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