+C*. The tunica vaginalis; c, the testicle invested by the tunic.

+

+D D. The corpora cavernosa seen in section.

+

+E. The scrotal raphe and septum scroti.

+

+

+FIGURE 3.

+

+A B. The perinaeal raphe.

+

+C. The place of the coccyx.

+

+D D. The projections of the ischiatic tuberosities.

+

+BE. The line of section in lithotomy.

+

+

+[Illustration: Legs and scrotum, showing bone, blood vessels

+and other internal organs.]

+Plate 50; Figure 2, Figure 3, Figure 1.

+

+

+PLATE 51.

+

+FIGURE 1.

+

+A. The superficial fascia covering the urethral space.

+

+B. The sphincter ani.

+

+C. The coccyx.

+

+D D. The right and left ischiatic tuberosities.

+

+H. The anus.

+

+I I. The glutei muscles.

+

+FIGURE 2.

+

+A, B, C, D, H, I. The same parts as in Fig. 1.

+

+E. The accelerator urinae muscle.

+

+F F. Right and left erector penis muscle.

+

+G G. Right and left transverse muscle.

+

+

+[Illustration: Abdomen, showing bone, blood vessels

+and other internal organs.]

+Plate 51; Figure 2, Figure 1.

+

+

+

+COMMENTARY ON PLATES 52 & 53.

+

+THE SURGICAL DISSECTION OF THE DEEP STRUCTURES OF THE MALE PERINAEUM.

+

+THE LATERAL OPERATION OF LITHOTOMY.

+

+The urethra, at its membranous part, M, Fig. 1, Plate 53, which

+commences behind the bulb, perforates the centre of the deep perinaeal

+fascia, E E, at about an inch and a 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 perinaeal fascia, the anterior fibres of K, the levator

+ani muscle, arise from either side of the pubic symphysis posteriorly,

+and descend obliquely down wards 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. 2, Plate 53, and must necessarily be

+divided in the operation of lithotomy. Previously to disturbing the

+lower end of the rectum from its natural position in the perinaeum, its

+close relation to the prostate and base of the bladder should be

+noticed. While the anus remains connected with the deep perinaeal 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, while 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.

+2, Plate 53, and detaching and depressing this from the perinaeal

+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 this manner the pelvic fascia

+serves to insulate the perinaeal space from the pelvic cavity. The

+prostate occupies the centre of the perinaeum. 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 membranous part of the urethra, M,

+Fig. 2, Plate 53, 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 perinaeal 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 urethrae 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. 2, Plate 53, 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

+neighbouring 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 perinaeum. 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 perinaeum should be incised, at the middle line, between the bulb of

+the urethra and the anus. The urethra in this situation will be found to

+curve backwards at the depth of an inch or more from the surface. The

+point of the staff 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 obstruction 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 full, 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

+perinaeum in order to determine the situation of the left tuberosity and

+ischio-pubic ramus, in relation to the perinaeal 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

+perinaeum, 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 fore-finger 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 fore-finger;

+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 fore-finger 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 grip 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 perinaeal 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 perinaeal 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. [Footnote]

+

+

+[Footnote: "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 least laceration, the opening can

+be so dilated as to admit the fore-finger 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 largest."--Practical Surgery, page 510. This doctrine

+(founded, no doubt, on Mr. Liston's own great experience) coincides with

+that first expressed by Scarpa, Le Cat, and others. Sir Benjamin Brodie,

+Mr. Stanley, and Mr. Syme are also advocates for limited incisions,

+extending no farther than a partial division of the prostate, the rest

+being 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 make it a rule to let the incision be rather too

+large than too small, and never to 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. Opinions of the highest

+authority being thus opposed, in reference to the question whether free

+or limited incisions in the neck of the bladder are followed

+respectively by the greater number of fatal or favourable results, and

+these being thought mainly to depend upon whether the pelvic fascia be

+opened 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 as the state of the constitution, the state of the bladder, and the

+relative position of the internal and external incisions. "Some

+individuals (observes Sir B. Brodie) are good subjects for the

+operation, and recover perhaps without a bad symptom, although the

+operation may have been very indifferently performed. Others may be

+truly said to be bad subjects, and die, even though the operation be

+performed in the most perfect manner. What is it that constitutes the

+essential difference between these two classes of cases? It is,

+according to my experience, the presence or absence of organic

+disease."--Diseases of the Urinary Organs.]

+

+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 perinaeum 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.

+

+

+DESCRIPTION OF THE FIGURES OF PLATES 52 & 53.

+

+PLATE 52.

+

+FIGURE 1.

+

+A. The urethra.

+

+B. Accelerator urinae muscle.

+

+C. Central perinaeal tendon.

+

+D D. Right and left erector penis muscle.

+

+E E. The transverse muscles.

+

+F. The anus.

+

+G G. The ischiatic tuberosities.

+

+H. The coccyx.

+

+I I. The glutei muscles.

+

+K K. The levator ani muscle.

+

+L. The left artery of the bulb.

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 52.--Figure 1

+

+

+FIGURE 2.

+

+A, D, F, G, H, I, K, L refer to the same parts as in Fig. 1, Plate 52.

+

+B. The urethra.

+

+C. Cowper's glands between the two layers of--

+

+E. The deep perinaeal fascia.

+

+M. The bulb of the urethra.

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 52.--Figure 2

+

+

+PLATE 53.

+

+FIGURE 1.

+

+A, B, C, E, F, G, H, I, K, L refer to the same parts as in Fig. 2, Plate

+52.

+

+D D. The two crura penis.

+

+M. The urethra in section

+

+N N. The rectum.

+

+O. The sacro-sciatic ligament.

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 53.--Figure 1

+

+

+FIGURE 2.

+

+A, B, D, G, H, I, K, L, O refer to the same parts as in Fig. 1, Plate 53.

+

+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.

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 53.--Figure 2.

+

+

+

+COMMENTARY ON PLATES 54, 55, & 56.

+

+THE SURGICAL DISSECTION OF THE MALE BLADDER AND URETHRA.--

+LATERAL AND BILATERAL LITHOTOMY COMPARED.

+

+Having examined the surgical relations of the bladder and adjacent

+structures, in reference to the lateral operation of lithotomy, it

+remains to reconsider these same parts as they are concerned in the

+bilateral operation and in catheterism.

+

+Fig. 1, Plate 54, represents the normal relations of the more important

+parts concerned in lithotomy as performed at the perinaeal region. The

+median line, AA, 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 different depths from the

+perinaeal surface. The bulb of the urethra and the lower end of the

+bowel are on the same plane comparatively 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

+staff in this part of the urethra, is made to enter the neck of the

+bladder deeply in the same direction. On comparing 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 perinaeum into the

+anterior and posterior spaces, and to intersect at right angles the

+median line A A. In the same way the line B B divides 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 perinaeum, the lateral incisions

+are made obliquely in the direction of the lines CD. 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.

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 54, Figure 1.

+

+

+Fig. 2, Plate 54.--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 D 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.

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 54, Figure 2.

+

+

+Fig. 1, Plate 55.--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

+D, 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 perinaeal

+incision should be made under the like necessity. If the prostate be

+wholly divided in either line of section, the pelvic fascia adhering to

+the 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 D

+being made through the forepart of the left lobe, F, these ducts will

+escape injury. [Footnote] On the whole, therefore, the lateral operation

+appears preferable to the bilateral one.

+

+[Footnote: 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 as 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, 3d Am. Ed., p. 610.]

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 55--Figure 1.

+

+

+Fig. 2, Plate 55.--The muscular structures surrounding the membranous

+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 spasmodic 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. 2, Plate 55, I

+have summed together all the facts recorded concerning them, [Footnote]

+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 B C D E F 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 D E F. When one or more of them are omitted from the

+series, there occurs anatomical 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 = 11 are when the mind is devoid of the power of calculation.

+

+[Footnote: 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.]

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 55--Figure 2

+

+

+Fig. 3, Plate 55.--The membranous urethra A is also in some instances

+embraced by two symmetrical fasciculi of muscular fibres B B, 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. 2, Plate 55, are between the two layers of the deep perinaeal

+fascia, while the muscle B B, Fig. 3, Plate 55, lies like the forepart

+of the levator ani, C C, behind this structure and between it and the

+anterior ligaments of the bladder. [Footnote] 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.

+

+[Footnote: This is the muscle, B B, which is described by Santorini as

+the "levator prostatae;" by Winslow as "le prostatique superieur;" by

+Wilson as the "pubo-urethrales;" by Muller as not existing; by Mr.

+Guthrie as forming (when existing), with the parts B C, Fig. 2, Plate

+55, his "compressor isthmi urethrae;" and by M. Cruveilhier as being

+part of the levator ani muscle. "As in one case," (observes Mr. Quain,)

+"I myself saw a few vertical muscular fibres connected with the

+transverse compressor, it has been thought best to retain the muscle in

+the text."--Dr. Quain's Anat., Am. Ed. vol. ii. p. 539.]

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 55--Figure 3

+

+

+Fig. 1, Plate 56, 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 procumbent to the right side

+[capital S rotated 90 degrees right] or to the left [capital S rotated

+90 degrees left]. But as the anterior half of the canal is moveable, and

+liable thereby to obliterate the general form, while 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 performance 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 semicircle,

+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, F 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 F, which is free, relaxed,

+and moveable, can by traction towards the umbilicus be made to continue

+in the direction of the fixed curve F 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 different individuals, and its structure

+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 larger 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

+urinae muscle. The bulb and glans are expansions or enlargements 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 (lacunae), one of which, larger than

+the rest, appears on the upper side of the canal near the meatus. Some

+of these lacunae 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 montanum, upon which the two

+seminal ducts open by orifices directed forwards. On either side of the

+veru montanum the floor of the prostate may be seen perforated by the

+"excretory ducts" of this so-called gland. 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. 2, Plate

+56. 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

+Bell as "the muscles of the ureters;" but as they do not appear in the

+bladder when in a state of health, 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 vesicae." The

+form of that portion of the base of the bladder which is named "trigone

+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 called "bas fond" is formed in the base

+of the bladder. Fig. 2, Plate 56, represents the prostate of a boy nine

+years of age. Fig. 3, Plate 56, represents that of a man aged forty

+years. A difference as to form and size, &c., is observable between

+both.

+

+

+[Illustration: Abdomen, showing blood vessels and other internal organs.]

+Plate 56--Figure 1, 2, 3

+

+

+

+COMMENTARY ON PLATES 57 & 58.

+

+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 perfect 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.

+

+Fig. 1, Plate 57, represents the prepuce in a state of congenital

+phymosis. 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.

+

+

+[Illustration]

+Plate 57.--Figure 1.

+

+

+Fig. 2, Plate 57, represents the prepuce in the condition of

+paraphymosis 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 contracted. 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 inflammation by the

+ordinary means.

+

+

+[Illustration]

+Plate 57.--Figure 2.

+

+

+Fig. 3, Plate 57, exhibits the form of a gonorrhoeal 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.

+

+

+[Illustration]

+Plate 57.--Figure 3.

+

+

+Fig. 4, Plate 57, 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.

+

+

+[Illustration]

+Plate 57.--Figure 4.

+

+

+Fig. 5, Plate 57.--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.

+

+

+[Illustration]

+Plate 57.--Figure 5.

+

+

+Fig. 6, Plate 57.--In this figure the glans appears protruding through

+the upper surface of the prepuce, which is thickened and corrugated.

+This state of the parts was caused by a venereal ulceration 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.

+

+

+[Illustration]

+Plate 57.--Figure 6.

+

+

+Fig. 7, Plate 57.--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.

+

+

+[Illustration]

+Plate 57.--Figure 7.

+

+

+Fig. 8, Plate 57, 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 fraenum praeputii, 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.

+

+

+[Illustration]

+Plate 57.--Figure 8.

+

+

+Fig. 9, Plate 57, 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.

+

+

+[Illustration]

+Plate 57.--Figure 9.

+

+

+Fig. 10, Plate 57.--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.

+

+

+[Illustration]

+Plate 57.--Figure 10.

+

+

+Fig. 11, Plate 57, 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 taliacotian operation, by

+which lost quantity is supplied, is the measure most likely to succeed

+in closing the canal.

+

+

+[Illustration]

+Plate 57.--Figure 11

+

+

+Fig. 12, Plate 57.--Behind the meatus, and on the right of the fraenum,

+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.

+

+

+[Illustration]

+Plate 57.--Figure 12.

+

+

+Fig. 13, Plate 57.--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.

+

+

+[Illustration]

+Plate 57.--Figure 13.

+

+Fig. 14, Plate 57, 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.

+

+

+[Illustration]

+Plate 57.--Figure 14.

+

+

+Fig. 15, Plate 57, 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, b, 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 a b; 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 corresponding 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 features in

+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; 3rdly, the formation (on an abscess opening

+externally) of a fistulous communication between the canal and the

+surface of some part of the perinaeum; 4thly, 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 operations 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 pervious, 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.)

+

+

+[Illustration]

+Plate 57.--Figure 15.

+

+

+Fig. 1, Plate 58.--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.)

+

+

+[Illustration]

+Plate 58.--Figure 1.

+

+

+Fig. 2, Plate 58, represents two 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 elsewhere in the urethral canal. These

+occurrences--the disease and the accident--would 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 owing

+to the anatomical fact, that the urethra at and close to the bulb is the

+most dependent part of the curve, F K, Fig. 1, Plate 56; and hence, that

+instruments descending 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

+elsewhere, this circumstance will 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 owing 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.

+

+

+[Illustration]

+Plate 58.--Figure 2.

+

+

+Fig. 3, Plate 58.--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 forwards as far as the

+meatus, within which, owing to the narrowness of this aperture, it

+lodges permanently. If the calculus forms a complete obstruction to the

+passage of the urine, and its removal cannot be effected by other means,

+an incision should be made to effect this object.

+

+

+[Illustration]

+Plate 58.--Figure 3.

+

+

+Fig. 4, Plate 58, represents the neck of the bladder and neighbouring

+part of the urethra of an ox, in which a polypous growth 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 lacunae distended by their own secretion, their

+orifices being closed by inflammation, are also found to obstruct the

+urethral canal.

+

+

+[Illustration]

+Plate 58.--Figure 4.

+

+

+Fig. 5, Plate 58.--In this figure is represented a small calculus

+impacted in and dilating the membranous part of the urethra.

+

+

+[Illustration]

+Plate 58.--Figure 5.

+

+

+Fig. 6, Plate 58.--Two strictures are here shown 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.

+

+

+[Illustration]

+Plate 58.--Figure 6.

+

+

+Fig. 7, Plate 58.--A stricture is here shown situated at the bulb.

+

+

+[Illustration]

+Plate 58.--Figure 7.

+

+

+Fig. 8, Plate 58, represents a stricture of the canal in front of the bulb.

+

+

+[Illustration]

+Plate 58.--Figure 8.

+

+

+Fig. 9, Plate 58, 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

+chiefly 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. (Stafford.)

+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 knowledge less likely to be attained if the stricture be

+situated behind than in front of the triangular ligament.

+

+

+[Illustration]

+Plate 58.--Figure 9.

+

+

+Fig. 10, Plate 58, exhibits a lateral view of the muscular parts which

+surround the membranous portion of the urethra and the prostate; a, the

+membranous urethra embraced by the compressor urethrae muscle; b, the

+levator prostatae muscle; c, the prostate; d, the anterior ligament of

+the bladder.

+

+

+[Illustration]

+Plate 58.--Figure 10.

+

+

+Fig. 11, Plate 58.--A posterior view of the parts seen in Fig. 10; a,

+the urethra divided in front of the prostate; b b, the levator prostatae

+muscle; c c, the compressor urethrae; d d, parts of the obturator

+muscles; e e, the anterior fibres of the levator ani muscle; f g, the

+triangular ligament enclosing between its layers the artery of the bulb,

+Cowper'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 occasionally to be suddenly arrested, and

+this circumstance contrasted with the opposite fact that the organic

+stricture is of slow formation, originated the idea that the former

+occurrence arose from a spasmodic muscular contraction. By many this

+spasm was supposed to be due to the urethra being itself muscular. By

+others, it was demonstrated as being dependent upon the muscles which

+surround the membranous part of the urethra, and which act upon this

+part and constrict it. From my own observations I have formed 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.

+

+

+[Illustration]

+Plate 58.--Figure 11.

+

+

+

+COMMENTARY ON PLATES 59 & 60.

+

+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 calculus in the

+canal, or any morbid growth (a polypus, &c.) being situated therein, or

+from an abscess which, though forming externally 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 stricture

+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 spasmodic 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, however, 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.[Footnote]

+

+[Footnote: 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 anyone, 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 anatomical or pathological, can one part of

+the urethra be more liable to the organic stricture than another?]

+

+Figs. 1 and 2, Plate 59.--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 b, Fig. 2. In b, 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 d, Fig. 1, the

+canal is seen to be much contracted towards the left side by a

+crescentic fold of the lining membrane projecting from the right. In f,

+the canal appears contracted by a circular membrane, perforated in the

+centre; a section of which is seen at a, Fig. 2. The form of the organic

+stricture varies therefore according to the three following

+circumstances:--1st. When lymph becomes effused 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 a f.

+

+

+[Illustration]

+Plate 59.--Figure 1, Figure 2.

+

+

+Fig. 3, Plate 59.--In this there are seen three separate strictures, a,

+b, 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 strictures 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.

+

+

+[Illustration]

+Plate 59.--Figure 3.

+

+

+Fig. 4, Plate 59.--In this the canal is constricted at the point a,

+midway 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

+f, 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.

+

+

+[Illustration]

+Plate 59.--Figure 4.

+

+Fig. 5, Plate 59.--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.

+

+

+[Illustration]

+Plate 59.--Figure 5.

+

+

+Fig. 6, Plate 59.--Two instruments, a, b, have made false passages

+beneath the mucous membrane, in a case where no stricture at all

+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.

+

+

+[Illustration]

+Plate 59.--Figure 6.

+

+

+Fig. 7, Plate 59.--A bougie, b b, 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 d, for its

+whole length, re-enters the neck of the bladder through the body of the

+prostate.

+

+

+[Illustration]

+Plate 59.--Figure 7.

+

+

+Fig. 8, Plate 59.--A bougie, c c, appears tearing and passing beneath

+the lining membrane, d d, 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.

+

+

+[Illustration]

+Plate 59.--Figure 8.

+

+

+Fig. 9, Plate 59.--Two strictures are represented here, the one, e,

+close to the bulb d, the other, f, an inch anterior to this part. In the

+prostate, a b, are seen irregularly shaped abscess pits, communicating

+with each other, and projecting upwards the floor of this body to such a

+degree, that the prostatic canal appears nearly obliterated.

+

+

+[Illustration]

+Plate 59.--Figure 9.

+

+Fig. 10, Plate 59.--Two bougies, d e, are seen to enter the upper wall

+of the urethra, c, anterior to the prostate, a b. 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.

+

+

+[Illustration]

+Plate 59.--Figure 10.

+

+Fig. 11, Plate 59.--Two instruments appear transfixing the prostate, of

+which body the three lobes, a, b, c, are much enlarged. The instrument d

+perforates the third lobe, a; while the instrument e penetrates the

+right lobe, c, and the third lobe, a. This accident occurs when

+instruments not possessing the proper prostatic bend are forcibly pushed

+forwards against the resistance at the neck of the bladder.

+

+

+[Illustration]

+Plate 59.--Figure 11.

+

+

+Fig. 12, Plate 59.--In this case an instrument, d d, after passing

+beneath part of the lining membrane, e e, anterior to the bulb,

+penetrates b, the right lobe of the prostate. A second instrument, c c,

+penetrates the left lobe. A third smaller instrument, f f, 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 penetrating the prostate, made it seem,

+perhaps, that a tight stricture existed in this situation, to match

+which the smaller instrument, f f, was afterwards passed in the course

+marked out.

+

+

+[Illustration]

+Plate 59.--Figure 12.

+

+

+Figs. 1 to 5, Plate 60, represent a series of prostates, in which the

+third lobe gradually increases in size. In Fig. 1, 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. 2 it appears as the uvula vesicae, a.

+In Fig. 3 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. 4 the

+effect which the growth of the lobe, a, produces upon the form of the

+neck of the bladder becomes more marked, and the part presenting

+perforations, 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. 5 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. [Footnote]

+

+

+[Illustration]

+Plate 60.--Figures 1, 2, 3, 4, 5

+

+

+[Footnote: 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 had in reality as little reason for so doing as

+he would have had in naming any other tumour, a thing unknown to normal

+anatomy. Langenbeck (Neue Bibl. b. i. p. 360) denies its existence in

+the healthy state. Cruveilhier (Anat. Pathog. liv. xxvii.) deems it

+incorrect to reckon a third lobe as proper to the healthy bladder.]

+

+

+Fig. 6, Plate 60.--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 efficient as one formed by puncture or incision

+in any other way." (Fergusson.)

+

+

+[Illustration]

+Plate 60.--Figure 6

+

+

+Fig. 7, Plate 60.--The three lobes of the prostate, a, b, 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 new passage will be the more likely to become permanent. It is

+ascertained that all false passages and fistulae by which the urine

+escapes, become after a time lined with a membrane similar to that of

+the urethra. (Stafford.)

+

+

+[Illustration]

+Plate 60.--Figure 7

+

+

+Fig. 8, Plate 60.--The three lobes, a, b, c, of the prostate are

+irregularly enlarged. The third lobe, a a, projecting from below,

+distorts the prostatic canal upwards and to the right side.

+

+

+[Illustration]

+Plate 60.--Figure 8.

+

+

+Fig. 9, Plate 60.--The right lobe, a c c, 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 frequently 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.

+

+

+[Illustration]

+Plate 60.--Figure 9.

+

+

+Fig. 10, Plate 60.--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 instrument has made a

+false passage through the lobe a.

+

+

+[Illustration]

+Plate 60.--Figure 10.

+

+

+Fig. 11, Plate 60.--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.

+

+

+[Illustration]

+Plate 60.--Figure 11.

+

+Fig. 12, Plate 60.--The prostatic lobes are uniformly enlarged, and

+cause the corresponding part of the urethra to be uniformly contracted,

+so as closely to embrace the catheter, d d, occupying it, and to offer

+considerable resistance to the passage of the instrument.

+

+

+[Illustration]

+Plate 60.--Figure 12.

+

+

+Fig. 13, Plate 60.--The prostate, bc, is considerably enlarged

+anteriorly, b, in 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, b, of the prostate, and to act

+like a stopper to the neck of the bladder. The body 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.

+

+

+[Illustration]

+Plate 60.--Figure 13.

+

+

+

+COMMENTARY ON PLATES 61 & 62.

+

+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 behooves 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-b, and a+b the only difference which exists depends upon the

+subtraction or the addition of the quantity, b. 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 frutra, 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 call down an

+interpretation of the part from the unfrequented bourne of comparative

+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. [Footnote]

+

+

+[Footnote: 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 obstruction to them. In texture the prostate is similar to an

+unimpregnated uterus. In form it is, like the uterus, symmetrical. In

+position it corresponds 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 membrane. 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.]

+

+Fig. 1, Plate 61.--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.

+

+

+[Illustration]

+Plate 61.--Figure 1.

+

+

+Fig. 2, Plate 61.--The prostate, a b, 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. [Footnote]

+

+[Footnote: When a stricture exists immediately behind the bulb, this

+circumstance 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 ordinarily 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.) ]

+

+

+[Illustration]

+Plate 61.--Figure 2

+

+

+Fig. 3, Plate 61.--A cyst, c, is seen to grow from the left side of the

+base of the prostate, a b, and to form an obstruction at the vesical

+orifice.

+

+

+[Illustration]

+Plate 61.--Figure 3.

+

+

+Fig. 4, Plate 61.--A globular excrescence, a, 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.

+

+

+[Illustration]

+Plate 61.--Figure 4

+

+

+Fig. 5, Plate 61.--The prostate, d, is considerably enlarged, and the

+vesical orifice is girt by a prominent ring, b b, 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.

+

+

+[Illustration]

+Plate 61.--Figure 5.

+

+

+Fig. 6, Plate 61.--The lateral lobes of the prostate, c c, are seen

+enlarged, and from the inner side and base of each, irregularly shaped

+masses, a, b, d, project, and bend the prostatic urethra first to the

+right side, then to the left. The part, a, resting upon the part, b,

+acts like a valve against the vesical outlet, which would become closed

+the tighter according to the degree of superincumbent 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.

+

+

+[Illustration]

+Plate 61.--Figure 6.

+

+Fig. 7, Plate 61.--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.

+

+

+[Illustration]

+Plate 61.--Figure 7.

+

+Fig. 8, Plate 61.--The lateral lobes, b 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.

+

+

+[Illustration]

+Plate 61.--Figure 8.

+

+

+Fig. 9, Plate 61.--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 supposition 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.

+

+

+[Illustration]

+Plate 61.--Figure 9, 10.

+

+Fig. 10, Plate 61.--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. [Footnote]

+

+[Footnote: 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

+other, even supposing it to be matter of fact, which it is not. But the

+observations made by Cruveilhier (Anat. Pathol.), that the lobulated

+projections of the prostate always take place internally at its vesical

+aspect, is as true as the manner in which he accounts for the fact is

+plausible. The dense fibrous envelope of the prostate is sufficient to

+repress its irregular growth externally.]

+

+

+Fig. 11, Plate 61.--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.

+

+

+[Illustration]

+Plate 61.--Figure 11.

+

+Fig. 12, Plate 61.--The prostate, c b, 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 efforts, made to void the

+bladder while the vesical orifice was closed above.

+

+

+[Illustration]

+Plate 61.--Figure 12.

+

+

+Fig. 13, Plate 61.--The lateral lobes, d e, of the prostate are

+enlarged; and, occupying the position of the third lobe, appear as three

+masses, a b 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 consequence of the regurgitation of the contents of the

+bladder during the retention which existed ..

+

+

+[Illustration]

+Plate 61.--Figure 13.

+

+

+Fig. 1, Plate 62, 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.

+

+

+[Illustration]

+Plate 62.--Figure 1.

+

+

+Fig. 2, Plate 62.--The three lobes, a, d, 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, a, which

+has been half denuded of the calcareous crust, b, 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.

+

+

+[Illustration]

+Plate 62.--Figure 2, 3.

+

+

+Fig. 3, Plate 62, 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.

+

+Fig. 4, Plate 62.--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.

+

+

+[Illustration]

+Plate 62.--Figure 4, 5.

+

+

+Fig. 5, Plate 62.--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 bas fond of the bladder, a sound or staff cannot

+reach the stone, unless by perforating the prostate; and if, while the

+staff 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 perinaeal surface, and this circumstance occasions what is

+termed a "deep perinaeum."

+

+

+Fig. 6, Plate 62.--The lower half, c, b, f, 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 a e, 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, i. 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 d d d, then

+the knife, following the staff, will open, not the bladder which

+contains the stone, but the sac, which, moreover, if it happen to be

+filled with urine regurgigated from the urethra, will render the

+deception more complete.

+

+

+[Illustration]

+Plate 62.--Figure 6.

+

+

+Fig. 7, Plate 62.--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 prostatic 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 staff as a guide to the knife in lithotomy. If,

+however, the staff can be passed as far as the situation of the stone,

+the parts may be held with a sufficient degree of steadiness to enable

+the operator to incise the prostate upon the stone.

+

+

+[Illustration]

+Plate 62.--Figure 7.

+

+

+

+COMMENTARY ON PLATES 63 & 64.

+

+DEFORMITIES OF THE URINARY 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 pathological. 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 a

+uniform canal, or assumes a sacculated shape between the summit of the

+bladder and the umbilicus. The pathological deformities are, those in

+which vesical fistulae, opening either above the pubes, at the

+perinaeum, or into the rectum, have followed abscesses or the operation

+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 internally, 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.[Footnote] 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

+produced 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 peritonaeum; 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.

+

+[Footnote: 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 lithic diathesis by the humoral

+pathologists.

+

+The urinary apparatus (consisting of the kidneys, ureters, bladder, and

+urethra) is known to be the principal emunctory 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 sediment should present in the form of concrement in some and not

+in 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.] [End Footnote]

+

+

+FIG. 1, Plate 63.--The lateral lobes of the prostate, 3, 4, are

+enlarged, and contract the prostatic canal. Behind them the third lobe

+of smaller size occupies the vesical orifice, and completes 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, projects 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.

+

+

+[Illustration]

+Plate 63,--Figure 1.

+

+

+FIG. 2, Plate 63.--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, communicates 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 third 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.

+

+

+[Illustration]

+Plate 63,--Figure 2.

+

+

+FIG. 3, Plate 63.--The urethra being strictured, the bladder has become

+sacculated. In the bas 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 effect by opening the

+depending sac through the bowel, than by entering the summit of the

+bladder above the pubes.

+

+

+[Illustration]

+Plate 63,--Figure 3, 4.

+

+

+FIG. 4, Plate 63.--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.

+

+

+FIG. 5, Plate 63.--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.

+

+

+[Illustration]

+Plate 63,--Figure 5.

+

+

+FIG. 6, Plate 63.--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.

+

+

+[Illustration]

+Plate 63,--Figure 6.

+

+

+FIG. 7, Plate 63.--Four calculi are contained in the bladder. This organ

+is divided by two septa, 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 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.

+

+

+[Illustration]

+Plate 63,--Figure 7.

+

+

+FIG. 8, Plate 63.-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.

+

+

+[Illustration]

+Plate 63,--Figure 8.

+

+

+FIG. 9, Plate 63.--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 secretion 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.

+

+

+[Illustration]

+Plate 63,--Figure 9.

+

+

+FIG. 1, Plate 64.--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.

+

+

+[Illustration]

+Plate 64,--Figure 1.

+

+

+Fig. 2, Plate 64.--The prostate is greatly enlarged, and forms a narrow

+ring around the vesical orifice. Through this an instrument, 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.

+

+

+[Illustration]

+Plate 64,--Figure 2.

+

+

+FIG. 3, Plate 64.--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.

+

+

+[Illustration]

+Plate 64,--Figure 3.

+

+FIG. 4, Plate 64.--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.

+

+

+[Illustration]

+Plate 64,--Figure 4.

+

+FIG. 5, Plate 64.--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 lithotomy, these calculi

+would not be within reach of the forceps.

+

+

+[Illustration]

+Plate 64,--Figure 5.

+

+FIG. 6, Plate 64.--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 performed in retention of

+urine.

+

+

+[Illustration]

+Plate 64,--Figure 6.

+

+FIG. 7, Plate 64.--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 all other calculous matter, a deposit

+from the urine.

+

+

+[Illustration]

+Plate 64,--Figure 7.

+

+

+FIG. 8, Plate 64, represents, in section, the relative position of the

+parts concerned in catheterism. [Footnote] In performing this operation,

+the patient is to be laid 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 perinaeum 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 instrument (the concavity of its curve being

+turned to the left groin) is now to be inserted into the meatus, and

+while being gently impelled through the canal, the urethra is to be

+drawn forwards, by the left hand, over the instrument. By stretching the

+urethra, we 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,

+6*, 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 perinaeal curve, 3, 6, 8, and is closely

+embraced by the middle fibres of the accelerator urinae muscle. 2nd, It

+is immediately 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 urethrae. 3d, 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 resistance, 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*, which 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

+backwards to the vesical orifice, 3, d, 3. In order that the point of

+the instrument may freely traverse the urethra in this direction, its

+handle, a, requires to be depressed, b c, slowly towards the perinaeum,

+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 accordingly 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 perinaeal structures prevent the handle being depressed

+beyond a certain degree, which is insufficient for the object to be

+attained, the instrument should possess the prostatic curve, c c,

+compared with c b.

+

+[Footnote: 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 and congenital deformities of the urethra, the

+prostate, and the bladder, have been made by myself from natural

+specimens in the museums and hospitals of London and Paris.]

+

+

+[Illustration]

+Plate 64,--Figure 8.

+

+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 irregularly enlarged, it will be safer to

+puncture the bladder above the pubes, and here the position of the organ

+in regard to the peritonaeum, 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 effected 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 backwards, h, h, in a line pointing to

+the hollow of the sacrum.

+

+

+

+COMMENTARY ON PLATES 65 & 66.

+

+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 integuments 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, Plate 65, 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, D 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 peronaeal 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*, Plate 66, below the insertion of

+the tendon into the head of the fibula, winds round the neck of this

+bone under cover of the peronaeus longus muscle, S, to join the anterior

+tibial artery. The posterior tibial nerve, H K, Plate 65, 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*, Plate 66, it then accompanies the posterior

+tibial artery. On the same plane with and close to the posterior tibial

+nerve in the popliteal space, will be seen the terminal branch of the

+lesser sciatic nerve, together with a small artery and vein destined for

+distribution 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 off 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, Plate 65, becomes superficial

+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

+popliteal space, we find the nerve occupying a comparatively superficial

+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, Plate 66, 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

+communication with each other, which cross behind the artery. In some

+instances the posterior saphena vein, instead of joining the popliteal

+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 muscular 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 inferior, 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 externally, 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

+anastomose 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

+peronaeal 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 peronaeal.

+

+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 peronaeal 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, F, Plate 66, 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 peronaeal, 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 peronaeal 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 Achillis, V V, Plate

+65, 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 fasciae. The peronaeal

+artery is deeply situated in its whole course. Soon after its origin, it

+passes under cover of the flexor longus pollicis, R, 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

+Achillis, 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 relative 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, while the peronaeal is

+small, or absent; and, in others, the peronaeal supplies the place of

+the posterior tibial, when the latter is diminished in size. The

+peronaeal 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, there 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 haemorrhages 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 affected with aneurism, and

+when, in addition to the anatomical 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

+suppuration, 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 orifices, and tie both these in the

+wound. For this purpose, the following operation usually recommended 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 firmly 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 haemorrhage 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 knee is to

+be flexed and the foot 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

+divided. The artery will now appear 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 venae comites and

+the nerve.

+

+

+DESCRIPTION OF PLATES 65 & 66.

+

+PLATE 65.

+

+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 nerve.

+

+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 peronaeus 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 artery.

+

+

+PLATE 66.

+

+A C D E F G H I indicate the same parts as in Plate 65.

+

+B. The inner condyle of the femur.

+

+K. The plantaris muscle lying upon the popliteal artery.

+

+L. The popliteus muscle.

+

+M M M. The tibia.

+

+N N. The fibula.

+

+O O. The posterior tibial artery.

+

+P. The peronaeal artery.

+

+Q R S T U V W. The parts shown in Plate 65.

+

+X. The astragalus.

+

+

+[Illustration: Left leg, showing muscles, blood vessels and other

+internal organs.]

+Plates 65, 66

+

+

+COMMENTARY ON PLATES 67 & 68.

+

+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, Plate 67, 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, Plate 67, Figure 2, and on

+the outer side it passes over the peronaeal muscles to those forming the

+calf. Between the extensor communis digitorum, B b, and the peronaeus

+longus, F, 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 continued over the dorsum of the foot, forming

+sheaths for the tendons and muscles of this part. Behind the inner

+malleolus, d, Plate 67, 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

+peronaeal 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 peronaeal nerve, which pierces the fascia at about the

+middle of the limb, and descends superficially 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, D, Plate 67, Figure 1,

+will 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, d, 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, Plate 67, 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, a b c, 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 interosseous ligament,

+it arises tendinous and fleshy. This muscle is superficial in its whole

+length; its tendon commencing about the middle of the leg, passes in a

+separate loose sheath of the annular ligament 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 intermuscular 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 b b, over the dorsum

+of the foot, become inserted into the four outer toes. The peronaeus

+tertius or anterior, is that part of the common extensor muscle which is

+inserted into the base of the fifth metatarsal 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 outer 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, Plate 67, Figure 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 anterior 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 surface, 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 midway 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 between

+the two inner metatarsal bones, where it divides into two branches, one

+of which passes forwards in the first interdigital space, while 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 accompany the anterior tibial artery and its

+continuation on the dorsum of the foot. The anterior tibial nerve, a

+branch of the peronaeal, joins 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 which 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 peronaeal

+or posterior tibial, which pierces the interosseous ligament from

+behind.

+

+The anterior tibial artery when requiring a ligature to be applied to it

+in any part of its course, may be exposed by an incision, extending for

+three or four inches, (more or less, according 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 interosseous 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 will 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, Plate

+68, Figure 1, 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 digitorum brevis muscle, B, arising from the

+inferior part of the os calcis, and passing forwards to divide into four

+small tendons, b b b 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, L M, and nerves, are brought partially into view; and by

+further dividing the abductor pollicis, D, their continuity with the

+posterior tibial artery and nerves, K L, Plate 67, Figure 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, Plate 68, Figure 1, 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, F f f, and

+the tarso-metatarsal joints, to gain the outer side of the first

+metatarsal bone, H, Plate 68, Figure 2. 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,

+Plate 68, Figure 1, 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 midway between the

+tendo Achillis 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 will be

+seen between the venae 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 will be necessary to

+search for the divided ends of the vessel in the wound, and to apply a

+ligature to both. The expediency of this measure must become fully

+apparent when we consider the frequent 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 will not arrest the

+recurrent circulation through the vessels of the foot.

+

+

+DESCRIPTION OF PLATES 67 & 68.

+

+PLATE 67.

+

+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 peronaeus longus muscle.

+

+G G. The peronaeus brevis muscle; i, the peronaeus tertius.

+

+H H. The fascia.

+

+K. The extensor brevis digitorum muscle; k k, its tendons.

+

+L L. The anterior tibial artery and nerve descending to the dorsum of

+     the foot.

+

+

+[Illustration: Legs, showing muscles, blood vessels and other

+internal organs.]

+Plate 67, Figures 1, 2

+

+

+PLATE 68.

+

+FIGURE 1.

+

+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 f

+   f f f, tendons for the four outer toes.

+

+G. The tendon of the flexor pollicis longus muscle.

+

+H. The flexor pollicis brevis muscle.

+

+i i i i. The four lumbricales muscles.

+

+K. The external plantar nerve.

+

+L. The external plantar artery.

+

+M. The internal plantar nerve and artery.

+

+[Illustration: Bottom of left foot, showing muscles, blood vessels and

+other internal organs.]

+Plate 68, Figure 1

+

+

+FIGURE 2.

+

+A. The heel covered by the integument.

+

+B. The plantar fascia and flexor brevis digitorum muscle cut; b 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; f f f, 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 interosseous muscles.

+

+N. The external plantar nerve and artery cut.

+

+

+[Illustration: Bottom of left foot, showing muscles, blood vessels and

+other internal organs.]

+Plate 68, Figure 2

+

+

+

+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 way, 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 all 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 anastomose, 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 pulmonary 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 synchronously; 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 deteriorated.

+

+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 vertebrae, form the superior and inferior venae

+cavae, by which the blood is returned from the upper and lower parts of

+the body to the right auricle, 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 arrangement, 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 emanates. 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 still communicate

+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

+vertebrae, forming the future descending aorta. In this condition, the

+human heart and vessels resemble the Piscean pipe. The next changes

+which take place consist in the gradual subdivision, 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 interauricular and interventricular septa, by

+gradual development from without inwards, 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 the human

+heart, an aperture (foramen ovale) is left as being necessary to the

+foetal 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

+with the right, the other with 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, while 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

+ventricular artery (systemic aorta) is formed of the fourth arch of the

+left side, while the opposite arch (fourth right) is altogether

+obliterated. The third and second arches remain pervious on both sides,

+afterwards 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

+corresponded 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 below the cross branch (left brachio-cephalic) becomes obliterated,

+whilst the right vein (vena cava superior) receives the two

+brachio-cephalic veins, and in this condition remains throughout 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 foetal circulation 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 which yield the vessels in their normal adult condition, we

+obtain in this history an explanation of the signification not only of

+such of their anomalies as are on record, but of such also as are

+potential in the law of development; a few of them will suffice to

+illustrate the meaning of the whole number:--lst, The interventricular

+as well 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. 2nd. 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. 3rd. 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. [Footnote 1] 4th. As the two aortae

+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. 5th. The ductus

+arteriosus may remain pervious, and while co-existing with the proper

+aortic arch, two arches would then appear on the left side. 6th. The

+systemic normal aortic arch may be obliterated 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 would require (in order that the circulation of a

+mixed blood might be carried on) that the two ventricles freely

+communicate. 7th. If the 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.

+8th. If the fifth arch of the right side remained pervious opposite the

+open ductus arteriosus, both vessels would present a similar

+arrangement, as two symmetrical ducti arteriosi co-existing with

+symmetrical aortic arches. 9th. 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. 10th. 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 arteriosus divides itself into three parts, the two

+lateral parts, 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. 12th. When of the two original

+superior venae cavae 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. [Footnote 2] Of these malformations, some are

+rather frequently met with, others very seldom, and others cannot exist

+compatible with 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.

+

+[Footnote 1: 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. I. 1842.]

+

+[Footnote 2: 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 1., 1850, entitled, "On the

+Development of the Great Anterior Veins in Man and Mammalia." By John

+Marshall, F.R.C.S., &c. ]

+

+

+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 to prevail universally in the development of

+organized beings, forasmuch as every lateral organ or part has its

+counterpart, while 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 companion vein or

+veins. The inferior vena cava passes sidelong with the aorta in the

+abdomen. Every branch of the aorta which 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 otherwise. On viewing 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

+product of its secretion to the intestines. The trachea is as it were

+the duct of the lungs. In the liver, then, the portal and hepatic veins

+being continuous as veins, the two systems, notwithstanding their

+apparent distinctness, caused by the intervention of the hepatic

+lobules, may be regarded as the veins corresponding with the arteries of

+the coeliac 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.[Footnote]

+

+[Footnote: 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 correspond 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

+constituting 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:--1st. Between the opposite parts of the same

+organic entity (between the opposite leaves of the same plant, for

+example), nature manifests no such absolute difference 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 modification or

+metamorphosis of one of the two perfectly similar originals or

+archetypes, but never carried out to such an extreme degree as to

+annihilate all trace of their analogy. 3rdly. The liver and the spleen

+are opposite parts; and as such, they are associated by arteries which

+arise by a single trunk (coeliac 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. 4thly. 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 liver plus the spleen represents the whole structural

+quantity, so the liver minus the spleen signifies that the two organs

+now dissevered still relate to each other as parts of the same whole.

+5thly. 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 degenerate and functionless, for it seems that the

+animal economy suffers no loss of function when deprived of it. 6thly.

+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. 7thly. In

+animals devoid of the spleen, the liver appears of a symmetrical shape,

+both its lobes being equal; for that quantity which in other animals has

+become splenic, is in the former still hepatic. 8thly. 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 illa quae est in corporibus animalium. Habent videlicet

+animalia pleraque omnia, bina latera, dextrum et sinistrum, forma

+consimili: et in lateribus illis, a posteriore quidem corporis sui

+parte, pedes binos; ab anteriori autem parte, binos armos, vel pedes,

+vel alas, humeris affixos: interque humeros collum, in spinam excurrens,

+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.]

+

+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 capillary ramifications through

+its substance, in the manner of the nutrient vessels of all other organs.

+The two coronary arteries of the heart arise from the systemic aorta

+immediately outside the semilunar valves, situated in the root of this

+vessel, and in passing 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 anastomose 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 (foramina 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, be destroyed in the situation of the

+ligature, where it is most needed.

+

+XI.--The branches of the systemic aorta form frequent anastomoses with

+each other in all parts of the body. This anastomosis occurs chiefly

+amongst the branches 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 blood vessel 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 cerebral 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 effect 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 superficial 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,

+meningeal, 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 to the

+branches of the common carotid almost solely. In regard to the

+subclavian artery, the circulation would be carried on through the

+anastomosing branches of the two inferior thyroid in the thyroid body;

+of the two vertebral, in the cranium and upon the cervical vertebrae; of

+the two internal mammary, with each other behind the sternum, and with

+the thoracic branches of the axillary and the superior intercostal

+laterally; lastly, through the anastomosis of the ascending cervical

+with the descending branch of the occipital, and with the small lateral

+offsets of the vertebral.

+

+XIII.--The common carotid arteries, Of these two vessels, the left one

+arising, in general, from the arch of the aorta, is longer than the

+right one by the measure of the innominate artery from 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. When the vertebral or the inferior thyroid branch

+arises from the middle of the common carotid, this vessel will have an

+additional source of 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 aortic arch.

+

+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 arteries 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 numerous. 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 circulation in reference to the arm is maintained

+by the following anastomosing branches:--viz., those of the

+superficialis colli, 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. Whatever

+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.

+

+XV.--The axillary artery. As this vessel gives off throughout its whole

+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 applied 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 immediately 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 inosculate 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

+comparatively free through the anastomoses of the two profundi 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 branches 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 its

+course, the collateral circulation will depend principally upon the free

+communications between it and the ulnar, through the medium of the

+superficial and deep palmar arches and those of the  branches derived

+from both vessels, and from the two interossei distributed to the

+fingers and back of the hand.

+

+XVIII.--The ulnar artery. When this vessel is tied, the collateral

+circulation will depend upon the anastomosis of the palmar arches, as in

+the case last mentioned. While the radial, ulnar, and interosseous

+arteries spring from the same main vessel, and are continuous with each

+other in the hand, they represent the condition of a circle of which,

+when either side is tied, the blood will pass in a current of almost

+equal strength towards the seat of the ligature from above and below--a

+circumstance which renders it necessary to tie both ends of the vessel

+in cases of wounds.

+

+XIX.--The common iliac artery. When a ligature is applied 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 sacral; those of the superior with the middle and inferior

+haemorrhoidal; those of the aortic and internal iliac uterine branches

+in the female; and of the aortic and external iliac spermatic branches

+in 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 anastomoses of

+the internal mammary with the epigastric; by those of the ilio-lumbar

+with the circumflex ilii; those of the internal circumflex femoris, and

+superior perforating arteries of the profunda femoris, with the

+obturator, when this branch arises from the internal iliac; those of the

+gluteal with the external circumflex; those of the latter with the

+sciatic; and those of both obturators, with each other, when

+arising--the one from the internal, the other from the external iliac.

+Not unfrequently either the 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.

+

+XXI.--The common femoral artery. On considering the circles of

+inosculation formed around the innominate bone between the 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.--The 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

+arteries:--the long descending branches of the 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 renders 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 will 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 peronoeal arteries. As

+these vessels correspond to the arteries of the forearm, the

+observations which apply to the one set apply also to the other.

+[Footnote]

+

+[Footnote: For a complete history of the general vascular system, see

+The Anatomy 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, Tiedemann's, &c., systematically arranged with a view to

+operative surgery.]

+

+THE END.

+

+

+

+

+

+

+*** END OF THE PROJECT GUTENBERG EBOOK SURGICAL ANATOMY ***

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