certain standard characters with which we compare all its abnormal
conditions. Every region of the body exhibits fixed character proper to
its surface. The neck, the axilla, the thorax, the abdomen, the groin,
have each their special marks, by which we know them; and the eye, well
versed in the characters proper to the healthy state of each, will
soonest discover the nature of all effects of injury--such as
dislocations, fractures, tumours of various kinds, &c. By our
acquaintance with the perfect, we discover the imperfect; by a
comparison with the geometrically true rectangled triangle, or circle,
we estimate the error of these forms when they have become distorted;
and in the same way, by a knowledge of what is the healthy normal
standard of human form, we diagnose correctly its slightest degree of
deformity, produced by any cause whatever, whether by sudden accident,
or slowly-approaching disease.
Now, the abnormal conditions of the surface become at once apparent to
our senses; but those diseased conditions which concern the internal
organs require no ordinary exercise of judgment to discover them. The
outward form masks the internal parts, and conceals from our direct
view, like the covers of a closed volume, the marvellous history
contained within. But still the superficies is so moulded upon the
deeper situated structures, that we are induced to study it as a map,
which discourses of all which it incloses in the healthy or the diseased
state. Thus, the sternum points to A, the aorta; the middle of the
clavicles, to C, the subclavian vessels; the localities 9, 10 of the
coracoid processes indicate the place of the axillary vessels; the
navel, P, points to Q, the bifurcation of the aorta; the pubic
symphysis, Z, directs to the urinary bladder, Y. At the points 7, 8, may
be felt the anterior superior spinous processes of the iliac bones,
between which points and Z, the iliac vessels, V, 6, pass midway to the
thigh, and give off the epigastric vessels, 2, 3, to the abdominal
parietes. Between these points of general relations, which we trace on
the surface of the trunk of the body, the anatomist includes the entire
history of the special relations of the organs within contained. And not
until he is capable of summing together the whole picture of anatomical
analysis, and of viewing this in all its intricate relationary
combination--even through and beneath the closed surface of living
moving nature, is he prepared to estimate the conditions of disease, or
interfere for its removal.
When fluid accumulates on either side of the thoracic compartment to
such an excess that an opening is required to be made for its exit from
the body, the operator, who is best acquainted with the relations of the
parts in a state of health, is enabled to judge with most correctness in
how far these parts, when in a state of disease, have swerved from these
proper relations. In the normal state of the thoracic viscera, the left
thoracic space, G A K N, is occupied by the heart and left lung. The
space indicated within the points A N K, in the anterior region of the
thorax, is occupied by the heart, which, however, is partially
overlapped by the anterior edge of the lung, PLATE 22. If the thorax be
deeply penetrated at any part of this region, the instrument will wound
either the lung or the heart, according to the situation of the wound.
But when fluid becomes effused in any considerable quantity within the
pleural sac, it occupies space between the lung and the thoracic walls;
and the fluid compresses the lung, or displaces the heart from the left
side towards the right. This displacement may take place to such an
extent, that the heart, instead of occupying the left thoracic angle, A
K N, assumes the position of A K* N on the right side. Therefore, as the
fluid, whatever be its quantity, intervenes between the thoracic walls,
K K*, and the compressed lung, the operation of paracentesis thoracis
should be performed at the point K, or between K and the latissimus
dorsi muscle, so as to avoid any possibility of wounding the heart. The
intercostal artery at K is not of any considerable size.
In the normal state of the thoracic organs, the pericardial envelope of
the heart is at all times more or less uncovered by the anterior edge of
the left lung, as seen in PLATE 22. When serous or other fluid
accumulates to an excess in the pericardium, so as considerably to
distend this sac, it must happen that a greater area of pericardial
surface will be exposed and brought into immediate contact with the
thoracic walls on the left side of the sternal median line, to the
exclusion of the left lung, which now no longer interposes between the
heart and the thorax. At this locality, therefore, a puncture may be
made through the thoracic walls, directly into the distended
pericardium, for the escape of its fluid contents, if such proceeding be
in other respects deemed prudent and advisable.
The abdominal cavity being very frequently the seat of dropsical
effusion, when this takes place to any great extent, despite the
continued and free use of the medicinal diuretic and the hydragogue
cathartic, the surgeon is required to make an opening with the
instrumental hydragogue--viz., the trocar and cannula. The proper
locality whereat the puncture is to be made so as to avoid any large
bloodvessel or other important organ, is at the middle third of the
median line, between P the umbilicus, and Z the symphysis pubis. The
anatomist chooses this median line as the safest place in which to
perform paracentesis abdominis, well knowing the situation of 2, 3, the
epigastric vessels, and of Y, the urinary bladder.
All kinds of fluid occupying the cavities of the body gravitate towards
the most depending part; and therefore, as in the sitting or standing
posture, the fluid of ascites falls upon the line P Z, the propriety of
giving the patient this position, and of choosing some point within the
line P Z, for the place whereat to make the opening, becomes obvious. In
the female, the ovary is frequently the seat of dropsical accumulation
to such an extent as to distend the abdomen very considerably. Ovarian
dropsy is distinguished from ascites by the particular form and
situation of the swelling. In ascites, the abdominal swell is
symmetrical, when the body stands or sits erect. In ovarian dropsy, the
tumour is greatest on either side of the median line, according as the
affected ovary happens to be the right or the left one.
The fluid of ascites and that of the ovarian dropsy affect the position
of the abdominal viscera variously In ascites, the fluid gravitates to
whichever side the body inclines, and it displaces the moveable viscera
towards the opposite side. Therefore, to whichever side the abdominal
fluid gravitates, we may expect to find it occupying space between the
abdominal parietes and the small intestines. The ovarian tumour is, on
the contrary, comparatively fixed to either side of the abdominal median
line; and whether it be the right or left ovary that is affected, it
permanently displaces the intestines on its own side; and the sac lies
in contact with the neighbouring abdominal parietes; nor will the
intestines and it change position according to the line of gravitation.
Now, though the above-mentioned circumstances be anatomically true
respecting dropsical effusion within the general peritonaeal sac and
that of the ovary, there are many urgent reasons for preferring to all
other localities the line P Z, as the only proper one for puncturing the
abdomen so as to give exit to the fluid. For though the peritonaeal
ascites does, according to the position of the patient, gravitate to
either side of the abdomen, and displace the moveable viscera on that
side, we should recollect that some of these are bound fixedly to one
place, and cannot be floated aside by the gravitating fluid. The liver
is fixed to the right side, 11, by its suspensory ligaments. The
spleen occupies the left side, 12. The caecum and the sigmoid flexure of
the colon occupy, R R*, the right and left iliac regions. The colon
ranges transversely across the abdomen, at P. The stomach lies
transversely between the points, 11, 12. The kidneys, O, occupy the
lumbar region. All these organs continue to hold their proper places, to
whatever extent the dropsical effusion may take place, and
notwithstanding the various inclinations of the body in this or that
direction. On this account, therefore, we avoid performing the operation
of paracentesis abdominis at any part except the median line, P Z; and
as to this place, we prefer it to all others, for the following cogent
reasons--viz., the absence of any large artery; the absence of any
important viscus; the fact that the contained fluid gravitates in large
quantity, and in immediate contact with the abdominal walls anteriorly,
and interposes itself between these walls and the small intestines,
which float free, and cannot approach the parietes of the abdomen nearer
than the length which the mesenteric bond allows.
If the ovarian dropsy form a considerable tumour in the abdomen, it may
be readily reached by the trocar and cannula penetrating the line P Z.
And thus we avoid the situation of the epigastric vessels. The puncture
through the linea alba should never be made below the point, midway
between P and Z, lest we wound the urinary bladder, which, when
distended, rises considerably above the pubic symphysis.
Amongst the many mechanical obstructions which, by impeding the
circulation, give rise to dropsical effusion, are the following:--An
aneurismal tumour of the aorta, A, or the innominate artery, [Footnote
1] F, may press upon the veins, H or D, and cause an oedematous swelling
of the corresponding side of the face and the right arm. In the same way
an aneurism of the aorta, Q, by pressing upon the inferior vena cava, T,
may cause oedema of the lower limbs. Serum may accumulate in the
pericardium, owing to an obstruction of the cardiac veins, caused by
hypertrophy of the substance of the heart; and when from this cause the
pericardium becomes much distended with fluid, the pressure of this upon
the flaccid auricles and large venous trunks may give rise to general
anasarca, to hydrothorax or ascites, either separate or co-existing.
Tuberculous deposits in the lungs and scrofulous bronchial glands may
cause obstructive pressure on the pulmonary veins, followed by effusion
of either pus or serum into the pleural sac. [Footnote 2] An abscess or
other tumour of the liver may, by pressing on the vena portae, cause
serous effusion into the peritonaeal sac; or by pressure on the inferior
vena cava, which is connected with the posterior thick border of the
liver, may cause anasarca of the lower limbs. Matter accumulating
habitually in the sigmoid flexure of the colon may cause a hydrocele, or
a varicocele, by pressing on the spermatic veins of the left side. It is
quite true that these two last-named affections appear more frequently
on the left side than on the right; and it seems to me much more
rational to attribute them to the above-mentioned circumstance than to
the fact that the left spermatic veins open, at a disadvantageous right
angle, into the left renal vein.
[Footnote 1: The situation of this vessel, its close relation to the
pleura, the aorta, the large venous trunks, the vagus and phrenic
nerves, and the uncertainty as to its length, or as to whether or not a
thyroid or vertebral branch arises from it, are circumstances which
render the operation of tying the vessel in cases of aneurism very
doubtful as to a successful issue. The operation (so far as I know) has
hitherto failed. Anatomical relations, nearly similar to these, prevent,
in like manner, an easy access to the iliac arteries, and cause the
operator much anxiety as to the issue.]
[Footnote 2: The effusion of fluid into the pleural sac (from whatever
cause it may arise) sometimes takes place to a very remarkable extent. I
have had opportunities of examining patients, in whom the heart appeared
to be completely dislocated, from the left to the right side, owing to
the large collection of serous fluid in the left pleural sac. The
heart's pulsations could be felt distinctly under the right nipple.
Paracentesis thoracis was performed at the point indicated in PLATE 26.
In these cases, and another observed at the Hotel Dieu, the heart and
lung, in consequence of the extensive adhesions which they contracted in
their abnormal position, did not immediately resume their proper
situation when the fluid was withdrawn from the chest. Nor is it to be
expected that they should ever return to their normal character and
position, when the disease which caused their displacement has been of
long standing.]
DESCRIPTION OF PLATE 26.
A. The systemic aorta. Owing to the body being inclined forwards, the
root of the aorta appears to approach too near the lower boundary (N)
of the thorax.
B. The left brachio-cephalic vein.
C. Left subclavian vein.
D. Right brachia-cephalic vein.
E. Left common carotid artery.
F. Brachio-cephalic artery.
G G*. The first pair of ribs.
H. Superior vena cava.
I. Left bronchus.
K K*. Fourth pair of ribs.
L. Descending thoracic aorta.
M. Oesophagus.
N. Epigastrium.
O. Left kidney.
P. Umbilicus.
Q. Abdominal aorta, at its bifurcation.
R R*. Right and left iliac fossae.
S. Left common iliac vein.
T. Inferior vena cava.
U. Psoas muscle, supporting the right spermatic vessels.
V. Left external iliac artery crossed by the left ureter.
W. Right external iliac artery crossed by the right ureter.
X. The rectum.
Y. The urinary bladder, which being fully distended, and viewed from
above, gives it the appearance of being higher than usual above the
pubic symphysis.
Z. Pubic symphysis.
2. The left internal abdominal ring complicated with the epigastric
vessels, the vas deferens, and the spermatic vessels.
3. The right internal abdominal ring in connection with the like vessels
and duct as that of left side.
4. Superior mesenteric artery.
5, 6. Right and left external iliac veins.
7, 8. Situations of the anterior superior iliac spinous processes.
9, 10. Situations of the coracoid processes.
11, 12. Right and left hypochondriac regions.
[Illustration: Chest and abdomen, showing bones, blood vessels, muscles
and other internal organs.]
Plate 26
COMMENTARY ON PLATE 27.
THE SURGICAL DISSECTION OF THE SUPERFICIAL BLOODVESSELS ETC.
OF THE INGUINO-FEMORAL REGION.
Hernial protrusions are very liable to occur at the inguino-femoral
region; and this fact has led the surgeon to study the anatomical
relations of this part with more than ordinary care and patience. So
minutely has he dissected every structure proper to this locality, and
so closely has he investigated every possible condition of it as being
the seat of hernial, that the only novelty which now remains to be
sought for is that of a simplification of the facts, already known to be
far too much obscured by an unwieldy nomenclature, and a useless detail
of trifling evidence. And it would seem that nothing can more directly
tend to this simplification, than that of viewing the inguinal and
femoral regions, not separately, but as a relationary whole. For as both
regions are blended together by structures which are common to both, so
do the herniae which are described as being proper to either region,
occur in such close connexion as at times to render it very difficult to
distinguish between them.
The human species is, of all others, most subject to hernial in the
groin. The erect attitude of the human form, and the fact that many of
its more powerful muscular efforts are performed in this posture, cause
its more frequent liability to the accidents called abdominal herniae or
ruptures.
The viscera of the abdomen occupy this cavity completely, and indeed
they naturally, at all times, subject the abdominal parietes to a state
of constant pressure, as may be proved by their escape from the abdomen
in cases of large wounds of this region. In the erect posture of the
body this pressure is increased, for the viscera now gravitate and force
downwards and forwards against the abdominal parietes. In addition to
this gravitating force, another power impels the viscera from above
downwards--namely, that of the muscles of the trunk, and the principal
agent amongst these is the diaphragm. The lungs, again, expanding above
the diaphragm, add also to the gravitation of the abdominal contents,
and these, under the pressure thus accumulated, occasionally make an
exit for themselves at the groins, which are the weakest and most
depending parts of the abdomen.
Herniae are variously named in accordance with the following
circumstances--viz., the precise locality at which they occur--the size
and form of the tumour--the time of life at which they happen. Sexual
peculiarities do not serve to distinguish herniae, though it is true
that the inguinal form, at the part D F, occurs more commonly in the
male, whilst the crural form, at the opening E, happens more frequently
in the female.
The most common forms of herniae happen at those localities where the
abdominal walls are traversed by the bloodvessels on their way to the
outstanding organs, and where, in consequence, the walls of the abdomen
have become weakened. It also happens, that at these very situations the
visceral pressure is greatest whilst the body stands erect. These
localities are, A, the umbilicus, a point characterized as having given
passage (in the foetal state) to the umbilical vessels; D, the place
where the spermatic vessels and duct pass from the abdomen to the
testicle; and immediately beneath this, the crural arch, which gives
exit to the crural vessels. Herniae may happen at other localities, such
as at the thyroid aperture, which transmits the thyroid vessels; and at
the greater sacrosciatic notch, through which the gluteal vessels pass;
and all regions of the abdominal walls may give exit to intestinal
protrusion in consequence of malformations, disease, or injury. But as
the more frequent varieties of herniae are those which traverse the
localities, A, D, E, and as these, fortunately, are the most manageable
under the care of the surgical anatomist, we proceed to examine the
structures concerned in their occurrence.
A direct opening from within outwards does not exist in the walls of the
abdomen; and anatomy demonstrates to us the fact, that where the
spermatic cord, D F, and the femoral vessels, pass from the abdomen to
the external parts, they carry with them a covering of the several
layers of structures, both muscular and membranous, which they encounter
in their passage. The inguinal and crural forms of herniae which follow
the passages made by the spermatic cord, and the crural vessels, must
necessarily carry with them the like investments, and these are what
constitute the coverings of the herniae themselves.
The groin in its undissected state is marked by certain elevations and
depressions which indicate the general relations of the subcutaneous
parts. The abdomen is separated from the thigh by an undulating grooved
line, extending from C*, the point of the iliac bone, to B, the
symphysis pubis This line or fold of the groin coincides exactly with
the situation of that fibrous band of the external oblique muscle named
Poupart's ligament. From below the middle of this abdomino-femoral
groove, C B, another curved line, D, b, springs, and courses obliquely,
inwards and downwards, between the upper part of the thigh and the
pubis, to terminate in the scrotum. The external border of this line
indicates the course of the spermatic cord, D F, which can be readily
felt beneath the skin. In all subjects, however gross or emaciated they
may happen to be, these two lines are readily distinguishable, and as
they bear relations to the several kinds of rupture taking place in
these parts, the surgeon should consider them with keen regard. A
comparison of the two sides of the figure, PLATE 27, will show that the
spermatic cord, D F, and Poupart's ligament, C B, determine the shape of
the inguino-femoral region. When the integument with the subcutaneous
adipose tissue is removed from the inguino-femoral region, we expose
that common investing membrane called the superficial fascia. This
fascia, a a a, stretches over the lower part of the abdomen and the
upper part of the thigh. It becomes intimately attached to Poupart's
ligament along the ilio-pubic line, C B; it invests the spermatic cord,
as shown at b, and descends into the scrotum, so as to encase this part.
Where this superficial fascia overlies the saphenous opening, E, of the
fascia lata, it assumes a "cribriform" character, owing to its being
pierced by numerous lymphatic vessels and some veins. As this
superficial fascia invests all parts of the inguino-femoral region, as
it forms an envelope for the spermatic cord, D F, and sheathes over the
saphenous opening, E, it must follow of course that wherever the hernial
protrusion takes place in this region, whether at D, or F, or E, or
adjacent parts, this membrane forms the external subcutaneous covering
of the bowel.
There is another circumstance respecting the form and attachments of the
superficial fascia, which, in a pathological point of view, is worthy of
notice--viz., that owing to the fact of its enveloping the scrotum,
penis, spermatic cord, and abdominal parietes, whilst it becomes firmly
attached to Poupart's ligament along the abdomino-femoral fold, B C, it
isolates these parts, in some degree, from the thigh; and when urine
happens to be from any cause extravasated through this abdominal-scrotal
bag of the superficial fascia, the thighs do not in general participate
in the inflammation superinduced upon such accident.
The spermatic cord, D, emerges from the abdomen and becomes definable
through the fibres of the sheathing tendon of the external oblique
muscle, H, at a point midway between the extremities of the ilio-pubic
line or fold. In some cases, this place, whereat the cord first
manifests itself in the groin, lies nearer the pubic symphysis; but
however much it may vary in this particular, we may safely regard the
femoro-pubic fold, D, b, as containing the cord, and also that the place
where this fold meets the iliopubic line, C B, at the point D, marks the
exit of the cord from the abdomen.
The spermatic cord does not actually pierce the sheathing tendon of the
external oblique muscle at the point D, and there does not, in fact,
exist naturally such an opening as the "external abdominal ring," for
the cord carries with it a production of the tendon of the external
oblique muscle, and this has been named by surgical anatomists the
"intercolumnar fascia," [Footnote] the "spermatic fascia." The fibres of
this spermatic fascia are seen at D F, crossing the cord obliquely, and
encasing it. This covering of the cord lies beneath the spermatic
envelope formed by, a b, the superficial fascia; and when a hernial
protrusion descends through the cord, both these investing membranes
form the two outermost envelopes for the intestine in its new and
abnormal situation.