From 83f9a7b14bfb2fc90044d2809485b1c0a39cc841 Mon Sep 17 00:00:00 2001 From: LLLL Colonq Date: Fri, 3 Jan 2025 14:41:11 -0500 Subject: Update --- assets/medical.txt | 13744 +++++++++++++++++++++++++++++++++++++++++++++++++++ 1 file changed, 13744 insertions(+) create mode 100644 assets/medical.txt (limited to 'assets/medical.txt') diff --git a/assets/medical.txt b/assets/medical.txt new file mode 100644 index 00000000..b225494d --- /dev/null +++ b/assets/medical.txt @@ -0,0 +1,13744 @@ +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 *** + + + + +Updated editions will replace the previous one—the old editions will +be renamed. + +Creating the works from print editions not protected by U.S. copyright +law means that no one owns a United States copyright in these works, +so the Foundation (and you!) can copy and distribute it in the United +States without permission and without paying copyright +royalties. 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