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]