PAUL A. STRUCK 
 
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 415 LEXINGTON AVE. 
 _ NEW YORK _ 
 
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SURGICAL ANATOMY. 
 
 JOSEPH MACLISE, 
 
 FELLOW OF THE ROYAL COLLEGE OF SURGEONS. 
 
 PHILADELPHIA: 
 
 BLANCHARD AND LEA. 
 
 1851 . 
 
I INSCRIBE THIS WORK 
 
 TO THE GENTLEMEN WITH WHOM AS A EELLOW-STUDENT I WAS ASSOCIATED 
 
 AT THE 
 
 X a ii it d n itn inn's if i] College: 
 
 AND IN AN ESPECIAL MANNER, IN THEIR NAME AS WELL AS MY OWN, I AVAIL MYSELF OF TIIE OPPORTUNITY TO RECORD, 
 
 ON THIS PAGE, 
 
 ALBEIT IN CHARACTERS LESS IMPRESSIVE THAN THOSE WHICH ARE WRITTEN 
 ON THE LIVING TABLET OF MEMORY, 
 
 THE DEBT OF GRATITUDE WHICH WE OWE 
 
 TO THE LATE 
 
 SAMUEL COOPER, E.R.S., AND ROBERT LISTON, F.B.S., 
 
 TWO AMONG THE MANY DISTINGUISHED PROFESSORS OF THAT INSTITUTION, 
 
 WHOSE PUPILS WE HAVE BEEN, 
 
 AND FROM WHOM WE INHERIT THAT BETTER POSSESSION THAN LIFE ITSELF, 
 
 AN ASPIRATION FOR TnE LIGHT OF SCIENCE. 
 
 JOSEPH MACLISE. 
 
PREFACE. 
 
 The object of this work is to present to the student 
 of medicine and the practitioner removed from the 
 schools, a series of dissections demonstrative of the 
 relative anatomy of the principal regions of the 
 human body. Whatever title may most fittingly 
 apply to a work with this intent, whether it had 
 better be styled surgical or medical, regional, relative, 
 descriptive, or topographical anatomy, will matter 
 little, provided its more salient or prominent cha¬ 
 racter be manifested in its own form and feature. 
 The work, as I have designed it, will itself show that 
 my intent has been to base the practical upon the 
 anatomical, and to unite these wherever a mutual 
 dependence was apparent. 
 
 That department of anatomical research to which 
 the name topographical strictly applies, as confining 
 itself to the mere account of the form and relative 
 location of the several organs comprising the animal 
 body, is almost wholly isolated from the main ques¬ 
 tions of physiological and transcendental interest, 
 and cannot, therefore, he supposed to speak in those 
 comprehensive views which anatomy, taken in its 
 widest signification as a science, necessarily includes. 
 While the anatomist contents himself with describing 
 the form and position of organs as they appear 
 exposed, layer after layer, by his dissecting instru¬ 
 ments, he does not pretend to soar any higher in the 
 region of science than the humble level of other 
 mechanical arts, which merely appreciate the fitting 
 arrangement of things relative to one another, and 
 combinative to the whole design of the form or 
 machine of whatever species this may be, whether 
 organic or inorganic. The descriptive anatomist of 
 the human body aims at no higher walk in science 
 than this, and hence his nomenclature is, as it is, a 
 
 barbarous jargon of words, barren of all truthful 
 signification, inconsonant with nature, and blindly 
 irrespective of the cognitio certa ex pri/ricipiis certis 
 exorta. 
 
 Still, however, this anatomy of form, although so 
 much requiring purification of its nomenclature, in 
 order to clothe it in the high reaching dignity of a 
 science, does not disturb the medical or surgical 
 practitioner, so far as their wants are concerned. 
 Although it may, and actually does, trammel the 
 votary who aspires to the higher generalizations and 
 the development of a law of formation, yet, as this is 
 not the object of the surgical anatomist, the nomen¬ 
 clature, such as it is, will answer conveniently enough 
 the present purpose. 
 
 The anatomy of the human form, contemplated in 
 reference to that of all other species of animals to 
 which it bears comparison, constitutes the study of 
 the comparative anatomist, and, as such, establishes 
 the science in its full intent. But the anatomy of 
 the human figure, considered as a species, per se, is 
 confessedly the humblest walk of the understanding 
 in a subject which, as anatomy, is relationary, and 
 branches far and wide through all the domain of an 
 animal kingdom. While restricted to the study of 
 the isolated human species, the cramped judgment 
 wastes in such narrow confine; whereas, in the 
 expansive gaze over all allying and allied species, 
 the intellect bodies forth to its vision the full ap¬ 
 pointed form of natural majesty; and after having 
 experienced the manifold analogies and differentials 
 of the many, is thereby enabled, when it returns to 
 the study of the one, to view this one of human type 
 under manifold points of interest, to the appreciation 
 of which the understanding never wakens otherwise. 
 
 (v) 
 
' - - _ ; _ 
 
 vi 
 
 PREFACE. 
 
 If it did not happen that the study of the human 
 form (confined to itself) had some practical bearing, 
 such study could not deserve the name of anatomical, 
 while anatomical means comparative, and whilst 
 comparison implies inductive reasoning. 
 
 However, practical anatomy, such as it is, is con¬ 
 cerned with an exact knowledge of the relationship 
 of organs as they stand in reference to each other, 
 and to the whole design of which these organs are 
 the integral parts. The figure, the capacity, and the 
 contents of the thoracic and abdominal cavities, 
 become a study of not more urgent concernment to 
 the physician, than are the regions named cervical, 
 axillary, inguinal, &c., to the surgeon. He who 
 would combine both modes of a relationary practice, 
 such as that of medicine and surgery, should be well 
 acquainted with the form and structures characteristic 
 of all regions of the human body; and it may be 
 doubted whether he who pursues either mode of 
 practice, wholly exclusive of the other, can do so 
 with honest purpose and large range of understand¬ 
 ing, if he be not equally well acquainted with the 
 subject matter of both. It is, in fact, more triflingly 
 fashionable than soundly reasonable, to seek to define 
 the line of demarcation between the special callings 
 of medicine and surgery, for it will ever be as vain 
 an endeavour to separate the one from the other 
 without extinguishing the vitality of both, as it 
 would be to sunder the trunk from the head, and 
 give to each a separate living existence. The neces¬ 
 sary division of labour is the only reason that can be 
 advanced in excuse of specialisms; but it will be 
 readily agreed to, that that practitioner who has 
 first laid within himself the foundation of a general 
 knowledge of matters relationary to his subject, will 
 always be found to pursue the speciality according to 
 the light of reason and science. 
 
 Anatomy — the rvwi)i ceawov, the knowledge based 
 on principle — is the foundation of the curative art, 
 cultivated as a science in all its branchings; and 
 comparison is the nurse of reason, which we are fain 
 to make our guide in bringing the practical to bear 
 productively. The human body, in a state of health, 
 
 is the standard where unto we compare the same 
 body in a state of disease. The knowledge of the 
 latter can only exist by the knowledge of the former, 
 and by the comparison of both. 
 
 Comparison may be fairly termed the pioneer to 
 all certain knowledge. It is a potent instrument— 
 the only one, in the hands of the pathologist, as well 
 as in those of the philosophic generalizer of anato¬ 
 mical facts, gathered through the extended survey 
 of an animal kingdom. We best recognise the con¬ 
 dition of a dislocated joint after we have become well 
 acquainted with the contour of its normal state; all 
 abnormal conditions are best understood by a know¬ 
 ledge of what we know to be normal character. 
 Every anatomist is ar comparer, in a greater or lesser 
 degree; and he is the greatest anatomist who com¬ 
 pares the most generally. 
 
 Impressed with this belief, I have laid particular 
 emphasis on imitating the character of the normal 
 form of the human figure, taken as a whole; that of 
 its several regions as parts of this whole, and that of 
 the various organs (contained within those regions) 
 as its integrals or elements. And in order to present 
 this subject of relative anatomy in more vivid reality 
 to the understanding of the student, I have chosen 
 the medium of illustrating by figure rather thali by 
 that of written language, which latter, taken alone, 
 is almost impotent in a study of this nature. 
 
 It is wholly impossible for any one to describe 
 form in words without the aid of figures. Even the 
 mathematical strength of Euclid would avail nothing, 
 if shorn of his diagrams. The professorial robe is 
 impotent without its diagrams. Anatomy being a 
 science existing by demonstration, (for as much as 
 form in its actuality is the language of nature,) 
 must be discoursed of by the instrumentality of 
 figure. 
 
 An anatomical illustration enters the understand¬ 
 ing straight-forward in a- direct passage, and is almost 
 independent of the aid of written language. A pic¬ 
 ture of form is a proposition which solves itself. It 
 is an axiom encompassed in a frame-work of self- 
 evident truth. The best substitute for Nature her- 
 
PREFACE. 
 
 self, upon which to teach the knowledge of her, is an 
 exact representation of her form. 
 
 Every surgical anatomist will (if he examine him¬ 
 self) perceive that, previously to undertaking the 
 performance of an operation upon the living body, 
 he stands reassured and self-reliant in that degree in 
 which he is capable of conjuring up before his mental 
 vision a distinct picture of his subject. Mr. Liston 
 could draw the same anatomical picture mentally 
 which Sir Charles Bell’s handicraft could draw in 
 reality of form and figure. Scarpa was his own 
 draughtsman. 
 
 If there may he any novelty now-a-days possible to 
 be recognised upon the out-trodden track of human 
 relative anatomy, it can only be in truthful and well- 
 planned illustration. Under this view alone may 
 the anatomist plead an excuse for reiterating a theme 
 which the beautiful works of Cowper, Haller, Hunter, 
 Scarpa, Soemmering, and others, have dealt out so 
 respectably. Except the human anatomist turns 
 now to what he terms the practical ends of his study, 
 and marshals his little knowledge to bear upon those 
 ends, one may proclaim anthropotomy to have worn 
 itself out. Dissection can do no more, except to 
 repeat Cruveilhier. And that which Cruveilhier has 
 done' for human anatomy, Muller has completed for 
 the physiological interpretation of human anatomy; 
 Burdach has philosophised, and Magendie has expe¬ 
 rimented to the full upon this theme, so far as it 
 would permit. All have pushed the subject to its 
 furthest limits, in one aspect of view. The narrow 
 circle is footworn. All the needful facts are long 
 since gathered, sown, and known. We have been 
 seekers after those facts from the days of Aristotle. 
 Are we to put off the day of attempting interpretation 
 for three thousand years more, to allow the human 
 physiologist time to slice the brain into more delicate 
 atoms than he has done hitherto, in order to coin 
 more names, and swell the dictionary? No! The 
 work must now be retrospective, if we would render 
 true knowledge progressive. It is not a list of new 
 and disjointed facts that Science at present thirsts 
 for; but she is impressed with the conviction that 
 
 vii 
 
 her wants can alone be supplied by the creation of a 
 new and truthful theory, — a generalization which 
 the facts already known are sufficient to supply, if 
 they were well ordered according to their natural 
 relationship and mutual dependence. “Le temps 
 viendra peut-etre,” says Fontenelle, “que l’on joindra 
 en un corps r4gulier ces memhres 4pars; et, s’ils sont 
 tels qu’on le souhaite, ils s’assembleront en quelque 
 sorte d’eux-memes. Plusieurs v6rit4s s4par4es, des 
 qu’elles sont en assez grand nombre, offrent si vive- 
 ment a l’esprit leurs rapports et leur mutuelle d4pend- 
 ance, qu’il semhle qu’apres les avoir detachees par 
 une esp&ce de violence les unes des autres, elles 
 cherchent naturellement 5- se reunir.” — (Preface sur 
 l’utilitd des Sciences, &c.) 
 
 The comparison of facts already known must 
 henceforward he the scalpel which we are to take in 
 hand. We must return by the same road on which 
 we set out, and re-examine the things and phenomena 
 which, as novices, we passed by too lightly. The 
 travelled experience may now sit down and con¬ 
 template. 
 
 That which I have said and proved elsewhere in 
 respect to the skeleton system may, with equal truth, 
 be remarked of the nervous system—namely, that 
 the question is not in how far does the limit of diver¬ 
 sity extend through the condition of an evidently 
 common analogy, but by what rule or law the uni¬ 
 form ens is rendered the diverse entity ? The womb 
 of anatomical science is pregnant of the true inter¬ 
 pretation of the law of unity in variety; but the 
 question is of longer duration than was the life of 
 the progenitor. Though Aristotle and Linnaaus, and 
 Buffon and Cuvier, and Geoffroy St. Hilaire and 
 Leibnitz, and Gothe, have lived and spoken, yet the 
 present state of knowledge proclaims the Newton of 
 physiology to be as yet unborn. The iron scalpel 
 has already made acquaintance with not only the 
 greater parts, but even with the infinitesimals of the 
 human body; and reason, confined to this narrow 
 range of a subject, perceives herself to be imprisoned, 
 and quenches her guiding light in despair. Origin¬ 
 ality has outlived itself; and discovery is a long- 
 
PREFACE. 
 
 viii 
 
 forgotten enterprise, except as pursued in the micro¬ 
 cosm on the field of the microscope, which, it must 
 be confessed, has drawn forth demonstrations only 
 commensurate in importance with the magnitude of 
 the littleness there seen. 
 
 The subject of our study, whichever it happen to 
 be, may appear exhausted of all interest, and the 
 promise of valuable novelty, owing to two reasons:— 
 It may be, like descriptive human anatomy, so cold, 
 poor and sterile in its own nature, and so barren of 
 product, that it will be impossible for even the genius 
 of Promethean fire to warm it; or else, like existing 
 physiology, the very point of view from which the 
 mental eye surveys the theme, will blight the fair 
 prospect of truth, distort induction, and clog up the 
 paces of ratiocination. The physiologist of the pre¬ 
 sent day is too little of a comparative anatomist, and 
 far too closely enveloped in the absurd jargon of the 
 anthropotomist, ever to hope to reveal any great 
 truth for science, and dispel the mists which still 
 hang over the phenomena of the nervous system. 
 He is steeped too deeply in the base nomenclature of 
 the antique school, and too indolent to question the 
 import of Pons, Commissure, Island, Tamia, Nates, 
 Testes, Cornu, Hippocamp, Thalamus, Yermes, Arbor 
 YitaB, Respiratory Tract, Ganglia of Increase, and all 
 such phrase of unmeaning sound, ever to be produc¬ 
 tive of lucid interpretation of the cerebro-spinal ens. 
 Custom alone sanctions his use of such names; but 
 
 “Custom calls him to it! 
 
 "What custom wills; should custom always do it, 
 
 The dust on antique time would lie unswcpt, 
 
 And mountainous error be too highly heaped, 
 
 For truth to overpeer.” 
 
 Of the illustrations of this work I may state, in 
 guarantee of their anatomical accuracy, that they 
 have been made by myself from my own dissections, 
 first planned at the "London University College, and 
 afterwards realised at the Ecole Pratique, and School 
 of Anatomy adjoining the Hospital La Piti6, Paris, a 
 few years since. As far as the subject of relative 
 anatomy could admit of novel treatment, rigidly 
 confined to facts unalterable, I have endeavoured to 
 give it. 
 
 The unbroken surface of the human figure is as 
 a map to the surgeon, explanatory of the anatomy 
 arranged beneath; and I have therefore left appended 
 to the dissected regions as much of the undissected 
 as was necessary. My object was to indicate the 
 interior through the superficies, and thereby illus¬ 
 trate the whole living body which concerns surgery, 
 through its dissected dead counterfeit. We dissect 
 the dead animal body in order to furnish the memory 
 with as clear an account of the structure contained 
 in its living representative, which we are not allowed 
 to analyse, as if this latter were perfectly translucent, 
 and directly demonstrative of its component parts. 
 
 J. M 
 
TABLE OF CONTENTS. 
 
 PREFACE, 
 
 INTRODUCTORY TO THE STUDY OF ANATOMY AS A SCIENCE. 
 
 COMMENTARY ON PLATES 1 & 2 . v. 9 
 
 THE FORM OF THE THORAX, AND THE RELATIVE POSITION OF 
 ITS CONTAINED PARTS—THE LUNGS, HEART, AND LARGER 
 BLOODVESSELS. 
 
 The structure, mechanism, and respiratory motions of the thoracic 
 apparatus. Its varieties in form, according to age and sex. Its de¬ 
 formities. Applications to the study of physical diagnosis. 
 
 COMMENTARY ON PLATES 3 & 4.p.ia 
 
 THE SURGICAL FORM OF THE SUPERFICIAL, CERVICAL, AND 
 FACIAL REGIONS, AND THE RELATIVE POSITION OF THE 
 PRINCIPAL BLOODVESSELS, NERVES, ETC. 
 
 The cervical surgical triangles considered in reference to the position 
 of the subclavian and carotid vessels, &c. Venesection in respect to 
 the external jugular vein. Anatomical reasons for avoiding transverse 
 incisions in the neck. The parts endangered in surgical operations on 
 the parotid and submaxillary glands, &c. 
 
 COMMENTARY ON PLATES 5 & 6.p. n 
 
 THE SURGICAL FORM OF THE DEEP CERVICAL AND FACIAL 
 REGIONS, AND THE RELATIVE POSITION OF THE PRINCI¬ 
 PAL BLOODVESSELS, NERVES, ETC. 
 
 The course of the carotid and subclavian vessels in reference to each 
 other, to the surface, and to their respective surgical triangles. Differ¬ 
 ences in the form of the neck in individuals of different age and sex. 
 Special relations of the vessels. Physiological remarks on the carotid 
 artery. Peculiarities in the relative position of the subclavian artery. 
 
 COMMENTARY ON PLATES 7 & 8 .p. 21 
 
 THE SURGICAL DISSECTION OF THE SUBCLAVIAN AND CAROTID 
 REGIONS, AND THE RELATIVE ANATOMY OF THEIR CON¬ 
 TENTS. 
 
 General observations. Abnormal complications of the carotid and 
 subclavian arteries. Relative position of the vessels liable to change 
 by the motions of the head and shoulder. Necessity for a fixed surgical 
 
 position in operations affecting these vessels. The operations for tying 
 the carotid or the subclavian at different situations in cases of aneurism, 
 &c. The operation for tying the innominate artery. Reasons of the 
 unfavourable results of this proceeding. 
 
 COMMENTARY ON PLATES 9 & 10.p. 25 
 
 THE SURGICAL DISSECTION OF THE EPISTERNAL OR TRACHEAL 
 REGION, AND THE RELATIVE POSITION OF ITS MAIN 
 BLOODVESSELS, NERVES, ETC. 
 
 Varieties of the primary aortic branches explained by the law of 
 metamorphosis. The structures at the median line of the neck. The 
 operations of tracheotomy and laryngotomy in the child and adult. 
 The right and left brachio-cephalic arteries and their varieties considered 
 surgically. 
 
 COMMENTARY ON PLATES 11 & 12.p.29 
 
 THE SURGICAL DISSECTION OF THE AXILLARY AND BRACHIAL 
 REGIONS, DISPLAYING THE RELATIVE POSITION OF THEIR 
 CONTAINED PARTS. 
 
 The operation for tying the axillary artery. Remarks on fractures 
 of the clavicle and dislocation of the humerus in reference to the axil¬ 
 lary vessels. The operation for tying the brachial artery near the 
 axilla. Mode of compressing this vessel against the humerus. 
 
 COMMENTARY ON PLATES 13 & 14 .p. 33 
 
 THE SURGICAL FORMS OF THE MALE AND FEMALE AXILLiE 
 COMPARED. 
 
 The mammary and axillary glands in health and disease. Excision 
 of these glands. Axillary abscess. General surgical observations on 
 the axilla. 
 
 COMMENTARY ON PLATES 15 & 16 .p. st 
 
 THE SURGICAL DISSECTION OF THE BEND OF THE ELBOW AND 
 THE FOREARM, SHOWING THE RELATIVE POSITION OF 
 TIIE VESSELS AND NERVES. 
 
 General remarks. Operation for tying the brachial artery at its 
 middle and lower thirds. Varieties of the brachial artery. Vene¬ 
 section at the bend of the elbow. The radial and ulnar pulse. Opera¬ 
 tions for tying the radial and ulnar arteries in several parts. 
 
 (ix) 
 
X 
 
 TABLE 
 
 COMMENTARY ON PLATES 17, IS, & 19. . 
 
 OP CONTENTS. 
 
 THE SURGICAL DISSECTION OF THE WHIST AND HAND. 
 
 General observations. Superficial and deep palmar arcbes. Wounds 
 of these vessels requiring a ligature to be applied to both ends. 
 General surgical remarks on the arteries of the upper limb. Palmar 
 abscess, &c. 
 
 COMMENTARY ON PLATES 20 & 21. e.« 
 
 THE RELATIVE POSITION OF THE CRANIAL, NASAL, ORAL, AND 
 PHARYNGEAL CAVITIES, ETC. 
 
 Fractures of the cranium, and the operation of trephining anatomi¬ 
 cally considered. Instrumental measures in reference to the fauces 
 tonsils, oesophagus, and lungs. 
 
 COMMENTARY ON PLATE 22. P . 49 
 
 THE RELATIVE POSITION OF THE SUPERFICIAL ORGANS OF THE 
 THORAX AND ABDOMEN. 
 
 Application to correct physical diagnosis. Changes in the relative 
 position of the organs during tho respiratory motions. Changes 
 effected by disease. Physiological remarks on wounds of the thorax 
 and on pleuritic effusion. Symmetry of the organs, &c. 
 
 COMMENTARY ON PLATE 23. P . 53 
 
 THE RELATIVE POSITION OF THE DEEPER ORGANS OF THE 
 THORAX AND THOSE OF THE ABDOMEN. 
 
 and abnormal conditions. Varieties as to the length of these arteries 
 considered surgically. Measurements of tho abdomen and thorax 
 compared. Anastomosing branches of the thoracic and abdominal 
 parts of the aorta. 
 
 COMMENTARY ON PLATE 26. P . 65 
 
 THE RELATION OF THE INTERNAL PARTS TO THE EXTERNAL 
 SURFACE. 
 
 In health and disease. Displacement of the lungs from pleuritic 
 effusion. Paracentesis thoracis. Hydrops pericardii. Puncturation. 
 Abdominal and ovarian dropsy as influencing the position of the viscera. 
 Diagnosis of both dropsies. Paracentesis abdominis. Vascular ob¬ 
 structions and their effects. 
 
 COMMENTARY ON PLATE 27. P . w 
 
 THE SURGICAL DISSECTION OF THE SUPERFICIAL PARTS AND 
 BLOODVESSELS OF THE INGUINO-FEMORAL REGION. 
 
 Physical causes of the greater frequency of inguinal and femoral 
 hernise. The surface considered in reference to the subjacent parts. 
 
 COMMENTARY ON PLATES 28 & 29. P . 73 
 
 THE SURGICAL DISSECTION OF TnE FIRST, SECOND, THIRD, AND 
 FOURTH LAYERS OF THE INGUINAL REGION, IN CONNEXION 
 WITH THOSE OF THE THIGH. 
 
 Of the heart in reference to auscultation and percussion. Of the ^ Tlje exter nal abdominal ring and spermatic cord. Cremaster muscle 
 lungs, ditto. Relative capacity of the thorax and abdomen as influenced ~ how formed - The parts considered in reference to inguinal hernia, 
 by the motions of the diaphragm. Abdominal respiration. Physical The saphenous opening, spermatic cord, and femoral vessels in relation 
 
 to femoral hernia. 
 
 by the motions of the diaphragm. Abdominal respiration. Physical 
 causes of abdominal hcraim. Enlarged liver as affecting the capacity 
 of the thorax and abdomen. Physiological remarks on wounds of the 
 lungs. Pneumothorax, emphysema, Ac. 
 
 COMMENTARY ON PLATE 24. P . s7 
 
 TnE RELATIONS OF THE PRINCIPAL BLOODVESSELS TO THE 
 VISCERA OF THE THORACICO-ABDOMINAL CAVITY. 
 
 Symmetrical arrangement of the vessels arising from the median 
 thoraeico-abdominal aorta, &c. Special relations of the aorta. Aortic 
 sounds. Aortic aneurism and its effects on neighbouring organs. 
 Paracentesis thoracis. Physical causes of dropsy. ITepatio abscess. 
 Chronio enlargements of the liver and spleen as affecting the relative 
 position of other parts. Biliary concretions. Wounds of the intes¬ 
 tines. Artificial anus. 
 
 COMMENTARY ON PLATES 30 & 31. r. tt 
 
 TIIE SURGICAL DISSECTION OF THE FIFTH, SIXTH, SEVENTH 
 AND EIGHTn LAYERS OF THE INGUINAL REGION, AND 
 TIIEIR CONNEXION WITH TnOSE OF THE THIGH. 
 
 The conjoined tendon, internal inguinal ring, and cremaster muscle, 
 considered iu reference to tho descent of thn testicle and of the hernia. 
 The structure and direction of the inguinal canal. 
 
 COMMENTARY ON PLATE 25.. P . „ 
 
 TIIE RELATION OF TOE PRINCIPAL BLOODVESSELS OF THE 
 THORAX AND ABDOMEN TO THE OSSEOUS SKELETON. 
 
 The vessels conforming to tho shape of the skeleton. Analogy be¬ 
 tween the branches arising from both ends of the aorta. Their normal 
 
 COMMENTARY ON PLATES 32, 33, & 34. p. „ 
 
 TIIE DISSECTION OF THE OBLIQUE OR EXTERNAL, AND OF THE 
 DIRECT OR INTERNAL INGUINAL HERNIA. 
 
 Their points of origin and their relations to the inguinal rings. The 
 triangle of Hesselbach. Investments and varieties of the external in 
 guinal hernia, its relations to the epigastric artery, and its position in 
 the canal. Bubonocele, complete and scrotal varieties in the male. 
 Internal inguinal hernia considered in reference to the same points 
 Corresponding varieties of both hernim in the female. 
 
o 
 
 TABLE OF 
 
 COMMENTARY ON PLATES 35, 36, 37, & 38.... r. ss 
 
 THE DISTINCTIVE DIAGNOSIS BETWEEN EXTERNAL AND INTER¬ 
 NAL INGUINAL HERNIiE, THE TAXIS, SEAT OF STRICTURE, 
 AND THE OPERATION. 
 
 Both hernias compared as to position and structural characters. The 
 co-existence of both rendering diagnosis difficult. The oblique chang¬ 
 ing to the direct hernia as to position, but not in relation to the epigas¬ 
 tric artery. The taxis performed in reference to the position of both 
 as regards the canal and abdominal rings. The seat of stricture vary¬ 
 ing. The sac. The lines of incision required to avoid the epigastric 
 artery. Necessity for opening the sac. 
 
 COMMENTARY ON PLATES 39 & 40. p. so 
 
 DEMONSTRATIONS OF THE NATURE OF CONGENITAL AND INFAN¬ 
 TILE INGUINAL HERNLE, AND OF HYDROCELE. 
 
 Descent of the testicle. The testicle in the scrotum. Isolation of 
 its tunica vaginalis. The tunica vaginalis communicating with the ab¬ 
 domen. Sacculated serous spermatic canal. Hydrocele of the isolated 
 tunica vaginalis. Congenital hernia and hydrocele. Infantile hernia. 
 Oblique inguinal hernia. How formed and characterized. 
 
 COMMENTARY ON PLATES 41 & 42 . p. 93 
 
 DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF INGUINAL 
 IIERNIiE IN GENERAL. 
 
 Formation of the serous sac. Formation of congenital hernia. 
 Hernia in the canal of Nuck. Formation of infantile hernia. Dilata¬ 
 tion of the serous sac. Funnel-shaped investments of the hernia. 
 Descent of the hernia like that of the testicle. Varieties of infantile 
 hernia. Sacculated cord. Oblique internal inguinal hernia — cannot 
 be congenital. Varieties of internal hernia. Direct external hernia. 
 Varieties of the inguinal canal. 
 
 COMMENTARY ON PLATES 43 & 44.p. or 
 
 THE DISSECTION OF FEMORAL HERNIA AND THE SEAT OF 
 STRICTURE. 
 
 Compared with the inguinal variety. Position and relations. Sheath 
 of the femoral vessels and of the hernia. Crural ring and canal. For¬ 
 mation of the sac. Saphenous opening. Relations of the hernia. 
 Varieties of the obturator and epigastric arteries. Course of the 
 hernia. Investments. Causes and situations of the stricture. 
 
 COMMENTARY ON PLATES 45 & 46. p. ioi 
 
 DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF FEMORAL 
 nERNIA; ITS DIAGNOSIS, THE TAXIS, AND THE OPERA¬ 
 TION. 
 
 Its course compared with that of the inguinal hernia. Its invest¬ 
 ments and relations. Its diagnosis from inguinal hernia, &c. Its 
 varieties. Mode of performing the taxis according to the course of the 
 hernia. The operation for the strangulated condition. Proper lines in 
 which incisions should be made. Necessity for and mode of opening 
 the sac. 
 
 CONTENTS. xi 
 
 COMMENTARY ON PLATE 47.p. ios 
 
 THE SURGICAL DISSECTION OF THE PRINCIPAL BLOODVESSELS 
 AND NERVES OF THE ILIAC AND FEMORAL REGIONS. 
 
 The femoral triangle. Eligible place for tying the femoral artery. 
 The operations of Scarpa and Hunter. Remarks on the common 
 femoral artery. Ligature of the external iliac artery according to the 
 seat of aneurism. 
 
 COMMENTARY ON PLATES 48 & 49 .p. ioo 
 
 THE RELATIVE ANATOMY OF THE MALE PELVIC ORGANS. 
 
 Physiological remarks on the functions of the abdominal muscles. 
 Effects of spinal injuries on the processes of defecation and micturition. 
 Function of the bladder. Its change of form and position in various 
 states. Relation to the peritonaeum. Neck of the bladder. The 
 prostate. Puncturation of the bladder by the rectum. The pudic ar¬ 
 tery. 
 
 COMMENTARY ON PLATES 50 & 51.p. ns 
 
 THE SURGICAL DISSECTION OF THE SUPERFICIAL STRUCTURES 
 OF THE MALE PERINEUM. 
 
 Remarks on the median line. Congenital malformations. Extrava¬ 
 sation of urine into the sac of the superficial fascia. Symmetry of the 
 parts. Surgical boundaries of the perinaeum. Median and lateral im¬ 
 portant parts to be avoided in lithotomy, and the operation for fistula 
 in ano. 
 
 COMMENTARY ON PLATES 52 & 53.p. m 
 
 THE SURGICAL DISSECTION OF THE DEEP STRUCTURES OF THE 
 MALE PERINiEUM; THE LATERAL OPERATION OF LITHO¬ 
 TOMY. 
 
 Relative position of the parts at the base of the bladder. Puncture 
 of the bladder through the rectum and of the urethra in the perinmum. 
 General rules for lithotomy. 
 
 COMMENTARY ON PLATES 54, 55, & 56.p. 121 
 
 THE SURGICAL DISSECTION OF THE MALE BLADDER AND 
 URETHRA; LATERAL AND BILATERAL LITHOTOMY COM¬ 
 PARED. 
 
 Lines of incision in both operations. Urethral muscles — their 
 analogies and significations. Direction, form, length, structure, &c., of 
 the urethra at different ages. Third lobe of the prostate. Physiological 
 remarks. Trigone vesical. Bas fond of the bladder. Natural form 
 of the prostate at different ages. 
 
 COMMENTARY ON PLATES 57 & 58.p. 125 
 
 CONGENITAL AND PATHOLOGICAL DEFORMITIES OF THE PRE¬ 
 PUCE AND URETHRA; STRICTURES AND MECHANICAL 
 OBSTRUCTIONS OF THE URETHRA. 
 
 General remarks. Congenital phymosis. Gonorrhoeal paraphymosis 
 and phymosis. Effect of circumcision. Protrusion of the glans 
 
■ " _ 
 
 
 
 
 
 xn TABLE OF 
 
 through an ulcerated opening in the prepuce. Congenital hypospadias. 
 Ulcerated perforations of the urethra. Congenital epispadias. Urethral 
 fistula, stricture, and cathetcrism. Sacculated urethra. Stricture op¬ 
 posite the bulb and the membranous portion of the urethra. Observa¬ 
 tions respecting the frequency of stricture in these parts. Calculus at 
 the bulb. Polypus of the urethra. Calculus in its membranous por¬ 
 tion. Stricture midway between the meatus and bulb. Old callous 
 stricture, its form, &e. Spasmodic stricture of the urethra by the 
 urethral muscles. Organic stricture. Surgical observations. 
 
 COMMENTARY ON PLATES 59 & 60 .p. 129 
 
 THE VARIOUS FORMS AND POSITIONS OF STRICTURES AND 
 OTHER OBSTRUCTIONS OF THE URETHRA; FALSE PAS¬ 
 SAGES; ENLARGEMENTS AND DEFORMITIES OF THE PROS¬ 
 TATE. 
 
 General remarks. Different forms of the organic stricture. Co¬ 
 existence of several. Prostatic abscess distorting and constricting the 
 urethra. Perforation of the prostate by catheters. Series of gradual 
 enlargements of the third lobe of the prostate. Distortion of the canal 
 by the enlarged third lobe — by the irregular enlargement of the three 
 lobes — by a nipple-shaped excrescence at the vesical orifice. 
 
 COMMENTARY ON PLATES 61 & 62.p. 133 
 
 DEFORMITIES OF THE PROSTATE ; DISTORTIONS AND OBSTRUC¬ 
 TIONS OF THE PROSTATIC URETHRA. 
 
 Observations on the nature of the prostate—its signification. Cases 
 of prostate and bulb pouched by catheters. Obstructions of the vesical 
 orifice. Sinuous prostatic canal. Distortions of the vesical orifice. 
 Large prostatic calculus. Sacculated prostate. Triple prostatic urethra. 
 Encrusted prostate. Fasciculated bladder. Prostatic sac distinct from 
 the bladder. Practical remarks. Impaction of a large calculus in the 
 prostate. Practical remarks. 
 
 COMMENTARY ON PLATES 63 & 64.p. 137 
 
 DEFORMITIES OF THE URINARY BLADDER; THE OPERATIONS 
 OF SOUNDING FOR STONE ; OF CATIIETERISM AND OF 
 PUNCTURING THE BLADDER ABOVE THE PUBES. 
 
 General remarks on the causes of the various deformities, and of the 
 formation of stone. Lithic diathesis—its signification. The sacculated 
 bladder considered in reference to sounding, to catheterism, to punctu¬ 
 ation, and to lithotomy. Polypi in the bladder. Dilated ureters. 
 The operation of catheterism. General rules to be followed. Remarks 
 on the operation of puncturing the bladder above the pubes. 
 
 CONTENTS. 
 
 COMMENTARY ON PLATES 65 & 66.p. 111 
 
 THE SURGICAL DISSECTION OF THE POPLITEAL SPACE, AND THE 
 POSTERIOR CRURAL REGION. 
 
 Varieties of the popliteal and posterior crural vessels. Remarks on 
 popliteal aneurism, and the operation for tying the popliteal artery, in 
 wounds of this vessel. Wounds of the posterior crural arteries requir¬ 
 ing double ligatures. The operations necessary for reaching these 
 vessels. 
 
 COMMENTARY ON PLATES 67 & 68.p. 
 
 THE SURGICAL DISSECTION OF THE ANTERIOR CRURAL REGION; 
 THE ANKLES AND THE FOOT. 
 
 Varieties of the anterior and posterior tibial and the peronreal arteries. 
 The operations for tying these vessels in several situations. Practical 
 observations on wounds of the arteries of the leg and foot. 
 
 CONCLUDING COMMENTARY. P . 149 
 
 ON THE FORM AND DISTRIBUTION OF THE VASCULAR SYSTEM 
 AS A WHOLE; ANOMALIES; RAMIFICATION; ANASTO- 
 
 • MOSIS. 
 
 The double heart. Universal systemic capillary anastomosis. Its 
 division, by the median line, into two great lateral fields —those sub¬ 
 divided into two systems or provinces — viz., pulmonary and systemic. 
 Relation of pulmonary and systemic circulating vessels. Motions of 
 the heart. Circulation of the blood through the lungs and system. 
 Symmetry of the hearts and their vessels. Development of the heart 
 and primary vessels. Their stages of metamorphosis simulating the 
 permanent conditions of the parts in lower animals. The primitive 
 branchial arches undergoing metamorphosis. Completion of those 
 changes. Interpretation of the varieties of form in the heart and pri¬ 
 mary vessels. Signification of their normal condition. The portal 
 system no exception to the law of vascular symmetry. Signification of 
 the portal system. The liver and spleen as homologous organs, — as 
 parts of the same whole quantity. Cardiac anastomosing vessels. Vasa 
 vasorum. Anastomosing branches of the systemic aorta considered in 
 reference to the operations of arresting by ligature the direct circulation 
 through the arteries of the head, neck, upper limbs, pelvis, and lower 
 limbs. The collateral circulation. Practical observations on the most 
 eligible situations for tying each of the principal vessels, as determined 
 by the greatest number of their anastomosing branches on cither side 
 of the ligature, and the largest amount of the collateral circulation that 
 may be thereby carried on for the support of distal parts. 
 
COMMENTARY ON PLATES 1 & 2. 
 
 THE FORM OF THE THORACIC CAVITY, AND THE POSITION OF THE LUNGS, HEART, 
 
 AND LARGER BLOODVESSELS. 
 
 In the human body there does not exist any such 
 space as cavity , properly so called. Every space is 
 occupied by its contents. The thoracic space is com¬ 
 pletely filled by its viscera, which, in mass, take a 
 perfect cast or model of its interior. The thoracic 
 viscera lie so closely to one another, that they respect¬ 
 ively influence the form and dimensions of each 
 other. That space which the lungs do not occupy is 
 filled by the heart, &c., and vice versd. The thoracic 
 apparatus causes no vacuum by the acts of either 
 contraction or dilatation. Neither do the lungs or 
 the heart. When any organ, by its process of growth, 
 or by its own functional act, forces a space for itself, 
 it immediately inhabits that space entirely at the 
 expense of neighbouring organs. When the heart 
 dilates, the pulmonary space contracts; and when 
 the thoracic space increases, general space diminishes 
 in the same ratio. 
 
 The mechanism of the functions of respiration and 
 circulation consists, during the life of the animal, in 
 a constant oscillatory nisus to produce a vacuum 
 which it never establishes. These vital forces of the 
 respiratory and circulatory organs, so characteristic 
 of the higher classes of animals, are opposed to the 
 general forces of surrounding nature. The former 
 vainly strive to make exception to the irrevocable 
 law, that u nature abhors a vacuum ” This act of 
 opposition between both forces constitutes the respi¬ 
 ratory act, and thus the respiratory thoracic being 
 (like a vibrating pendulum) manifests respiratory 
 motion, not as an effort of volition originating solely 
 with itself, but according to the measure of the force 
 of either law; as entity is relationary, so is function¬ 
 ality likewise. The being is functional by relation¬ 
 ship; and just as a pendulum is functional, by reason 
 2 
 
 of the counteraction of two opposing forces,—viz., 
 the force of motion and the force of gravity,—so is a 
 thoracic cavity (considering it as a mechanical appa¬ 
 ratus) functional by two opposing forces—the vital 
 force and the surrounding physical force. The inspi¬ 
 ration of thoracic space is the expiration of general 
 space, and reciprocally. 
 
 The thoracic space is a symmetrical enclosure 
 originally, which aftercoming necessities modify and 
 distort in some degree. The spaces occupied by the 
 opposite lungs in the adult body do not exactly cor¬ 
 respond as to capacity, oo, Plate 1. Neither is the 
 cardiac space, aegd, Plate 1, which is traversed by 
 the common median line, symmetrical. The asym¬ 
 metry of the lungs is mainly owing to the form and 
 position of the heart; for this organ inclines towards 
 the left thoracib side. The left lung is less in capa¬ 
 city than the right, by so much space as the heart 
 occupies in the left pulmonary side. The general 
 form of the thorax is that of a cone, iinn, Plate 1, 
 bicleft through its perpendicular axis, H M. The line 
 of bicleavage is exactly median, and passes through 
 the centre of the sternum in front, and the centres 
 of the dorsal vertebra behind. Between the dorsal 
 vertebra and the sternum, the line of median cleav¬ 
 age is maintained and sketched out in membrane. 
 This membranous middle is formed by the adjacent 
 sides of the opposite pleura or enveloping bags in 
 which the lungs are enclosed. The heart, A, Plate 1, 
 is developed between these two pleural sacs, f f, and 
 separates them from each other to a distance cor¬ 
 responding to its own size. The adjacent sides of 
 the two pleural sacs are central to the thorax, and 
 form that space which is called mediastinum; the 
 heart is located in this mediastinum, u e, Plate 1. 
 
 O) 
 
10 
 
 COMMENTARY ON PLATES 1 & 2. 
 
 The extent of the thoracic region ranges perpendicu¬ 
 larly from the root of the neck, Q, Plate 1, to the 
 roof of the abdomen—viz., the diaphragm, p, trans¬ 
 versely from the ribs of one side, i n, Plate 1, to those 
 of the other, and antero-posteriorly from the sternum, 
 n M, to the vertebral column. All this space is pul¬ 
 monary, except the cardiac or median space, which, 
 in addition to the heart, A, Plate 1, and great blood¬ 
 vessels, g c b, contains the oesophagus, bronchi, &c. 
 The ribs are the true enclosures of thoracic space, 
 and, generally, in mammalian forms, they fail or 
 degenerate at that region of the trunk which is not 
 pulmonary or respiratory. In human anatomy, a 
 teleological reason is given for this—namely, that of 
 the ribs being mechanically subservient to the func¬ 
 tion of respiration alone. But the transcendental 
 anatomists interpret this fact otherwise, and refer it 
 to the operation of a higher law of formation. 
 
 The capacity of the thorax is influenced by the 
 capacity of the abdomen and its contents. In order 
 to admit of full inspiration and pulmonary expansion, 
 the abdominal viscera recede in the same ratio as the 
 lungs dilate. The diaphragm, p p, Plate 1, or trans¬ 
 verse musculo-membranous partition which divides 
 the pulmonary and alimentary cavities, is, by virtue 
 of its situation, as mechanically subservient to the 
 abdomen as to the thorax. And under general no¬ 
 tice, it will appear that even the abdominal muscles 
 are as directly related to the respiratory act as those 
 of the thorax. The connexion between functions is 
 as intimate and indissoluble as the connexion be¬ 
 tween organs in the same body. There can be no 
 more striking proof of the divinity of design than by 
 such revelations as anatomical science everywhere 
 manifests in facts such as this—viz., that each organ 
 serves in most cases a double, and in many a triple 
 purpose, in the animal economy. 
 
 The apex of the lung projects into the root of the 
 neck, even to a higher level, Q, Plate 1, than that 
 occupied by the sternal end of the clavicle, k. If 
 tlie point of a sword were pushed through the neck 
 above the clavicle, at k, Plate 1, it would penetrate 
 the apex of the right lung, where the subclavian 
 
 artery, q, Plate 1, arches over it. In connexion with 
 this fact, I may mention it as very probable that the 
 bruit , or continuous murmur which we hear through 
 the stethoscope, in chlorotic females, is caused by the 
 pulsation of the subclavian artery against the top of 
 the lung. The stays or girdle which braces the loins 
 of most women prevents the expansion of the thoracic 
 apparatus, naturally attained by the descent of the 
 diaphragm; and hence, no doubt, the lung will dis¬ 
 tend inordinately above towards the neck. It is an 
 interesting fact for those anatomists who study the 
 higher generalizations of their science, that at those 
 very localities—viz., the neck and loins, where the 
 lungs by their own natural effort are prone to extend 
 themselves in forced insjriration—happen the “ ano¬ 
 malous” creations of cervical and lumbar ribs. The 
 subclavian artery is occasionally complicated by the 
 presence of these costal appendages. 
 
 If the body be transfixed through any one of the 
 intercostal spaces, the instrument will surely wound 
 some part of the lung. If the thorax be pierced 
 from any point whatever, provided the instrument 
 be directed towards a common centre, A, Plate 1, the 
 lung will suffer lesion; for the heart is, almost com¬ 
 pletely, in the healthy living body, enveloped in the 
 lungs. So true is it that all the costal region (the 
 asternal as well as the sternal) is a pulmonary enclo¬ 
 sure, that any instrument which pierces intercostal 
 sjjace must wound the lung. 
 
 As the sternal ribs degenerate into the “false” 
 asternal or incomplete ribs from before, obliquely 
 backward down to the last dorsal vertebra, so the 
 thoracic space takes form. The lungs range through 
 a much larger space, therefore, posteriorly than they 
 do anteriorly. 
 
 The form of the thorax, in relation to that of the 
 abdomen, may be learned from the fact that a gun¬ 
 shot, which shall enter a little below n, Plate 1, and, 
 after traversing the body transversely, shall pass out 
 at a corresponding point at the opposite side, would 
 open the thorax and the abdomen into a common 
 cavity; for it would pierce the thorax at x, the arch¬ 
 ing diaphragm at the level of m, and thereat enter 
 
COMMENTARY ON PLATES 1. & 2. 
 
 11 
 
 the belly; then it would enter the thorax again at r, 
 and make exit below N, opposite. If a cutting instru¬ 
 ment were passed horizontally from before backward, 
 a little below m, it would first open the abdomen, 
 then pierce the arching diaphragm, and pass into the 
 thorax, opposite the ninth or eighth dorsal vertebra. 
 
 The outward form or superficies masks in some 
 degree the form of the interior. The width of the 
 thorax above does not exceed the diameter between 
 the points 11 , of Plate 1, or the points w w, of Plate 2. 
 If we make percussion directly from before back¬ 
 wards at any place external to i, Plate 1, we do not 
 render the lung vibrative. The diameters between 
 1 1 and N n, Plate 1, are not equal; and these measures 
 will indicate the form of the thorax in the living body, 
 between the shoulders above and the loins below. 
 
 The position of the heart in the thorax varies some¬ 
 what with several bodies. The size of the heart, 
 even in a state of perfect health, varies also in sub¬ 
 jects of corresponding ages, a condition which is often 
 mistaken for pathological. For the most part, its 
 form occupies a space ranging from two or three lines 
 right of the right side of the sternum to the middle 
 of the shafts of the fifth and sixth ribs of the left 
 side. In general, the length of the osseous sternum 
 gives the exact perpendicular range of the heart, 
 together with its great vessels. 
 
 The aorta, c, Plates 1 and 2, is behind the upper 
 half of the sternum, from which it is separated by 
 the pericardium, D, Plate 1, the thin edge of the lung, 
 and the mediastinal pleura, u e, Plate 1, &c. If the 
 heart be injected from the abdominal aorta, the 
 aortal arch will flatten against the sternum. Pulmo¬ 
 nary space would not be opened by a penetrating 
 instrument passed into the root of the neck in the 
 median line above the sternum, at L, Plate 1. But 
 the apices of both lungs would .be wounded if the 
 same instrument entered deeply on either side of this 
 median line at k k. An instrument which would 
 pierce the sternum opposite the insertion of the 
 
 second, third, or fourth costal cartilage, from n down¬ 
 wards, would transfix some part of the arch of the 
 aorta, c, Plate 1. The same instrument, if pushed 
 horizontally backward through the second, third, or 
 fourth interspaces of the costal cartilages close to the 
 sternum, would wound, on the right of the sternal 
 line, the vena cava superior, G, Plate 1; on the left, 
 the pulmonary artery, b, and the descending thoracic 
 aorta. In the healthy living body, the thoracic 
 sounds heard in percussion, or by means of the stetho¬ 
 scope, will vary according to the locality operated 
 upon, in consequence of the variable thickness of 
 those structures (muscular and osseous, &c.,) which 
 invest the thoracic walls. Uniformity of sound must, 
 owing to these facts, be as materially interrupted, as 
 it certainly is, in consequence of the variable contents 
 of the cavity. The variability of the healthy tho¬ 
 racic sounds will, therefore, be too often likely to be 
 mistaken for that of disease, if we forget to admit 
 these facts, as instanced in the former state. Con¬ 
 sidering the form of the thoracic space in reference to 
 the general form of the trunk of the living body, I 
 see reason to doubt whether the practitioner can, 
 by any boasted delicacy of manipulation, detect an 
 abnormal state of the pulmonary organs by percus¬ 
 sion, or the use of the stethoscope, applied at those 
 regions which he terms coracoid, scapulary, subcla¬ 
 vian, &c., if the line of his examination be directed 
 from before backwards. The scapula, covered by 
 thick carneous masses, does not lie in the living body 
 directly upon the osseous-thorax, neither does the 
 clavicle. As all antero-posterior examination in refer¬ 
 ence to the lungs external to the points, 11 , between 
 the shoulders cannot, in fact, concern the pulmonary 
 organs, so it cannot be diagnostic of their state either 
 in health or disease. The difficulties which oppose 
 the practitioner’s examination of the state of the tho¬ 
 racic contents are already numerous enough, inde¬ 
 pendent of those which may arise from unanatomical 
 investigation. 
 
DESCRIPTION OE PLATES 1 & 2. 
 
 Plate 1. 
 
 A. Right ventricle of the heart. 
 
 B. Origin of pulmonary artery. 
 
 C. Commencement of the systemic aorta, ascending 
 
 part of aortic arch. 
 
 D. Pericardium investing the heart and the origins 
 
 of the great bloodvessels. 
 
 E. Mediastinal pleura, forming a second investment 
 
 for the heart, bloodvessels, &c. 
 
 F. Costal pleura, seen to be continuous above with 
 
 that which forms the mediastinum. 
 
 G. Vena cava superior, entering pericardium to join 
 
 V, the right auricle. 
 
 H. Upper third of sternum. 
 
 I I. First ribs. 
 
 K K. Sternal ends of the clavicles. 
 
 L. Upper end of sternum. 
 
 M. Lower end of sternum. 
 
 N N. Fifth ribs. 
 
 0 0. Collapsed lungs. 
 
 P P. Arching diaphragm. 
 
 Q. Subclavian artery. 
 
 R. Common carotid artery, at its division into internal 
 
 and external carotids. 
 
 S S. Great pectoral muscles. 
 
 T T. Lesser pectoral muscles. 
 
 U. Mediastinal pleura of right side. 
 
 Y. Right auricle of the heart. 
 
 Plate 2. 
 
 A. Right ventricle of the heart. A a. Pericardium. 
 
 B. Pulmonary artery. B b. Pericardium. 
 
 C. Ascending aorta. C c. Transverse aorta. 
 
 D. Right auricle. 
 
 E. Ductus arteriosus in the loop of left vagus nerve, 
 
 and close to phrenic nerve of left side. 
 
 F. Superior vena cava. 
 
 G. Brachio-cephalic vein of left side. 
 
 H. Left common carotid artery. 
 
 I. Left subclavian vein. 
 
 K. Lower end of left internal jugular vein. 
 
 L. Right internal jugular vein. 
 
 M. Right subclavian vein. 
 
 N. Innominate artery—brachio-cephalic. 
 
 O. Left subclavian artery crossed by left vagus nerve. 
 
 P. Right subclavian artery crossed by right vagus 
 
 nerve, whose inferior laryngeal branch loops 
 under the vessel. 
 
 Q. Right common carotid artery 
 
 R. Trachea. 
 
 S. Thyroid body. 
 
 T. Brachial plexus of nerves. 
 
 U. Upper end of left internal jugular vein. 
 
 Y Y. Clavicles cut across and displaced downwards. 
 W W. The first ribs. 
 
 X X. Fifth ribs cut across. 
 
 Y Y. Right and left mammm. 
 
 Z. Lower end of sternum. 
 
 (12) 
 
COMMENTARY ON PLATES 3 & 4. 
 
 THE SUKGICAL FORM OF THE SUPERFICIAL CERVICAL AND FACIAL REGIONS, AND 
 THE RELATIVE POSITION OF THE PRINCIPAL BLOOD-VESSELS, NERVES, &c. 
 
 When the neck is extended in surgical position, as 
 seen in Plates 3 and 4, its general outline assumes a 
 quadrilateral shape, approaching to a square. The 
 sides of this square are formed anteriorly by the line 
 ranging from the mental symphysis to the top of the 
 sternum, and posteriorly by a line drawn between the 
 occiput and shoulder. The superior side of this cer¬ 
 vical square is drawn by the horizontal ramus of the 
 lower maxilla, and the inferior side by the horizontal 
 line of the clavicle. This square space, R 16, 8, 6, 
 Plate 4, is halved by a diagonal line, drawn by the 
 sterno-cleido-mastoid muscle b, which cuts the square 
 into two triangles. In the anterior triangle, f 16, 6, 
 Plate 4, is located the superficial common carotid 
 artery, c, and its branches, D, with accompanying 
 nerves. In the posterior triangle, 9, 8, 6, Plate 4, is 
 placed the superficial subclavian artery, A, its branches, 
 L m, and the brachial plexus of nerves, i. Both these 
 triangles and their contents are completely sheathed 
 by that thin scarf-like muscle, named platysma myoi- 
 des, A A, Plate 3, the fibres of which traverse the 
 neck slantingly in a line, o A, of diagonal direction 
 opposite to and secant of that of the sterno-mastoid 
 muscle. 
 
 When the skin and subcutaneous adipose mem¬ 
 brane are removed by careful dissection from the cer¬ 
 vical region, certain structures are exposed, which, 
 even in the undissected neck, projected on the super¬ 
 ficies, and are the unerring guides to the localities of 
 the blood-vessels and nerves, &c. In Plate 4, the top 
 of the sternum, 6; the clavicle, 7; the “ Pomum 
 Adami,” 1; the lower maxilla at v; the hyoid bone, 
 z ; the sterno-cleido-mastoid muscle, b ; and the cla¬ 
 vicular portion of the trapezius muscle, 8; will readily 
 be felt or otherwise recognised through the skin, &c. 
 When these several points are well considered in 
 their relation to one another, they will correctly de¬ 
 termine the relative locality of those structures—the 
 
 blood-vessels, nerves, &c., which mainly concern the 
 surgical operation. 
 
 The middle point, between 7, the clavicle, and 6, 
 the sternum, of Plate 4, is marked by a small trian¬ 
 gular space occurring between the clavicular and 
 sternal divisions of the sterno-cleido-mastoid muscle. 
 This space marks the situation (very generally) of 
 the bifurcation of the innominate artery into the 
 subclavian and common carotid arteries of the right 
 side; a penetrating instrument would, if passed into 
 this space at an inch depth, pierce first the root of the 
 internal jugular vein, and under it, but somewhat 
 internal, the root of either of these great arterial ves¬ 
 sels, and would wound the right vagus nerve, as it 
 traverses this region. For some extent after the sub¬ 
 clavian and carotid vessels separate from their main 
 common trunk, they lie concealed beneath the sterno- 
 mastoid muscle, b, Plate 4, and still deeper beneath 
 the sternal origins of the sterno-hyoid muscle, 5, and 
 sterno-thyroid muscle, some of whose fibres are trace¬ 
 able at the intervals. The omo-hyoid muscle and the 
 deep cervical fascia, as will be presently seen, conceal 
 these vessels also. 
 
 The subclavian artery, A, Plate 4, first appears 
 superficial to the above-named muscles of the cervical 
 region just at the point where, passing from behind 
 the scalenus muscle, n, Plate 4, which also conceals 
 it, it sinks behind the clavicle. The exact locality 
 of the artery in this part of its course would be indi¬ 
 cated by a finger’s breadth external to the clavicular 
 attachment of the sterno-mastoid muscle. The artery 
 passes beneath the clavicle at the middle of this bone, 
 a point which is indicated in most subjects by that 
 cellular interval occurring between the clavicular 
 origins of the deltoid and great pectoral muscles. 
 
 The posterior cervical triangle, 9, 8, 7, Plate 4, in 
 which the subclavian artery is situated, is again sub¬ 
 divided by the muscle omo-hyoid into two lesser 
 
 (13) 
 
14 
 
 COMMENTARY ON PLATES 3&4. 
 
 regions, each of which assumes somewhat of a trian¬ 
 gular shape. The lower one of these embraces the 
 vessel, A, and those nerves of the brachial plexus, i, 
 which are in contact with it. The posterior belly of 
 the omo-hyoid muscle, k, and the anterior scalenus 
 muscle, n, form the sides and apex of this lesser tri¬ 
 angular space, while the horizontal clavicle forms its 
 base. This region of the subclavian artery is well 
 defined in the necks of most subjects, especially when 
 the muscles are put in action. In lean but muscular 
 bodies, it is possible to feel'the projection of the ante¬ 
 rior scalenus muscle under the skin, external to the 
 sterno-mastoid. The form of the omo-hyoid is also 
 to be distinguished in the like bodies. But in all 
 subjects may be readily recognised that hollow which 
 occurs above the clavicle, apd between the trapezius, 
 8, and the sterno cleido-mastoid, 7 b, in the centre of 
 which hollow the artery lies. 
 
 The contents of the larger posterior cervical tri¬ 
 angle, formed by b, the sterno-mastoid before; 9, the 
 splenius; and 8, the trapezius • behind, and by the 
 clavicle below, are the following mentioned structures 
 —viz., A, the subclavian artery, in the third part of 
 its course, as it emerges from behind n, the scalenus 
 anticus; L, the transversalis colli artery, a branch of 
 the thyroid axis, which will be found to cross the 
 subclavian vessel at this region; I, the brachial plexus 
 of nerves, which lie external to and above the vessel; 
 n, the external jugular vein, which sometimes, in 
 conjunction with a plexus of veins coming from 
 behind the trapezius, muscle, entirely conceals the 
 artery; h, the posterior scapular artery, a branch of 
 the subclavian, given off from the vessel after it has 
 passed from behind the scalenus muscle; o, numerous 
 lymphatic glands; p, superficial descending branches 
 of the cervical plexus of nerves; and q, ascending 
 superficial branches of the same plexus. All these 
 structures, except some of the lymphatic glands, are 
 concealed by the platysma myoides A, as seen in Plate 
 3, and beneath this by the cervical fascia, which 
 latter shall be hereafter more clearly represented. 
 
 In somewhat the same mode as the posterior half 
 of the omo-hyoid subdivides the larger posterior tri¬ 
 
 angle into two of lesser dimensions, the anterior half 
 of the same muscle divides the anterior triangle into 
 two of smaller capacity. 
 
 The great anterior triangle, which is marked as 
 that space inclosed within the points, 6, the top of 
 the sternum, the mental symphysis and the angle of 
 the maxilla; and whose sides are marked by the 
 median line of the neck before, the sterno-mastoid 
 behind, and the ramus of the jaw above, contains c, 
 the common carotid artery, becoming superficial from 
 beneath the sterno-mastoid muscle, and dividing into 
 e, the internal carotid, and d, the external carotid. 
 The anterior jugular vein, 3, also occupies this region 
 below; while some venous branches, which join the 
 external and internal jugular veins, traverse it in all 
 directions, and present obstacles to the operator from 
 their meshy plexiform arrangement yielding, when 
 divided, a profuse hemorrhage. 
 
 The precise locality at which the common carotid 
 appears from under the sterno-mastoid muscle is, in 
 almost all instances, opposite to the thyroid cartilage. 
 At this place, if an incision, dividing the skin, pla¬ 
 tysma and some superficial branches of nerves, be 
 made along the anterior border of the sterno-mastoid 
 muscle, and this latter be turned a little aside, a pro¬ 
 cess of cervical fascia, and beneath it the sheath of 
 the carotid artery, will succession ally disclose them¬ 
 selves. In many bodies, however, some degree of 
 careful search requires to be made prior to the full 
 exposure of the vessel in its sheath, in consequence 
 of a considerable quantity of adipose tissue, some 
 lymphatic glands, and many small veins lying in the 
 immediate vicinity of the carotid artery and internal 
 jugular vein. This latter vessel, though usually lying 
 completely concealed by the sterno-mastoid muscle, 
 is frequently to be seen projecting from under its fore 
 part. In emaciated bodies, where the sterno-mastoid 
 presents wasted proportions, it will, in consequence, 
 leave both the main blood-vessels uncovered at this 
 locality in the neck. 
 
 The common carotid artery ascends the cervical 
 region almost perpendicularly from opposite the 
 sterno-clavicular articulation to the greater cornu of 
 
15 
 
 COMMENTARY ON PLATES 3 & 4. 
 
 the os hyoides. For the greater part of this extent 1 
 it is covered by the sterno-mastoid muscle; hut as 
 this latter takes an oblique course backwards to its 
 insertion into the mastoid process, while the mam 
 blood-vessel dividing into branches still ascends in its 
 original direction, so is it that the artery becomes un¬ 
 covered by the muscle. Even the root of the internal 
 carotid, E, may be readily reached at this place, 
 where it lies on the same plane as the external caro¬ 
 tid, but concealed in great part by the internal jugular 
 vein. It would be possible, while relaxing the sterno- 
 mastoid muscle, to compress either the common caro¬ 
 tid artery or its main branches against the cervical 
 vertebral column, if pressure were made in a direction 
 backwards and inwards. The facial artery v, which 
 springs from the external carotid, D, may be com¬ 
 pressed against the horizontal ramus of the lower 
 jaw-bone at the anterior border of the masseter 
 muscle. The temporal artery, as it ascends over the 
 root of the zygoma, may be compressed effectually 
 against this bony point. 
 
 The external jugular vein, n, Plate 4, as it descends 
 the neck from the angle of the jaw obliquely back¬ 
 wards over the sterno-mastoid muscle, may be easily 
 compressed and opened in any part of its course. 
 This vein courses downwards upon the neck in rela¬ 
 tion to that branch of the superficial cervical plexus, 
 named auricularis magnus nerve, Q, Plate 4, G, Plate 
 3. The nerve is generally situated behind the vein, 
 to which it lies sometimes in close proximity, and is 
 liable, therefore, to be accidentally injured in the per¬ 
 formance of phlebotomy upon the external jugular 
 vein. The coats of the external jugular vein, e, Plate 
 3, are said to hold connexion with some of the fibres 
 of the platysma-myoides muscle, A A, Plate 3, and 
 that therefore, if the vessel be divided transversely, 
 the two orifices will remain patent for a time. 
 
 The position of the carotid artery protects the 
 vessel, in some degree, against the suicidal act, as 
 generally attempted. The depth of the incision 
 necessary to reach the main blood-vessels from the 
 fore part of the neck is so considerable that the wound 
 seldom effects more than the opening of some part of 
 the larynx. The ossified condition of the thyroid 
 
 and cricoid parts of the laryngeal apparatus affords a 
 protection to the vessels. The more oblique the inci¬ 
 sion happens to be, the greater probability is there 
 that the wound is comparatively superficial, owing to 
 the circumstance of the instrument having encoun¬ 
 tered one or more parts of the hyo-laryngeal range; 
 but woeful chance sometimes directs the weapon 
 horizontally through that membranous interval be¬ 
 tween the thyroid and hyoid pieces, in which case, as 
 also in that where the laryngeal pieces persist perma- 
 nently cartilaginous, the resistance to the cutting 
 instrument is much less. 
 
 The anatomical position of the parotid, H, Plate 3, 
 and submaxillary glands, w, Plate 4, is so important, 
 that their extirpation, while in a state of disease, will 
 almost unavoidably concern other principal structures. 
 Whether the diseased parotid gland itself or a lym¬ 
 phatic body lying in connexion with it, be the subject 
 of operation, it seldom happens that the temporo- 
 maxillary branch of the external carotid, F, escapes 
 the knife. But an accident, much more liable to 
 occur, and one which produces a great inconvenience 
 afterwards to the subject, is that of dividing the 
 portio-dura nerve, s, Plate 4, at its exit from the 
 stylo-mastoid foramen, the consequence being that 
 almost all the muscles of facial expression become 
 paralyzed. The masseter, L, Plate 3, pterygoid, buc¬ 
 cinator, 15, Plate 4, and the facial fibres of the pla- 
 tysma muscles, A o, Plate 3, still, however, preserve 
 their power, as these structures are innervated from 
 a different source. The orbicularis oculi muscle, which 
 is principally supplied by the portio-dura nerve, is 
 paralyzed, though it still retains a partial power of 
 contraction, owing to the anatomical fact that some 
 terminal twigs of the third or motor pair of nerves of 
 the orbit branch into this muscle. 
 
 The facial artery, v, and the facial vein, u, Plate 4, 
 are in close connexion with the submaxillary gland. 
 Oftentimes they traverse the substance of it. The 
 lingual nerve and artery lie in some part of their 
 course immediately beneath the gland. The former 
 two are generally divided when the gland is excised; 
 the latter two are liabk A> be wounded in the same 
 operation. 
 
DESCRIPTION OF PLATES 3 & 4. 
 
 Plate 3. 
 
 AAA. Subcutaneous platysma myoides muscle, lying 
 on the face, neck, and upper part of chest, and 
 covering the structures contained in the two 
 surgical triangles of the neck. 
 
 B. Lip of the thyroid cartilage. 
 
 C. Clavicular attachment of the trapezius muscle. 
 
 D. Some lymphatic bodies of the post triangle. 
 
 E. External jugular vein. 
 
 F. Occipital artery, close to which are seen some 
 
 branches of the occipitalis minor nerve of the 
 cervical plexus. 
 
 G. Auricularis magnus nerve of the superficial cervi¬ 
 
 cal plexus. 
 
 H. Parotid gland. 
 
 I. Temporal artery, with its accompanying vein. 
 
 K. Zygoma. 
 
 L. Masseter muscle, crossed by the parotid duct, and 
 
 some fibres of platysma. 
 
 M. Facial vein. 
 
 N. Buccinator muscle. 
 
 O. Facial artery seen through fibres of platysma. 
 
 P. Mastoid half of sterno-mastoid muscle. 
 
 Q. Locality beneath which the commencements of 
 
 the subclavian and carotid arteries lie. 
 
 R. Locality of the subclavian artery in the third part 
 
 of its course. 
 
 S. Locality of the common carotid artery at its divi¬ 
 
 sion into internal and external carotids. 
 
 Plate 4. 
 
 A. Subclavian artery passing beneath the clavicle, 
 
 where it is crossed by some blood-vessels and 
 nerves. 
 
 B. Sternal attachment of the sterno-mastoid muscle, 
 
 marking the situation of the root of common 
 carotid. 
 
 C. Common carotid at its point of division, uncovered 
 
 by sterno-mastoid. 
 
 D. External carotid artery branching into lingual, 
 
 facial, temporal, and occipital arteries. 
 
 E. Internal carotid artery. 
 
 F. Temporo-maxillary branch of external carotid 
 
 artery. 
 
 G. Temporal artery and temporal vein, with some 
 
 ascending temporal branches of portio-dura 
 nerve. 
 
 H. External jugular vein descending from the angle 
 
 of the jaw, where it is formed by the union of 
 temporal and maxillary veins. 
 
 I. Brachial plexus of nerves in connexion with A, the 
 
 subclavian artery. 
 
 K. Posterior half of the omo-hyoid muscle. 
 
 L. Transversalis colli artery. 
 
 M. Posterior scapular artery. 
 
 N. Scalenus anticus muscle. 
 
 O. Lymphatic bodies of the posterior triangle of neck. 
 
 P. Superficial descending branches of the cervical 
 
 plexus of nerves. 
 
 Q. Auricularis magnus nerve ascending to join the 
 
 portio-dura. 
 
 R. Occipital artery, accompanied by its nerve, and 
 
 also by some branches of the occipitalis minor 
 t nerve, a branch of cervical plexus. 
 
 S. Portio-dura, or motor division of seventh pair of 
 
 cerebral nerves. 
 
 T. Parotid duct. 
 
 U. Facial vein. 
 
 V. Facial artery. 
 
 W. Submaxillary gland. 
 
 X. Digastric muscle. 
 
 Y. Lymphatic body. 
 
 Z. Hyoid bone. 
 
 1. Thyroid 
 
 cartilage. 
 
 2. Superior thyroid artery. 
 
 3. Anterior jugular vein. 
 
 4. Hyoid half of omo-hyoid muscle. 
 
 5. Sterno-hyoid muscle. 
 
 6. Top of the sternum. 
 
 7. Clavicle. 
 
 8. Trapezius muscle. 
 
 9. Splenius capitis and colli muscle. 
 
 10. Occipital half of occipito-frontalis muscle. 
 
 11. Levator auris muscle. 
 
 12. Frontal half of occipito-frontalis muscle. 
 
 13. Orbicularis oculi muscle. 
 
 14. Zygomaticus major muscle. 
 
 15. Buccinator muscle. 
 
 16. Depressor anguli oris muscle. 
 
 (16) 
 

COMMENTARY ON PLATES 5 & 6. 
 
 THE SURGICAL FORM OF THE DEEP CERVICAL AND FACIAL REGIONS, AND THE 
 RELATIVE POSITION OF THE PRINCIPAL BLOODVESSELS AND NERVES, &c. 
 
 While the human cervix is still extended in sur¬ 
 gical position, its deeper anatomical relations, viewed 
 as a whole, preserve the quadrilateral form. But as 
 it is necessary to remove the sterno-cleido-mastoid 
 muscle, in order to expose the entire range of the 
 greater bloodvessels and nerves, so the diagonal which 
 that muscle forms, as seen in Plates 3 and 4, dis¬ 
 appears, and thus both the cervical triangles are 
 thrown into one common region. Although, how¬ 
 ever, the sterno-mastoid muscle be removed, as seen 
 in Plate. 5, still the great bloodvessels and nerves 
 themselves will be observed to divide the cervical 
 square diagonally, as they ascend the neck from the 
 sterno-clavicular articulation to the ear. 
 
 The diagonal of every square figure is the junction 
 line of the opposite triangles which form the square. 
 The cervical square being indicated as that space 
 which lies within the mastoid process and the top of 
 the sternum—the symphysis of the lower maxilla 
 and the top of the shoulder, it will be seen, in 
 Plate 5, that the line which the common carotid and 
 internal jugular vein occupy in the neck, is the 
 diagonal; and hence the junction line of the two 
 surgical triangles. 
 
 The general course of the common carotid artery 
 and internal jugular vein is, therefore, obliquely 
 backwards and upwards through the diagonal of the 
 cervical square, and passing, as it were, from the 
 point of one angle of the square to that of the oppo¬ 
 site—viz., from the sterno-clavicular junction to the 
 masto-maxillary space; and, taking the anterior tri¬ 
 angle of the cervical square to be that space included 
 within the points marked h 8 A, Plate 5, it will be 
 seen that the common carotid artery ranges along 
 the posterior side of this anterior triangle. Again: 
 taking the points 5 z y to mark the posterior triangle 
 3 
 
 of the cervical square, so will it be seen that the 
 internal jugular vein and the common carotid artery, 
 with the vagus nerve between them, range the ante¬ 
 rior side of this posterior triangle, while the sub¬ 
 clavian artery, q, passes through the centre of the 
 inferior side of the posterior triangle, that is, under 
 the middle of the shaft of the clavicle. 
 
 The main bloodvessels (apparently according to 
 original design) will be found always to occupy the 
 centre of the animal fabric, and to seek deep-seated 
 protection under cover of the osseous skeleton. The 
 vertebrm of the neck, like those of the back and 
 loins, support the principal vessels. Even in the 
 limbs the large bloodvessels range alongside the pro¬ 
 tective shafts of the bones. The skeletal points are 
 therefore the safest guides to the precise localities of 
 the bloodvessels, and such points are always within 
 • the easy recognition of touch and sight. 
 
 Close behind the right sterno-clavicular articula¬ 
 tion, but separated from it by the sternal insertions 
 of the thin ribbon-like muscles named sterno-hyoid 
 and thyroid, together with the cervical fascia, is 
 situated the brachio-cephalic or innominate artery, 
 A b, Plates 5 and 6, having at its outer side the 
 internal jugular division of the brachio-cephalic vein, 
 w k, Plate 5. Between these vessels lies the vagus 
 nerve, e, Plate 6, n, Plate 5. The common carotid 
 artery, internal jugular vein, and vagus nerve, hold 
 in respect to each other the same relationship in the 
 neck, as far upwards as the angle of the jaw. While 
 we view the general lateral outline of the neck, we 
 find that, in the same measure as the bloodvessels 
 ascend from the thorax to the skull, they recede 
 from the fore-part of the root of the neck to the 
 angle of the jaw, whereby a much greater interval 
 occurs between them and the mental symphysis, or 
 
 ( 17 ) 
 
18 
 
 COMMENTARY ON PLATES 5 & 6. 
 
 the apex of the thyroid cartilage, than happens be¬ 
 tween them and the top of the sternum, as they lie at 
 the root of the neck. This variation as to the width 
 of the interval between the vessels and fore-part of 
 the neck, in these two situations, is owing to two 
 causes, 1st, the somewhat oblique course taken by 
 the vessels from below upwards; 2dly, the projecting 
 development of the adult lower jaw-bone, and also of 
 the laryngeal apparatus, which latter organ, as it 
 grows to larger proportions in the male than in the 
 female, will cause the interval at this place to be 
 much greater in the one than the other. In the 
 infant, the larynx is of such small size, as scarcely 
 to stand out beyond the level of the vessels, viewed 
 laterally. 
 
 The internal jugular vein is for almost its entire 
 length covered by the sterno-mastoid muscle, and by 
 that layer of the cervical aponeurosis which lies be¬ 
 tween the vessels and the muscle. The two vessels, 
 k c, Plate 5, with the vagus nerve, are enclosed in a 
 common sheath of cellular membrane, which sends 
 processes between them so as to isolate the structures 
 in some degree from one another. 
 
 The trunk of the common carotid artery is in close 
 proximity to the vagus nerve, this latter lying at the 
 vessel’s posterior side. The internal jugular vein, 
 which sometimes lies upon and covering the carotid, 
 will be found in general separated from it for a little 
 space. Opposite the os hyoides, the internal jugular 
 vein lies closer to the common carotid than it does 
 farther down towards the root of the neck. Oppo¬ 
 site to the sterno-clavicular articulation, the internal 
 jugular vein will be seen separated from the common 
 carotid for an interval of an inch and more in width, 
 and at this interval appears the root of the sub¬ 
 clavian artery, b, Plates 5 and 6, giving off its pri¬ 
 mary branches, viz., the thyroid axis, d, the vertebral 
 and internal mammary arteries, at the first part of 
 its course. 
 
 The length of the common carotid artery varies, 
 of course, according to the place where the innomi¬ 
 nate artery below divides, and also according to that 
 place whereat the common carotid itself divides into 
 internal and external carotids. In general, the length 
 
 of the common carotid is considerable, and ranges 
 between the sterno-clavicular articulation and the 
 level of the os hyoides; throughout the whole of 
 this length, it seldom or never happens that a large 
 arterial branch is given off from the vessel, and the 
 operation of ligaturing the common carotid is there¬ 
 fore much more likely to answer the results required 
 of that proceeding than can be expected from the 
 ligature of any part of the subclavian artery which 
 gives off large arterial branches from every part of 
 its course. 
 
 The sympathetic nerve, r, Plate 6, is as close to 
 the carotid artery behind, as the vagus nerve, n, 
 Plate 5, and is as much endangered in ligaturing this 
 vessel. The branch of the ninth nerve, e, Plate 5, 
 (descendens noni,) lies upon the common carotid, 
 itself or its sheath, and is likely to be included in 
 the ligature oftener than we are aware of. 
 
 The trunk of the external carotid, d, Plate 5, is in 
 all cases very short, and in many bodies can scarcely 
 be said to exist, in consequence of the thyroid, lin¬ 
 gual, facial, temporal, and occipital branches, spring¬ 
 ing directly from almost the same point at which the 
 common carotid gives off the internal carotid artery. 
 The internal carotid is certainly the continuation of 
 the common arterial trunk, while the vessel named 
 external carotid is only a series of its branches. If 
 the greater size of the internal carotid artery, com¬ 
 pared to that of the external carotid, be not sufficient 
 to prove that the former is the proper continuation 
 of the common carotid, a fact may be drawn from 
 comparative philosophy which will put the question 
 beyond doubt, namely — that as the common carotid 
 follows the line of the cervical vertebras, just as the 
 aorta follows that of the vertebrae of the trunk, so 
 does the internal carotid follow the line of the 
 cephalic vertebras. I liken, therefore, those branches 
 of the so-called external carotid to be, as it were, the 
 visceral arteries of the face and neck. It would be 
 quite possible to demonstrate this point of analogy, 
 were this the place for analogical reasoning. 
 
 The common carotid, or the internal, may be com¬ 
 pressed against the rectus capitis anticus major 
 muscle, 13, Plate 6, as it lies on the fore-part of the 
 
COMMENTARY ON PLATES 5 & 6. 
 
 19 
 
 vertebral column. The internal maxillary artery, 
 16, Plate 6, and the facial artery, G, Plate 5, are 
 those vessels which bleed when the lower maxilla is 
 amputated. In this operation, the temporal artery, 
 15, Plate 6, will hardly escape being divided also, it 
 lies in such close proximity to the neck and condyle 
 of the jaw-bone. 
 
 The subclavian artery, b q, Plate 5, traverses the 
 root of the neck, in an arched direction from the 
 sterno-clavicular articulation to the middle of the 
 shaft of the clavicle, beneath which it passes, being 
 destined for the arm. In general, this vessel rises to 
 a level considerably above the clavicle; and all that 
 portion of the arching course which it makes at this 
 situation over the first rib has become the subject of 
 operation. The middle of this arching subclavian 
 artery is (by as much as the thickness of the scalenus 
 muscle, x, Plate 5) deeper situated than either ex¬ 
 tremity of the arch of this vessel, and deeper also 
 than any part of the common carotid, by the same 
 fact. So many branches spring from all parts of the 
 arch of the subclavian artery, that the operation of 
 ligaturing this vessel is less successful than the same 
 operation exercised on others. 
 
 The structures which lie in connexion with the 
 arch of the subclavian also render the operation of 
 tying the vessel an anxious task. It is crossed and 
 recrossed at all points by large veins, important 
 nerves, and by its own principal branches. The 
 vagus nerve, s e, Plate 6, crosses it at b, its root; 
 external to which place the large internal jugular 
 vein, K, Plate 5, lies upon it; external to this latter, 
 the scalenus muscle, x, Plate 5, with the phrenic 
 nerve lying upon the muscle, binds it fixedly to the 
 first rib; more external still, the common trunk of 
 the external jugular and shoulder veins, u, Plate 5, 
 lie upon the vessel, and it is in the immediate vicinity 
 of the great brachial plexus of nerves, p p, which pass 
 down along its humeral border, many branches of the 
 same plexus sometimes crossing it anteriorly. 
 
 The depth at which the middle of the subclavian 
 artery lies may be learned by the space which 
 those structures, beneath which it passes, necessarily 
 occupy. The clavicle at its sternal end is round and 
 
 thick, where it gives attachment to the sterno-cleido- 
 mastoid muscle. The root of the internal jugular 
 vein, when injected, will be seen to occupy consider¬ 
 able space behind the clavicle; and the anterior sca¬ 
 lenus muscle is substantial and fleshy. The united 
 spaces occupied by these structures give the depth of 
 the subclavian artery in the middle part of its course. 
 
 The length of the subclavian artery between its 
 point of branching from the innominate and that 
 where it gives off its first branches varies in different 
 bodies, but is seldom so extensive as to assure the 
 operator of the ultimate success of the process of 
 ligaturing the vessel. Above and below d, Plate 6, 
 the thyroid axis, come off the vertebral and internal 
 mammary arteries internal and anterior to the sca¬ 
 lenus muscle. External and posterior to the scalenus, 
 a large vessel, the post scapular, G, Plate 6, R, Plate 5, 
 arises. If an aneurism attack any part of this sub¬ 
 clavian arch, it must be in close connexion -with 
 some one of these branches. If a ligature is to be 
 applied to any part of the arch, it will seldom happen 
 that it can be placed farther than half an inch from 
 some of these principal collateral branches. 
 
 When the shoulder is depressed, the clavicle follows 
 it, and the subclavian artery will be more exposed 
 and more easily reached than if the shoulder be 
 elevated, as this latter movement raises the clavicle 
 over the locality of the vessel. Dupuytren alludes 
 practically to the different depths of the subclavian 
 artery in subjects with short necks and high shoulders, 
 and those with long necks and pendent shoulders. 
 When the clavicle is depressed to the fullest extent, 
 if then the stemo-cleido-mastoid and scalenus muscles 
 be relaxed by inclining the head and neck towards 
 the artery, I believe it may be possible to arrest the 
 flow of blood through the artery by compressing it 
 against the first rib, and this position will also facili¬ 
 tate the operation of ligaturing the vessel. 
 
 The subclavian vein, w, Plate 5, is removed to 
 some distance from the artery, Q, Plate 5. The 
 width of the scalenus muscle, x, separates the vein 
 from the artery. An instance is recorded by Blandin 
 in which the vein passed in company with the artery 
 under the scalenus muscle. 
 
DESCRIPTION OF PLATES 5 & 6. 
 
 Plate 5. 
 
 A. Innominate artery at its point of bifurcation. 
 
 B. Subclavian artery crossed by the vagus nerve. 
 
 C. Common carotid artery with the vagus nerve at its outer 
 
 side, and the descendens noni nerve lying on it. 
 
 D. External carotid artery. 
 
 E. Internal carotid artery with the descendens noni nerve 
 
 lying on it. 
 
 F. Lingual artery passing under the fibres of the hyo-glossus 
 
 muscle. 
 
 G. Tortuous facial artery. 
 
 II. Temporo-maxillary artery. 
 
 I. Occipital artery crossing the internal carotid artery and 
 
 jugular vein. 
 
 K. Internal jugular vein crossed by some branches of the cer¬ 
 
 vical plexus, which join the descendens noni nerve. 
 
 L. Spinal accessory nerve, which pierces the sterno-mastoid 
 
 muscle, to be distributed to it and the trapezius. 
 
 M. Cervical plexus of nerves giving off the phrenic nerve to 
 
 descend the neck on the outer side of the internal 
 jugular vein and over the scalenus muscle. 
 
 N. Vagus nerve between the carotid artery and internal jugular 
 
 vein. 
 
 O. Ninth or hypoglossal nerve distributed to the muscles of 
 
 the tongue. 
 
 P P. Branches of the brachial plexus of nerves. 
 
 Q. Subclavian artery in connexion with the brachial plexus of 
 nerves. 
 
 R R. Post scapular artery passing through the brachial plexus. 
 
 S. Transversalis humeri artery. 
 
 T. Transversalis colli artery. 
 
 U. Union of the post scapular and external jugular veins, 
 
 which enter the subclavian vein by a common trunk. 
 
 V. Post-half of the omo-hyoid muscle. 
 
 W. Part of the subclavian vein seen above the clavicle. 
 
 X. Scalenus muscle separating the subclavian artery from vein. 
 
 Y. Clavicle. 
 
 Z. Trapezius muscle. 
 
 1. Sternal origin of sterno-mastoid muscle of left side. 
 
 2. Clavicular origin of sterno-mastoid muscle of right side 
 
 turned down. 
 
 3. Scalenus posticus muscle. 
 
 4. Splenius muscle. 
 
 5. Mastoid insertion of sterno-mastoid muscle. 
 
 6. Internal maxillary artery passing behind the neck of lower 
 
 jaw-bone. 
 
 7. Parotid duct. 
 
 8. Genio-hyoid muscle. 
 
 9. Mylo-hyoid muscle, cut and turned aside. 
 
 10. Superior thyroid artery. 
 
 II. Anterior half of omo-hyoid muscle. 
 
 12. Sterno-hyoid muscle, cut. 
 
 13. Sterno-thyroid muscle, cut. 
 
 Plate 6. 
 
 A. Root of the common carotid artery. 
 
 B. Subclavian artery at its origin. 
 
 C. Trachea. 
 
 D. Thyroid axis of the subclavian artery. 
 
 E. Vagus nerve crossing the origin of subclavian artery. 
 
 F. Subclavian artery at the third division of its arch. 
 
 G. Post scapular branch of the subclavian artery. 
 
 H. Transversalis humeri branch of subclavian artery. 
 
 I. Transversalis colli branch of subclavian artery. 
 
 K. Posterior belly of omo-hyoid muscle, cut. 
 
 L. Median nerve branch of brachial plexus. 
 
 M. Musculo-spiral branch of same plexus. 
 
 N. Anterior scalenus muscle. 
 
 O. Cervical plexus giving off the phrenic nerve, which takes 
 
 tributary branches from brachial plexus of nerves. 
 
 P. Upper part of internal jugular vein. 
 
 Q. Upper part of internal carotid artery. 
 
 R. Superior cervical ganglion of sympathetic nerve. 
 
 S. Vagus nerve lying external to sympathetic nerve, and giving 
 
 off t. its laryngeal branch. 
 
 T. Superior thyroid artery. 
 
 U. Lingual artery separated by hyo-glossus muscle from 
 
 V. Lingual or ninth cerebral nerve. 
 
 W. Sublingual salivary gland. 
 
 X. Genio-hyoid muscle. 
 
 Y. Mylo-hyoid muscle, cut and turned aside. 
 
 Z. Thyroid cartilage. 
 
 1. Upper part of sterno-hyoid muscle. 
 
 2. Upper part of omo-hyoid muscle. 
 
 3. Inferior constrictor of pharynx. 
 
 4. Cricoid cartilage. 
 
 5. Crico-thyroid muscle. 
 
 6. Thyroid body. 
 
 7. Inferior thyroid artery of thyroid axis. 
 
 8. Sternal tendon of sterno-mastoid muscle, turned down. 
 
 9. Clavicular portion of sterno-mastoid muscle, turned down. 
 
 10. Clavicle. 
 
 11. Trapezius muscle. 
 
 12. Scalenus posticus muscle. 
 
 13. Rectus capitis anticus major muscle. 
 
 14. Stylo-hyoid muscle, turned aside. 
 
 15. Temporal artery. 
 
 16. Internal maxillary artery. 
 
 17. Inferior dental branch of fifth pair of cerebral nerves. 
 
 18. Gustatory branch of fifth pair of nerves. 
 
 19. External pterygoid muscle. 
 
 20. Infernal pterygoid muscle. 
 
 21. Temporal muscle cut to show the deep temporal branches 
 
 of fifth pair of nerves. 
 
 22. Zygomatic arch. 
 
 23. Buccinator muscle, with buccal nerve and parotid duct. 
 
 24. Masseter muscle cut on the lower maxilla. 
 
 25. Middle constrictor of pharynx. 
 
 (20) 
 
_ 
 
COMMENTARY ON PLATES 7 & 8. 
 
 THE SURGICAL DISSECTION OF THE SUBCLAVIAN AND CAROTID REGIONS, 
 THE RELATIVE ANATOMY OF THEIR CONTENTS. 
 
 A perfect knowledge of the relative anatomy of 
 any of the surgical regions of the body must include 
 an acquaintance with the superposition of parts con¬ 
 tained in each region, as well as the plane relation¬ 
 ship of organs which hold the same level in each 
 layer or anatomical stratum. The dissections in 
 Plates 7 and 8 exhibit both these modes of relation. 
 A portion of each of those superficial layers, which it 
 was necessary to divide, in order to expose a deeper 
 organ, has been left holding its natural level. Thus 
 the order of superposition taken by the integument, 
 the fasciae, the muscles, bones, veins, nerves, and 
 arteries, which occupy both the surgical triangles of 
 the neck, will be readily recognised in the opposite 
 Plates. 
 
 The depth of a bloodvessel or other organ from 
 surface will vary for many reasons, even though the 
 same parts in the natural order of superposition shall 
 overlie the whole length of the vessel or organ which 
 we make search for. The principal of those reasons 
 are : — 1st, that the stratified organs themselves vary 
 in thickness at several places; 2d, that the organ or 
 vessel which we seek will itself incline to surface 
 from deeper levels occupied elsewhere; 3d, that the 
 normal undulations of surface will vary the depth of 
 the particular vessels, &c.; and 4th, that the natural 
 mobility of the superimposed parts will allow them 
 to change place in some measure, and consequently 
 influence the relative position of the object of search. 
 On this account it is that tin? surgical anatomist 
 chooses to give a fixed position to the subject about 
 to be operated on, in order to reduce the number of 
 these difficulties as much as possible. 
 
 In Plate 7 will be seen the surgical relationship of 
 parts lying in the vicinity of the common carotid 
 
 artery, at the point of its bifurcation into external 
 and internal carotids. At this locality, the vessel 
 will be found, in general, subjacent to the following 
 mentioned structures, numbered from the superficies 
 to its own level—viz., the common integument and 
 subcutaneous adipose membrane, which will vary in 
 thickness in several individuals; next, the platysma 
 myoides muscle, F l, which is identified with the 
 superficial fascia, investing the outer surface of the 
 sterno-mastoid muscle; next, the deeper layer of the 
 same fascia, R s., which passes beneath the sterno- 
 mastoid muscle, but over the sheath of the vessels; 
 and next, the sheath of the vessels, Q, which invests 
 them and isolates them from adjacent structures. 
 Though the vessel lies deeper than the level of the 
 sterno-mastoid muscle at this locality, yet it is not 
 covered by the muscle in the same manner, as it is 
 lower down in the neck. At this place, therefore, 
 though the actual depth of the artery from surface 
 will be the same, whether it be covered or uncovered 
 by the sterno-mastoid muscle, still we know that the 
 locality of the vessel relative to the parts actually 
 superimposed will vary according^. This observa¬ 
 tion will apply to the situation and relative position 
 of all the other vessels as well 
 
 Other occurrences will vary the relations of the 
 artery in regard to superjacent structures, though 
 the actual depth of the vessel from surface may be 
 the same. If the internal jugular vein covers the 
 carotid artery, as it sometimes does, or if a plexus of 
 veins, gathering from the fore-part of the neck or 
 face, overlie the vessel, or if a chain of lymphatic 
 bodies be arranged upon it, as is frequently the case, 
 the knowledge of such occurrences will guard the 
 judgment against being led into error by the conven- 
 
 ( 21 ) 
 
22 
 
 COMMENTARY 
 
 tionalities of the descriptive method of anatomists. 
 The normal relative anatomy of the bloodvessels is 
 taken by anatomists to be the more frequent dispo¬ 
 sition of their main trunks and branches, considered 
 X>er se, and in connexion with neighbouring parts. 
 But it will be seen by this avowal that those vessels 
 are liable to many various conditions; and such is 
 the case, in fact. No anatomist can pronounce with 
 exactness the precise figure of vessels or other organs 
 while they lie concealed beneath the surface. An 
 approach to truth is all that the best exjierience can 
 boast of. The form and relations of the carotid 
 vessels of Plate 7 may or may not be the same as 
 those concealed beneath the same region of Plate 8, 
 at the point r. 
 
 The motions of the head upon the neck, or of the 
 neck upon the trunk, will influence the relative posi¬ 
 tion of the vessels a c b, of Plate 7, and therefore we 
 take a fixed surgical position, in the expectation of 
 finding that the carotid artery projects from under 
 the anterior border of the upper third of the sterno- 
 mastoid muscle, opposite the upper border of the thy¬ 
 roid cartilage; at this situation of the vessels, viz., 
 R, Plate 8, opposite o, the thyroid projection, is in 
 general to be found the anatomical relation of the 
 vessels as they appear dissected in Plate 7. Of these 
 vessels, the main trunks are less liable to anomalous 
 character than the minor branches. 
 
 The relative position of the subclavian artery is as 
 liable to be influenced by the motions of the clavicle 
 on the sternum, as that of the carotid is by the 
 motions of the lower jaw-bone on the skull, or by 
 the larynx, in its own motions at the fore-part of the 
 neck. It becomes as necessary, therefore, in the per¬ 
 formance of surgical operations upon the subclavian 
 artery, to fix the clavicle by depressing it, as in 
 Plate 8, as it is to give fixity to the lower maxilla 
 and larynx, in the position of Plate 7, when the 
 carotid is the subject of operation. 
 
 The same named structures, but different as to 
 their parts, will be found to overlie the subclavian 
 artery as are found to conceal the carotid artery. 
 The skin, the fascia, and platysma muscle, the sterno- 
 
 ON PLATES 7 & 8. 
 
 cleido-mastoid muscle, the deep layer of the cervical 
 fascia, &c., cover both vessels. One additional muscle 
 binds down the subclavian artery, viz., the scalenus 
 anticus. The omo-liyoid relates to both vessels, the 
 anterior division to the carotid, the posterior to the 
 subclavian. 
 
 The carotid artery lies uncovered by the sterno- 
 mastoid muscle, opposite to the upper border of the 
 thyroid cartilage, or the hyoid bone; and the sub¬ 
 clavian artery emerges from under cover of a different 
 part of the same muscle, opposite the middle of the 
 clavicle. These points of relationship to the skeletal 
 parts can be ascertained by the touch, in both in¬ 
 stances, even in the undissected body. The thyroid 
 point, o, of Plate 8, indicates the line, r n, which the 
 carotid artery traverses in the same figure, along the 
 anterior border of the sterno-mastoid muscle, as seen 
 in the dissected region of Plate 7. The mid-point of 
 the clavicle, u, Plate 7, and the top of the sternum 
 in the same figure, will, while the eye follows the 
 arching line, z x t v, indicate with correctness the 
 arching course of the subclavian, such as is repre¬ 
 sented in the dissection of that vessel, b, Plate 8. 
 
 The subclavian artery has no special sheath, pro¬ 
 perly so called; but the deep layer of the cervical 
 fascia, p, Plate 8, which passes under A, the clavicular 
 portion of the sterno-mastoid muscle, and becomes of 
 considerable thickness and density, sheaths over the 
 vessel in this region of its course. 
 
 A very complex condition of the veins which join 
 the external jugular at this part of the course of the 
 subclavian artery is now and then to be found over- 
 lying that vessel. If the hemorrhage consequent 
 upon the opening of these veins, or that of the 
 external jugular, be so profuse as to impede the 
 operation of ligaturing the subclavian artery, it may 
 in some measure be arrested by compressing them 
 against the resisting parts adjacent, when the ope¬ 
 rator, feeling for d, the scalenus muscle, and the first 
 rib to which it is attached, cannot fail to alight upon 
 the main artery itself, b, Plate 8. 
 
 The middle of the shaft of the clavicle is a much 
 safer guide to the vessel than are the muscles which 
 
COMMENTARY ON PLATES 7 & 8. 
 
 23 
 
 contribute to form this posterior triangle of the neck, 
 in which the subclavian vessel is located. The form 
 or position of the clavicle in the depressed condition 
 of the shoulder, as seen in Plate 8, is invariable; 
 whereas that of the trapezius and sterno-mastoid 
 muscles is inconstant, these muscles being found to 
 stand at unequal intervals from each other in several 
 bodies. The space between the insertions of both 
 these muscles is indefinite, and may vary in degrees 
 of width from the whole length of the clavicle to half 
 an inch; or, as in some instances, leaving no interval 
 whatever. The position of the omo-hyoid muscle 
 will not be accounted a sure guide to the locality of 
 the subclavian artery, since, in fact, it varies con¬ 
 siderably as to its relationship with that vessel. 
 The tense cords of the brachial plexus of nerves, 
 f, Plate 8, which will be found, for the most part, 
 ranging along the acromial border of the artery, are 
 a much surer guide to the vessel. 
 
 On comparing the subclavian artery, at b, Plate 8, 
 with the common carotid artery, at A, Plate 7, I 
 believe that the former will be found to exhibit, on 
 the whole a greater constancy in respect to the 
 following-mentioned condition—viz., a single main 
 arterial trunk arches over the first rib to pass beneath 
 the middle of the clavicle, while the carotid artery 
 opposite the thyroid piece of the larynx is by no 
 means constantly single as’ a common carotid trunk. 
 The place of division of the common carotid is not 
 definite, and, therefore, the precise situation in the 
 upper two-thirds of the neck, where it may present 
 as a single main vessel, cannot, be predicted with cer¬ 
 tainty in the undissected body. There is no other 
 main artery of the body more liable to variation than 
 that known as external carotid. It is subject to as 
 many changes of character in respect to the place of 
 its branching from the common carotid, and also in 
 regard to the number of its own branches, as any of 
 the lesser arteries of the system. It is but as an 
 aggregate of the branches of that main arterial trunk 
 
 which ranges from the carotid foramen of the tem¬ 
 poral bone to the aorta; and, as a branch of a larger 
 vessel, it is, therefore, liable to spring from various 
 places of the principal trunk, just as we find to be 
 the case with all the other minor branches of the 
 larger arteries. Its name, external carotid, is as 
 unfittingly applied to it, in comparison with the 
 vessel from which it springs, as the name external 
 subclavian would be if applied to the thyroid axis 
 of the larger subclavian vessel. The nomenclature 
 of surgical anatomy does not, however, court a philo¬ 
 sophical inquiry into that propriety of speech which 
 comparative science demands, nor is it supposed to 
 be necessary in a practical point of view. 
 
 It will, however, sound more euphoneously with 
 reason, and at the same time, I believe, be found not 
 altogether unrelated to the useful, if, when such 
 conditions as the “ anomalies of form” present them¬ 
 selves, we can advance an interpretation of the same, 
 in addition to the dry record of them as isolated 
 facts. Comparative anatomy, which alone can fur¬ 
 nish these interpretations, will therefore prove to be 
 no alien to the practical, while it may lend explana¬ 
 tion to those bizarreries which impede the way of the 
 anthropotomist. All the anomalies of form, both as 
 regards the vascular, the muscular, and the osseous 
 systems of the human body, are analyzed by com¬ 
 parison through the animal series. Numerous cases 
 are on record of the subclavian artery being found 
 complicated with supernumerary ribs jutting from 
 the 5th, 6th, or 7th cervical vertebra).* To these I 
 shall add another, in respect of the carotid arteries— 
 viz., that I have found them complicated with an 
 osseous shaft of bone, taking place of the stylo-hyoid 
 ligament, a condition which obtains permanently in 
 the ruminant and other classes of mammals. 
 
 * I have given an explanation of these facts in my work on Com¬ 
 parative Osteology and the Archetype Skeleton, to which, and also 
 to Professor Owen’s work, entitled Homologies of the Vertebrate 
 Skeleton, I refer the reader. 
 
DESCRIPTION OF PLATES 7 & 8. 
 
 Plate 7. 
 
 A. Common carotid at its place of division. 
 
 B. External carotid. 
 
 C. Internal carotid, with the descending branch of 
 
 the ninth nerve lying on it. 
 
 D. Facial vein entering the internal jugular vein. 
 
 E. Sterno-mastoid muscle, covered by 
 
 F. Part of the platysma muscle. 
 
 G. External jugular vein. 
 
 II. Parotid gland, sheathed over by the cervical 
 fascia. 
 
 I. Facial vein and artery seen beneath the facial 
 fibres of the platysma. 
 
 K. Submaxillary salivary gland. 
 
 L. Upper part of the platysma muscle cut. 
 
 M. Cervical fascia cut. 
 
 N. Sterno-hyoid muscle. 
 
 O. Omo-hyoid muscle. 
 
 P. Sterno-thyroid muscle. 
 
 Q. Fascia proper of the vessels. 
 
 R. Layer of the cervical fascia beneath the sterno- 
 
 mastoid muscle. 
 
 S. Portion of the same fascia. 
 
 T. External jugular vein injected beneath the skin. 
 
 U. Clavicle at the mid-point, where the subclavian 
 
 artery passes beneath it. 
 
 Y. Locality of the subclavian artery in the third 
 part of its course. 
 
 W. Prominence of the trapezius muscle. 
 
 X. Prominence of the clavicular portion of the sterno- 
 
 cleido-mastoid muscle. 
 
 Y. Place indicating the interval between the clavi¬ 
 
 cular and sternal insertions of sterno-cleido- 
 mastoid muscle. 
 
 Z. Projection of the sternal portion of the stemo- 
 
 cleido-mastoid muscle. 
 
 Plate 8. 
 
 A. Clavicular attachment of the sterno-mastoid muscle 
 
 lying over the internal jugular vein, &c. 
 
 B. Subclavian artery in the third part of its course. 
 
 C. \ ein formed by the union of external jugular, 
 
 scapular, and other veins. 
 
 D. Scalenus anticus muscle stretching over the artery, 
 
 and separating it from the internal jugular 
 vein. 
 
 E. Post-half of omo-hyoid muscle. 
 
 F. Inner branches of the brachial jdexus of nerves. 
 
 G. Clavicular portion of trapezius muscle. 
 
 H. Transversalis colli artery. 
 
 I. Layer of the cervical fascia, which invests the 
 
 sterno-mastoid and trapezius muscles. 
 
 K. Lymphatic bodies lying between two layers of 
 
 the cervical fascia. 
 
 L. Descending superficial branches of the cervical 
 
 plexus of nerves. 
 
 M. External jugular vein seen under the fascia which 
 
 invests the sterno-mastoid muscle. 
 
 N. Platysma muscle cut on the body of sterno-mas¬ 
 
 toid muscle. 
 
 O. Projection of the thyroid cartilage. 
 
 P. Layer of the cervical fascia lying beneath the cla¬ 
 
 vicular portion of the sterno-mastoid muscle. 
 
 Q. Layer of the cervical fascia continued from the 
 
 last over the subclavian artery and brachial 
 plexus of nerves. 
 
 ( 24 ) 
 
COMMENTARY ON PLATES 9 & 10. 
 
 THE SURGICAL DISSECTION OP THE STERNO-CLAYICULAR OR TRACHEAL REGION, AND 
 THE RELATIVE POSITION OP ITS MAIN BLOODVESSELS, NERVES, &c. 
 
 The law of symmetry governs tlie development of 
 all structures which compose the human body; and 
 all organized beings throughout the animal kingdom 
 are produced in obedience to this law. The general 
 median line of the human body is characterized as 
 the point of fusion of the two sides; and all structures 
 or organs which range this common centre are either 
 symmetrically azygos, or symmetrically duplex. The 
 azygos organ presents as a symmetrical unity, and the 
 duplex organ as a symmetrical duality. The surgi¬ 
 cal anatomist takes a studious observation of this law 
 of symmetry; and knowing it to be one of general and 
 almost unexceptional occurrence, he practises accord¬ 
 ing to its manifestation. 
 
 The vascular as well as the osseous skeleton dis¬ 
 plays the law of symmetry; but while the osseous sys¬ 
 tem offers no exception to this law, the vascular sys¬ 
 tem offers one which, in a surgical point of view, is 
 of considerable importance — namely, that behind the 
 right sterno-clavicular articulation, c, Plate 9, is found 
 the artery, A, named innominate, this being the com¬ 
 mon trunk of the right common carotid and subclavi¬ 
 an vessels; while on the left side, behind the left 
 sterno-clavicular junction, Q, Plate 10, the two vessels 
 (subclavian, b, and carotid, A,) spring separately from 
 the aortic arch. This fact of asymmetrical arrange¬ 
 ment in the arterial trunks at the fore part of the root 
 of the neck is not, however, of invariable occurrence; 
 on the contrary, numerous instances are observed 
 where the arteries in question, on the right side as 
 well as the left, arise separately from the aorta; and 
 thus Nature reverts to the original condition of per¬ 
 fect symmetry as governing the development of even 
 the vascular skeleton. And not unfrequently, as if 
 to invite us to the inquiry whether a separate origin 
 of the four vessels (subclavian and carotid) from the 
 4 
 
 aorta, or a double innominate condition of the vessels, 
 were the original form with Nature, we find her also 
 presenting this latter arrangement of them. An in¬ 
 nominate or common aortic origin may happen for 
 the carotid and subclavian arteries of the left side, as 
 well as the right. Hence, therefore, while experience 
 may arm the judgment with a general rule, such gen¬ 
 erality should not render us unmindful of the possi¬ 
 ble exception. 
 
 When, as in Plate 9, A, the innominate artery rises 
 to a level with c, the right sterno-clavicular junction, 
 and when at this place it bifurcates, having on its left 
 side, d, the trachea, and on its right side, b, the root 
 of the internal jugular vein, together with a, the va¬ 
 gus nerve, the arterial vessel is said to be of normal 
 character, and holding a normal position relative to 
 adjacent organs. When, as in Plate 10, A, the com¬ 
 mon carotid, and b, the subclavian artery, rise sepa¬ 
 rately from the aortic arch to a level with Q, the left 
 sterno-clavicular articulation, the vessels having M, 
 the trachea, to their inner side, and c d, the junction 
 of the internal jugular and subclavian veins, to their 
 outer side, with b, the left vagus nerve, between them, 
 then the arterial vessels are accounted as being of 
 normal character, and as holding a normal relative 
 position. Every exception to this condition of A, Plate 
 9, or to that of A b, Plate 10, is said to be abnormal 
 or peculiar, and merely because the disposition of the 
 vessels, as seen in Plates 9 and 10, is taken to be gen¬ 
 eral or of more frequent occurrence. 
 
 Now, though it is not my present purpose to burden 
 this subject of regional anatomy with any lengthy 
 inquiry into the comparative meaning of the facts, 
 why a common innominate trunk should occur on 
 the right of the median line, while separate arterial 
 trunks for the carotid and subclavian arteries should 
 
 (25) 
 
26 
 
 COMMENTARY ON PLATES 9 & 10. 
 
 spring from the aorta on the left of this mid-line, thus 
 making a remarkable exception to the rule of symme¬ 
 try which characterizes all the arterial vessels else¬ 
 where, still I cannot but regard this exceptional fact 
 of asymmetry as in itself expressing a question by no 
 means foreign to the interests of the practical. 
 
 In the abstract or general survey of all those pecu¬ 
 liarities of length to which the innominate artery, A, 
 Plate 9, is subject, I here lay it down as a proposition, 
 that they occur as graduated phases of the bicleavage 
 of this innominate trunk from the level of A, to the 
 aortic arch, in which latter phasis the aorta gives a 
 separate origin to the carotid and subclavian vessels 
 of the right side as well as the left. On the other 
 hand, I observe that the peculiarities to the normal 
 separate condition of A and b, the carotid and subcla¬ 
 vian arteries of Plate 10, display, in the relationary 
 aggregate, a phasial gradation of a and b joining into 
 a common trunk union, in which state we then find 
 the aorta giving origin to a right and left innominate 
 artery. Between these two forms of developement— 
 viz., that where the four vessels spring separately 
 from the aortic arch, and that where two innominate 
 or brachio-cephalic arteries arise from the same — 
 may be read all the sum of variation to which these 
 vessejs are liable. It is true that there are some states 
 of these vessels which cannot be said to be naturally 
 embraced in the above generalization; but though I 
 doubt not that these might be encompassed in a high¬ 
 er generalization; still, for all practical ends, the less¬ 
 er general rule is all-sufficient. 
 
 In many instances, the innominate artery, A, Plate 
 9, is of such extraordinary length, that it rises consid¬ 
 erably (for an inch, or even more) above the level of 
 c, the sternal end of the clavicle. In other cases, the 
 innominate artery bifurcates soon after it leaves the 
 first part of the aortic arch; and between these ex¬ 
 tremes as to length, the vessel varies infinitesimally. 
 
 The innominate artery lies closer behind the right 
 sterno-clavicular junction than the left carotid or sub¬ 
 clavian arteries lie in relation to the left sterno-clavi¬ 
 cular articulation; and this difference of depth between 
 the vessel of the right side and those of the left is 
 
 mainly owing to the form and direction of the aortic 
 arch from which they take origin. The aortic arch 
 ranges, not alone transversely, but also from before 
 backward, and to the left side of the dorsal spine; and 
 consequently, as the innominate artery, A, Plate 9, 
 springs from the first or fore part of the aorta, while 
 the left carotid and subclavian arteries arise from the 
 second and deeper part of its arch, the vessels of both 
 sides rising into the neck perpendicularly from the root 
 in the thorax, will still, in the cervical region, mani¬ 
 fest a considerable difference as to antero-posterior 
 depth. The depth of the left subclavian artery, b, 
 Plate 10, from cervical surface, is even greater than 
 that of the left common carotid, A, Plate 10, and this 
 latter, at its root in the aortic arch, is deeper than 
 the innominate artery. Both common carotids, A a, 
 Plates 9 and 10, hold nearly the same antero-posterior 
 depth on either side of the trachea, m, Plate 10, and 
 d, Plate 9. Although the relative depth of the arteri¬ 
 al vessels on both sides of the trachea is different, still 
 they are covered by an equal number of identical 
 structures, taking the same order of superposition. 
 
 On either side of the episternal cervical pit, which, 
 even in the undissected body of male or female, infant 
 or adult, is always a well-marked surgical feature, 
 may be readily recognised the converging sternal at¬ 
 tachments of the sterno-mastoid muscles, l g, Plate 10; 
 and midway between these symmetrical muscular 
 prominences in the neck, but holding a deeper level 
 than them, is situated that part of the trachea which 
 is generally the subject of the operation of tracheo¬ 
 tomy. The relative anatomy of the trachea, m, Plate 
 10, d, Plate 9, at this situation requires therefore to 
 be carefully considered. The trachea is said to in¬ 
 cline rather to the right side of the median line; but 
 perhaps this observation would be more true to nature 
 if it were accompanied by the remark, that this seem¬ 
 ing inclination to the right side is owing to the fact, 
 that the innominate artery, a, Plate 9, lies obliquely 
 over its fore part, near the sternum. However this 
 may be, it certainly will be the safer step in the op¬ 
 eration to regard the median position of the trachea 
 as fixed, than to encroach upon the locality of the 
 
COMMENTARY ON PLATES 9 & 10. 
 
 27 
 
 carotid vessels; and to make the incision longitudi- I 
 nally and exactly through the median line, while the 
 neck is extended backwards, and the chin made to 
 correspond with the line of incision. And when the 
 operator takes into consideration the situation of the 
 vessel A, Plate 9, and A, Plate 10, at this region of 
 the neck, he will at once own to the necessity of open¬ 
 ing the trachea, d, Plate 9, m, Plate 10, at a situation 
 nearer the larynx than the point marked in the fig¬ 
 ures. The course taken by the common carotid arte¬ 
 ries is, in respect to the trachea, divergent from be¬ 
 low upwards; and as these vessels will consequently 
 be found to stand wider apart at the level of k, i, Plate 
 10, than they do at the level of M, Plate 10, so the 
 farther upwards from the sternum we choose the 
 point at which to open the trachea, the less likely are 
 we to endanger the great arterial vessels. 
 
 In addition to the fact, that the carotid arteries at 
 an inch above the sternum lie nearer the median line 
 than they do higher up in the neck, it should always 
 be remembered, that the trachea itself is situated 
 much deeper at the point h, Plate 10, d, Plate 9, than 
 it is opposite the points f and k of the same figures. 
 The laryngo-tracheal line is, in the lateral view of the 
 neck, downwards and backwards, and therefore it will 
 be found always at a considerable depth from cervical 
 surface, as it passes behind the first bone of the ster¬ 
 num, midway between both sterno-mastoid muscles. 
 
 In the operation of tracheotomy, the cutting instru¬ 
 ment divides the following named structures as they 
 lie beneath the common integument: If the incision 
 be made directly upon the median line, the muscles 
 F, sterno-hyoid, and E, sterno-thyroid, Plate 9, are not 
 necessarily divided, as these structures and their fel¬ 
 lows hold a somewhat lateral position opposite to each 
 other. Beneath these muscles and above them, thus 
 encasing them, the cervical fascia,//, Plate 10, is re¬ 
 quired to be divided, in order to expose the trachea. 
 Beneath // the cervical fascia, will next be felt the 
 rounded bilobed mass of the thyroid body, lying on 
 the forepart of the trachea; above the thyroid body, 
 the cricoid and some tracheal cartilaginous rings will 
 be felt j and since the thyroid body varies much as to 
 
 hulk in several individuals of the same and different 
 sexes, as also from a consideration that its substance 
 is traversed by large arterial and venous vessels, it will 
 he therefore preferable to open the trachea above it, 
 than through it or below it. 
 
 On the forepart of the tracheal median line, either 
 superficial to, or deeper than, the cervical fascia, the 
 tracheotomist occasionally meets with a chain of lym¬ 
 phatic glands or a plexus of veins, which latter, when 
 divided, will trammel the operation by the copious 
 hcemorrliage which all veins at this region of the neck 
 are prone to supply, owing to their direct communi¬ 
 cation with the main venous trunks of the heart; and 
 not unfrequently the inferior thyroid artery overlies 
 the trachea at the point d, Plate 9, when this thyroid 
 vessel arises directly from the arch of the aorta, be¬ 
 tween the roots of the innominate and left common 
 carotid, or when it springs from the innominate itself. 
 The inferior thyroid vein, sometimes single and some¬ 
 times double, overlies the trachea at the point d, Plate 
 9, when this vein opens into the left innominate 
 venous trunk, as this latter crosses over the root of 
 the main arteries springing from the aorta. 
 
 Laryngotomy is, anatomically considered, a far less 
 dangerous operation than tracheotomy, for the above- 
 named reasons; and the former should always he pre¬ 
 ferred when particular circumstances do not render 
 the latter operation absolutely necessary. In addition 
 to the fact, that the carotid arteries lie farther apart 
 from each other and from the median place—viz., the 
 crico-thyroid interval, which is the seat of laryngotomy 
 — than they do lower down on either side of the tra¬ 
 chea, it should also be noticed that the tracheal tube 
 being more moveable than the larynx, is hence more 
 liable to swerve from the cutting instrument, and im¬ 
 plicate the vessels. Tracheotomy on the infant is a 
 far more anxious proceeding than the same operation 
 performed on the adult; because the trachea in the 
 infant’s body lies more closely within the embrace of 
 the carotid arteries, is less in diameter, shorter, and 
 more mobile than in the adult body. 
 
 The episternal or interclavicular region is a locality 
 traversed by so many vitally important structures 
 
28 
 
 COMMENTARY ON PLATES 9 & 10. 
 
 gathered together in a very limited space, that all 
 operations which concern this region require more 
 steady caution and anatomical knowledge than most 
 surgeons are hold enough to test their possession of. 
 The reader will (on comparing Plates 9 and 10) be 
 enabled to take account of those structures which it 
 is necessary to divide in the operation required for 
 ligaturing the innominate artery, A, Plate 9, or either 
 of those main arterial vessels (the right common caro¬ 
 tid and subclavian) which spring from it; and he will 
 also observe that, although the same number and kind 
 of structures overlie the carotid and subclavian vessels, 
 A e, of the left side, Plate 10, still, that these vessels 
 themselves, in consequence of their separate condition, 
 will materially influence the like operation in respect 
 to them. An aneurism occurring in the first part of 
 the course of the right subclavian artery, at the local¬ 
 ity a, Plate 9, will lie so close to the origin of the 
 right common carotid as to require a ligature to be 
 
 passed around the innominate common trunk, thus 
 cutting off the flow of blood from both vessels ; where¬ 
 as an aneurism implicating either the left common ca¬ 
 rotid at the point A, or the left subclavian artery at 
 the point B, does not, of course, require that both ves¬ 
 sels should be included in the same ligature. There 
 seems to be, therefore, a greater probability of effectu¬ 
 ally treating an aneurism of the left brachio-cephalic 
 vessels by ligature than attaches to those of the right 
 side; for if space between collateral branches, and 
 also a lesser caliber of arterial trunk, be advantages, 
 allowing the ligature to hold more firmly, then the 
 vessels of the left side of the root of the neck manifest 
 these advantages more frequently than those of the 
 right, which spring from a common trunk. When¬ 
 ever, therefore, the “ peculiarity ” of a separate aortic 
 origin of the right carotid and subclavian arteries oc¬ 
 curs, it is to be regarded more as a happy advantage 
 than otherwise. 
 
 DESCRIPTION OF PLATES 9 & 10. 
 
 Plate 9. 
 
 A. Innominate artery, at its point of bifurcation. 
 
 B. Right internal jugular vein, joining the subclavian 
 
 vein. 
 
 C. Sternal end of the right clavicle. 
 
 D. Trachea. 
 
 E. Right sterno-thyroid muscle, cut. 
 
 F. Right sterno-hyoid muscle, cut. 
 
 G. Right sterno-mastoid muscle, cut. 
 
 a. Right vagus nerve, crossing the subclavian artery. 
 
 b. Anterior jugular vein, piercing the cervical fascia 
 
 to join the subclavian vein. 
 
 Plate 10. 
 
 A. Common carotid artery of left side. 
 
 B. Left subclavian artery, having b, the vagus nerve, 
 
 between it and A. 
 
 C. Lower end of left internal jugular vein, joining— 
 
 D. Left subclavian vein, which lies anterior to d, the 
 
 scalenus anticus muscle. 
 
 E. Anterior jugular vein, coursing beneath sterno- 
 
 mastoid muscle and over the fascia. 
 
 F. Deep cervical fascia, enclosing in its layers ///, 
 
 the several muscles. 
 
 G. Left sterno-mastoid muscle, cut across, and sepa¬ 
 
 rated from g g, its sternal and clavicular attach¬ 
 ments. 
 
 H. Left sterno-hyoid muscle, cut. 
 
 I. Left sterno-thyroid muscle, cut. 
 
 K. Right sterno-hyoid muscle. 
 
 L. Right sterno-mastoid muscle. 
 
 M. Trachea. 
 
 N. Projection of the thyroid cartilage. 
 
 O. Place of division of common carotid. 
 
 P. Place where the subclavian artery passes beneath 
 
 the clavicle. 
 
 Q. Sternal end of the left clavicle. 
 

COMMENTARY ON PLATES 11 & 12. 
 
 THE SURGICAL DISSECTION OF THE AXILLARY AND BRACHIAL REGIONS, DISPLAYING 
 THE RELATIVE ORDER OF THEIR CONTAINED PARTS. 
 
 All surgical regions have only artificial boundaries; 
 and these, as might he expected, do not express the 
 same meaning while viewed from more points than 
 one. These very boundaries themselves, being move- 
 able parts, must accordingly influence the relative po¬ 
 sition of the structures which they bound, and thus 
 either include within or exclude from the particular 
 region those structures wholly or in part which are 
 said to he proper to it. Of this kind of conventional 
 surgical boundary the moveable clavicle is an example; 
 and the bloodvessels which it overarches manifest con¬ 
 sequently neither termination nor origin except arti¬ 
 ficially from the fixed position which the bone, r, as¬ 
 sumes, as in Plate 11, or c* Plate 12. In this posi¬ 
 tion of the arm in relation to the trunk, the subclavi¬ 
 an artery, e, terminates at the point where, properly 
 speaking, it first takes its name; and from this point 
 to the posterior fold of the axilla formed by the latis- 
 simus dorsi muscle, o, Plate 11, N, Plate 12, and the 
 anterior fold formed by the great pectoral muscle, k, 
 Plate 11, i, Plate 12, the continuation of the subcla¬ 
 vian artery is named axillary. From the posterior 
 fold of the axilla, o p, Plate 11, to the bend of the el¬ 
 bow, the same main vessels take the name of brachial. 
 
 When the axillary space is cut into from the fore¬ 
 part through the great pectoral muscle, n K, Plate 11, 
 and beneath this through the lesser pectoral muscle, 
 L I, together with the fascial processes which invest 
 these muscles anteriorly and posteriorly, the main 
 bloodvessels and nerves which traverse this space are 
 displayed, holding in general that relative position 
 which they exhibit in Plate 11. These vessels, with 
 their accompanying nerves, will be seen continued 
 from those of the neck; and thus may be attained in 
 one view a comparative estimate of the cervical and 
 axillary regions, together with their line of union be¬ 
 
 neath the clavicle, c* Plate 12, r, Plate 11, which 
 serves to divide them surgically. 
 
 In the neck, the subclavian artery, b, Plate 11, is 
 seen to be separated from the subclavian vein, A, by 
 the breadth of the anterior scalenus muscle, D, as the 
 vessels arch over the first rib, f. In this region of 
 the course of the vessels, the brachial plexus of nerves, 
 0 , ranges along the outer border of the artery, b, and 
 is separated by the artery from the vein, A, as all three 
 structures pass beneath the clavicle, R, and the sub- 
 clavius muscle, E. From this latter point the vessels 
 and nerves take the name axillary, and in this axilla- 
 ry region the relative position of the nerves and ves¬ 
 sels to each other and to the adjacent organs is some¬ 
 what changed. For now in the axillary region the 
 vein, a, is in direct contact with the artery, b, on the 
 forepart and somewhat to the inner side of which the 
 vein lies; while the nerves, n, cl, Plate 12, embrace 
 the artery in a mesh or plexus of chords, from which 
 it is often difficult to extricate it, for the purpose of 
 ligaturing, in the dead subject, much less the living. 
 The axillary plexus of nerves well merits the name, 
 for I have not found it in any two bodies assuming a 
 similar order or arrangement. Perhaps the order in 
 which branches spring from the brachial plexus that 
 is most constantly met with is the one represented at 
 D, Plate 12, where we find, on the outer border of B, 
 the axillary artery, a nervous chord, cl, giving off a 
 thoracic branch to pass behind n, the lesser pectoral 
 muscle, while the main chord itself, d, soon divides 
 into two branches, one the musculo-cutaneous, e, which 
 pierces 6, the coraco-brachialis muscle, and the other 
 which forms one of the roots of the median nerve, h. 
 Following that order of the nerves as they are shown 
 in Plate 12, they may be enumerated from without 
 inwards as follows:—the external or musculo-cutane- 
 
 ( 29 ) 
 
30 
 
 COMMENTARY ON PLATES 11 & 12. 
 
 ous, e ; the two roots of the median, h ; the ulnar, f; 
 the musculo-spiral, g ; the circumflex, i; close to which 
 are seen the origins of the internal cutaneous, the 
 nerve of Wrisberg, some thoracic branches, and pos¬ 
 teriorly the subscapular nerve not seen in this view 
 of the parts. 
 
 The branches which come off from the axillary ar¬ 
 tery are very variable both as to number and place 
 of origin, but in general will be found certain branch¬ 
 es which answer to the names thoracic, subscapular, 
 and circumflex. These vessels, together with nume¬ 
 rous smaller arteries, appear to be confined to no fixed 
 point of origin, and on this account the place of elec¬ 
 tion for passing a ligature around the main axillary 
 artery sufficiently removed from collateral branches 
 must be always doubtful. The subscapular artery, Q, 
 Plate 12, is perhaps of all the other branches that one 
 which manifests the most permanent character; its 
 point of origin being in general opposite the interval 
 between the latissimus and sub-scapular muscles, but 
 I have seen it arise from all parts of the axillary main 
 trunk. If it be required to give, in a history of the 
 arteries, a full account of all the deviations from the 
 so-called normal type to which these lesser branches 
 here and elsewhere are subject, such account can 
 scarcely be said to be called for in this place. 
 
 The form of the axillary space is conical, while the 
 arm is abducted from the side, and while the osseous 
 and muscular structures remain entire. The apex of 
 the cone is formed at the root of the neck beneath the 
 clavicle, R, Plate 11, and the subclavious muscle, e, 
 and between the coracoid process, l*, of the scapula 
 and the serratus magnus muscle, as this lies upon the 
 thoracic side; at this apex the subclavian vessels, A b, 
 enter the axillary space. The base of the cone is be¬ 
 low, looking towards the arm, and is formed in front 
 by the pectoralis major, k n, and behind by the latis¬ 
 simus dorsi, o, and teres muscles, p, together with a 
 dense thick fascia; at this base the axillary vessels, a 
 b, pass out to the arm, and become the brachial ves¬ 
 sels, a* b *. The anterior side of the cone is formed by 
 the great pectoral muscle, h k, Plate 11, and the. les¬ 
 ser pectoral, L i. The inner side is formed by the 
 serratus magnus muscle, m, Plate 12, on the side of 
 
 the thorax; the external side is formed by the scapu¬ 
 lar and humeral insertion of the subscapular muscle, 
 the humerus and coraco-brachialis muscle; and the 
 posterior side is formed by the latissimus dorsi, the 
 teres and body of the subscapular muscle. 
 
 In this axillary region is contained a complicated 
 mass of bloodvessels, nerves, and lymphatic glands, 
 surrounded by a large quantity of loose cellular mem¬ 
 brane and adipose tissue. All the arterial branches 
 here found are given off from the axillary artery; and 
 the numerous veins which accompany these branches 
 enter the axillary vein. Nerves from other sources 
 besides those of the axillary plexus traverse the axil¬ 
 lary space; such nerves, for example, as those named 
 intercosto-humeral, seen lying on the latissimus ten¬ 
 don, o, Plate 11. The vein named cephalic, s, enters 
 the axillary space at that cellular interval occurring 
 between the clavicular origin of the deltoid muscle, G, 
 and the humeral attachment of the pectoralis major, 
 n, which interval marks the place of incision for tying 
 the axillary artery. 
 
 The general course of the main vessels through the 
 axillary space would be indicated with sufficient ac¬ 
 curacy by a line drawn from the middle of the clavi¬ 
 cle, R R, Plate 11, to the inner border of the biceps 
 muscle, n. In this direction of the axillary vessels, 
 the coracoid process, L*, from which arises the tendon 
 of the pectoralis minor muscle, l, is to be taken as a 
 sure guide to the place of the artery, b, which passes, 
 in general, close to the inner side of this bony process. 
 Even in the undissected body the coracoid process may 
 be felt as a fixed resisting point at that cellular inter¬ 
 val between the clavicular attachments of the deltoid 
 and great pectoral muscles. Whatever necessity shall 
 require a ligature to be placed around the axillary in 
 preference to the subclavian artery, must, of course, 
 be determined by the particular case; but certain it 
 is that the main artery, at the place b, a little above 
 the clavicle, will always be found freer and more iso¬ 
 lated from its accompanying nerves and vein, and also 
 more easily reached, owing to its comparatively super¬ 
 ficial situation, than when this vessel has become ax¬ 
 illary. The incision required to be made, in order to 
 reach the axillary artery, b, from the forepart, through 
 
COMMENTARY ON PLATES 11 & 12. 
 
 31 
 
 the skin, both pectoral muscles, and different layers 
 of fascia:, must be very deep, especially in muscular, 
 well-conditioned bodies; and even when the level of 
 the vessel is gained, it will be found much complicated 
 by its own branches, some of which overlie it, as also 
 by the plexuB of nerves, d, Plate 12, which embraces 
 it on all sides, while the large axillary vein, a, Plate 
 11, nearly conceals it in front. This vein in Plate 11 
 is drawn somewhat apart from the artery. 
 
 Sometimes the axillary artery is double, in conse¬ 
 quence of its high division into brachial branches. 
 But as this peculiarity of premature division never 
 takes place so high up as where the vessel, b, Plate 11, 
 overarches the first rib, F, this circumstance should 
 also have some weight with the operator. 
 
 When we view the relative position of the subcla¬ 
 vian vessels, A b, Plate 11, to the clavicle, r, we can 
 readily understand why a fracture of the middle of 
 this bone through that arch which it forms over the 
 vessels, should interfere with the free circulation of 
 the blood which these vessels supply to the arm. 
 When the clavicle is severed at its middle, the natu¬ 
 ral arch which the bone forms over the vessels and 
 nerves is lost, and the free moving broken ends of the 
 bone will be acted on in opposing directions by the 
 various muscles attached to its sternal and scapular 
 extremities. The outer fragment follows more freely 
 than the inner piece the action of the muscles; but, 
 most of all, the weight of the unsupported shoulder 
 and arm causes the displacement to which the outer 
 fragment is liable. The subclavius muscle, e, like 
 the pronator quadratus muscle of the forearm, serves 
 rather to further the displacement of the broken ends 
 of the bone than to hold them in situ. 
 
 If the head of the humerus be dislocated forwards 
 beneath L, Plate 11, the coracoid attachment of the 
 pectoralis minor muscle, it must press out of their 
 proper place and put tensely upon the stretch the ax¬ 
 illary vessels and plexus o# nerves. So large and re- 
 sistent a body as the head of the humerus displaced 
 forwards, and taking the natural position of these 
 vessels and nerves, will accordingly be attended with 
 other symptoms — such as obstructed circulation and 
 pain or partial paralysis, besides those physical signs 
 
 by which we distinguish the presence of it as a new 
 body in its abnormal situation. 
 
 When the main vessels and nerves pass from the 
 axillary space to the inner side of the arm, they be¬ 
 come comparatively superficial in this latter situation. 
 The inner border of the biceps muscle is taken as a 
 guide to the place of the brachial artery for the whole 
 extent of its course in the arm. In plate 11, the ar¬ 
 tery, b *, is seen in company with the median nerve, 
 which lies on its fore part, and with the veins called 
 comites winding round it and passing with it and the 
 nerve beneath the fascia which encases in a fold of 
 itself all three structures in a common sheath. Though 
 the axillary vein is in close contact with the axillary 
 artery and nerves, yet the basilic vein, d *, the most 
 considerable of those vessels which form the axillary 
 vein, is separated from the brachial artery by the fas¬ 
 cia. The basilic vein, however, overlies the brachial 
 artery to its inner side, and is most commonly attend¬ 
 ed by the internal cutaneous nerve, seen lying upon 
 it in Plate 11, as also by that other cutaneous branch 
 of the brachial plexus, named the nerve of Wrisberg. 
 If a longitudinal incision in the course of the brachial 
 artery be made (avoiding the basilic vein) through 
 the integument down to the fascia of the arm, and the 
 latter structure be slit open on the director, the artery 
 will be exposed, having the median nerve lying on its 
 outer side in the upper third of the arm, and passing 
 to its inner side towards the bend of the elbow, as at 
 5*, Plate 12. The superior and inferior profunda ar¬ 
 teries, seen springing above and below the point b, 
 Plate 12, are those vessels of most importance which 
 are given off from the brachial artery, but the situiv 
 tion of their origin is very various. The ulnar nerve, 
 /, lies close to the *inner side of the main arterial 
 trunk, as this latter leaves the axilla, but from this 
 place to the inner condyle, Q, behind which the ulnar 
 nerve passes into the forearm, the nerve and artery 
 become gradually more and more separated from each 
 other in their descent. The musculo-spiral nerve, y, 
 winds under the brachial artery at the middle of the 
 arm, but as this nerve passes deep between the short 
 and long heads of the triceps muscle, p, and behind 
 the humerus to gain the outer aspect of the limb, a 
 
32 
 
 COMMENTARY ON PLATES 11 & 12. 
 
 little care will suffice for avoiding the inclusion of it 
 in the ligature. 
 
 The brachial artery may be so effectually compress¬ 
 ed by the fingers on the tourniquet, against the hume¬ 
 rus in any part of its course through the arm, as to 
 stop pulsation at the wrist. 
 
 The tourniquet is a less manageable and not more 
 certain compressor of the arterial trunk than is the 
 hand of an intelligent assistant. At every region of 
 the course of an artery where the tourniquet is appli¬ 
 
 cable, a sufficient compression by the hand is also at¬ 
 tainable with greater ease to the patient; and the hand 
 may compress the vessel at certain regions where the 
 tourniquet would be of little or no use, or attended 
 with inconvenience, as in the locality of the subclavi¬ 
 an artery, passing over the first rib, or the femoral 
 artery, passing over the pubic bone, or the carotid 
 vessels in the neighbourhood of the trachea, as they 
 lie on the fore part of the cervical spinal column. 
 
 DESCRIPTION OP 
 
 Plate 11. 
 
 A. Subclavian vein, crossed by a branch of the brachi¬ 
 
 al plexus given to the subclavius muscle; a, the 
 axillary vein ; a*, the basilic vein, having the in¬ 
 ternal cutaneous nerve lying on it. 
 
 B. Subclavian artery, lying on f, the first rib; h, the 
 
 axillary artery ; b *, the brachial artery, accompa¬ 
 nied by the median nerve and vena? comites. 
 
 C. Brachial plexus of nerves; c*, the median nerve. 
 
 D. Anterior scalenus muscle. 
 
 E. Subclavius muscle. 
 
 F F. First rib. 
 
 G. Clavicular attachment of the deltoid muscle. 
 
 H. Humeral attachment of the great pectoral muscle. 
 
 I. A layer of fascia, encasing the lesser pectoral muscle. 
 
 K. Thoracic half of the great pectoral muscle. 
 
 L. Coracoid attachment of the lesser pectoral muscle. 
 L*. Coracoid process of the scapula. 
 
 M. Coraco-brachialis muscle. 
 
 N. Biceps muscle. 
 
 O. Tendon of the latissimus dorsi muscle, crossed by 
 
 the intercosto-humeral nerves. 
 
 P. Teres major muscle, on which and o is seen lying 
 
 Wrisberg’s nerve. 
 
 Q. Brachial fascia, investing the triceps muscle. 
 
 R R. Scapular and sternal ends of the clavicle. 
 
 S. Cephalic vein, coursing between the deltoid and 
 pectoral muscles, to enter at their cellular inter- 
 
 PLATES 11 & 12. 
 
 val into the axillary vein beneath e, the subcla¬ 
 vius muscle. 
 
 Plate 12. 
 
 A. Axillary vein, cut and tied; a, the basilic vein, cut. 
 
 B. Axillary artery; b, brachial artery, in the upper 
 
 part of its course, having 7t, the median nerve, 
 lying rather to its outer side; b *, the artery in 
 the lower part of its course, with the median 
 nerve to its inner side. 
 
 C. Subclavius muscle. 
 
 C*. Clavicle. 
 
 D. Axillary plexus of nerves, of which cl is a branch on 
 
 the coracoid border of the axillary artery; e, the 
 musculo-cutaneous nerve, piercing the coraco-bra¬ 
 chialis muscle; f the ulnar nerve; (j, musculo-spiral 
 nerve; h , the median nerve; i, the circumflex nerve. 
 
 E. Humeral part of the great pectoral muscle. 
 
 F. Biceps muscle. 
 
 G. Coraco-brachialis muscle. 
 
 II. Thoracic half of the lesser pectoral muscle. 
 
 I. Thoracic half of the greater pectoral muscle. 
 
 K. Coracoid attachment of the lesser -pectoral muscle. 
 K*. Coracoid process of the scapula. 
 
 L. Lymphatic glands. * 
 
 M. Serratus magnus muscle. 
 
 N. Latissimus dorsi muscle. 
 
 O. Teres major muscle. 
 
 P. Long head of triceps muscle. 
 
 Q. Inner condyle of humerus. 
 
rv- 
 
COMMENTARY ON PLATES 13 & 14. 
 
 THE SURGICAL FORM OF THE MALE AND FEMALE AXILLiE COMPARED. 
 
 Certain characteristic features mark those differen¬ 
 ces which are to be found in all corresponding regions 
 of both sexes. Though the male and female bodies, 
 in all their regions, are anatomically homologous or 
 similar at basis, yet the constituent and corresponding 
 organs of each are gently diversified by the plus or 
 minus condition, the more or the less, which the devel¬ 
 opment of certain organs exhibits; and this diversity, 
 viewed in the aggregate, constitutes the sexual diffe¬ 
 rence. That diversity which defines the sexual char¬ 
 acter of beings of the same species, is but a link in 
 that extended chain of differential gradation which 
 marks its progress through the whole animal kingdom. 
 The female breast is a plus glandular organ, situated, 
 pendent, in that very position where, in a male body, 
 the unevolved mamma is still rudimentarily mani¬ 
 fested. 
 
 The male and female axillae contain the same num¬ 
 ber and species of organs; and the difference by which 
 the external configuration of both are marked mainly 
 arises from the presence of the enlarged mammary 
 gland, which, in the female, Plate 14, masks the natural 
 outline of the pectoral muscle, E, whose axillary border 
 is overhung by the gland; and thus this region derives 
 its peculiarity of form, contrasted with that of the 
 male subject. 
 
 When the dissected axilla is viewed from below, 
 the arm being raised, and extended from the side, its 
 contained parts, laid deeply in their conical recess, are 
 sufficiently exposed, at the same time that the proper 
 boundaries of the axillary cavity are maintained. In 
 this point of view from which the axillary vessels are 
 now seen, their relative position, in respect to the 
 thorax and the arm, are best displayed. The thick¬ 
 ness of that fleshy anterior boundary formed by both 
 pectoral muscles, e f, Plate 13, will be marked as con¬ 
 siderable; and the depth at which these muscles conceal 
 5 
 
 the vessels, a b, in the front aspect of the thoracico-hu- 
 meral interval, will prepare the surgeon for the dif¬ 
 ficulties he is to encounter when proceeding to ligature 
 the axillary artery at the incision made through the 
 anterior or pectoral wall of this axillary space. 
 
 The bloodvessels of the axilla follow the motions 
 of the arm; and according to the position assumed by 
 the arm, these vessels describe various curves, and lie 
 more or less removed from the side of the thorax. 
 While the arm hangs close to the side, the axillary 
 space does not (properly speaking) exist; and in this 
 position, the axillary vessels and nerves make a gen¬ 
 eral curve from the clavicle at the point k, Plate 14, 
 to the inner side of the arm, the concavity of the curve 
 being turned towards the thoracic side. But when 
 the arm is abducted from the side, and elevated, the 
 vessels which are destined to supply the limb follow 
 it, and in this position they take, in reality, a serpen¬ 
 tine course; the first curve of which is described, in 
 reference to the thorax, from the point k to the head 
 of the humerus; and the next is that bend which the 
 head of the humerus, projecting into the axilla in the 
 elevated position of the member, forces them to make 
 around itself in their passage to the inner side of the 
 arm. The vessels may be readily compressed against 
 the upper third of the humerus by the finger, passed 
 into the axilla, and still more effectually if the arm 
 be raised, as this motion will rotate the tuberous head 
 of the humerus downwards against them. 
 
 The vessels and nerves of lhe axilla are bound to¬ 
 gether by a fibrous sheath derived from the membrane 
 called costo-coracoid; and the base or humeral outlet 
 of this axillary space, described by the muscles c, k, e, 
 g, Plate 13, is closed by a part of the fascial membrane, 
 g, extended across from the pectoral muscle, e, to the 
 latissimus dorsi tendon, K. In the natural position of 
 the vessels at that region of their course represented in 
 
 ( 33 ) 
 
 

 I 
 
 34 COMMENTARY 0 
 
 the Plates, the vein A overlies the artery b, and also 
 conceals most of the principal nerves. In order to 
 show some of these nerves, in contact with the artery 
 itself, the axillary vein is drawn a little apart from 
 them. 
 
 The axillary space gives lodgment to numerous lym¬ 
 phatic glands, which are either directly suspended 
 from the main artery, or from its principal branches, 
 by smaller branches, destined to supply them. These 
 glands are more numerous in the female axilla, Plate 
 14, than in the male, Plate 13, and while they seem 
 to be, as it were, indiscriminately scattered here and 
 there through this region, we observe the greater 
 number of them to be gathered together along the ax¬ 
 illary side of the great pectoral muscle; at which situ¬ 
 ation, h, in the diseased condition of the female breast, 
 they will be felt to form hard, nodulated masses, which 
 frequently extend as for up through the axillary space 
 as the root of the neck, involving the glands of this 
 latter region also in the disease. 
 
 The contractile motions of the pectoral muscle, E, 
 of the male body, Plate 13, are during life readily dis¬ 
 tinguishable ; and that boundary which it furnishes 
 to the axillary region is well defined; but in the fe¬ 
 male form, Plate 14, the general contour of the mus¬ 
 cle E, w'hile in motion, is concealed by the hemispher¬ 
 ical mammary gland, F, which, surrounded by its pro¬ 
 per capsule, lies loosely pendent from the fore part of 
 the muscle, to which, iu the healthy state of the organ, 
 it is connected only by free-moving bonds of lax cellu¬ 
 lar membrane. The motions of the shoulder upon the 
 trunk do not influence the position of the female 
 mammary gland, for the pectoral muscle acts freely 
 beneath it; but when a scirrhus or other malignant 
 growth involves the mammary organ, and this latter 
 contracts, by the morbid mass, a close adhesion to the 
 muscle, then these motions are performed with pain 
 and difficulty. 
 
 When it is required to excise the diseased female 
 breast, (supposing the disease to be confined to the 
 structure of the gland itself,) the operation may be 
 performed confidently and without difficulty, in so far 
 as the seat of operation does not involve the immedi- 
 
 f PLATES 13 & 14. 
 
 ate presence of any important nerves or bloodvessels. 
 But when the disease has extended to the axillary 
 glands, the extirpation of these (as they lie in such 
 close proximity to the great axillary vessels and their 
 principal branches) requires cautious dissection. It 
 has more than once happened to eminent surgeons, 
 that in searching for and dissecting out these diseased 
 axillary glands, rr, h, Plate 14, the main artery has 
 been wounded. 
 
 As the coracoid process points to the situation of the 
 artery in the axilla, so the coraco-brachialis muscle, c, 
 marks the exact locality of the vessel as it emerges 
 from this region; the artery ranges along the inner 
 margin of both the process and the muscle, which 
 latter, in fleshy bodies, sometimes overhangs and con¬ 
 ceals it. When the vessel has passed the insertion of 
 the coraco-brachialis, it becomes situated at the inner 
 side of the biceps, which also partly overlaps it, as it 
 now lies on the forepart of the brachialis anticus. 
 As the general course of the artery, from where it 
 leaves the axilla to the bend of the elbow, is one of 
 winding from the inner side to the forepart of the limb, 
 so should compression of tile vessel, when necessary, 
 
 be directed in reference to the bone accordingly_viz., 
 
 in the upper or axillary region of the arm, from with¬ 
 in outwards, and in the lower part of the arm, from 
 before backwards. 
 
 All incised, lacerated, or contused wounds of the 
 arm and shoulder, happening by pike, bayonet, sabre, 
 bullet, mace, or arrow, on the outer aspect of the limb, 
 are (provided the weapon has not broken the bones) 
 less likely to implicate the great arteries, veins, and 
 nerves. These instruments encountering the inner 
 or axillary aspect of the member, will of course be 
 more likely to involve the vessels and nerves in the 
 wound. In severe compound fractures of the hume¬ 
 rus occurring from force applied at the external side 
 of the limb, the brachial vessels and nerves have been 
 occasionally lacerated by the sharp jagged ends of the 
 broken bone,—a circumstance which calls for immedi¬ 
 ate amputation of the member. 
 
 The axilla becomes very frequently the seat of mor¬ 
 bid growths, which, when they happen to be situated 
 
COMMENTARY ON PLATES 13 & 14. 
 
 35 
 
 beneath the dense axillary fascia, and have attained 
 to a large size, will press upon the vessels and nerves 
 of this region, and cause very great inconvenience. 
 Adipose and other kind of tumours occurring in the 
 axilla beneath the fascia, and in close contact with 
 the main vessels, have been known to obstruct these 
 vessels to such a degree, as to require the collateral 
 or anastomatic circulation to be set up for the support 
 of the limb. When abscesses take place in the axilla, 
 beneath the fascia, it is this structure which will pre¬ 
 vent the matter from pointing; and it is required, 
 therefore, to lay this fascia freely open by a timely 
 incision. The accompanying Plates will indicate the 
 proper direction in which such incision should be 
 made, so as to avoid the vessels A, b. When the limb 
 is abducted from the side, the main vessels and nerves 
 take their position parallel with the axis of the arm. 
 The axillary vessels and nerves being thus liable to 
 pressure from the presence of large tumours happen¬ 
 ing in their neighbourhood, will suggest to the prac¬ 
 titioner the necessity for fashioning of a proper form 
 and size all apparatus, which in fracture or disloca¬ 
 tion of the shoulder-bones shall be required to bear 
 forcibly against the axillary region. While we know 
 that the locality of the main vessels and nerves is that 
 very situation upon which a pad or fulcrum presses, 
 when placed in the axilla for securing the reduction 
 of fractures of the clavicle, the neck of the humerus, 
 or scapula, so should this member of the fracture ap¬ 
 paratus be adapted, as well to obviate this pressure 
 upon these structures, as to give the needful support 
 to the limb in reference to the clavicle, &c. The ha¬ 
 bitual use, for weeks or more, of a hard, resisting ful¬ 
 crum in the axilla, must act in some degree like the 
 pad of a tourniquet, arresting the flow of a vigorous 
 circulation, which is so essential to the speedy union 
 of all lesions of bones. And it should never be lost 
 sight of, that all grievously coercive apparatus, which 
 incommode the suffering patient, under treatment, are 
 those very instruments which impede the curative 
 process of Nature herself. 
 
 The anatomical mechanism of the human body, con¬ 
 sidered as a whole, or divisible into regions, forms a 
 
 study so closely bearing upon practice, that the sur¬ 
 geon, if he be not also a mechanician, and fully capa¬ 
 ble of making his anatomical knowledge suit with the 
 common principles of mechanics, while devising meth¬ 
 ods for furthering the efforts of Nature curatively, 
 may be said to have studied anatomy to little or no 
 purpose. The shoulder apparatus, when studied 
 through the principle of mechanics, derives an interest 
 of practical import which all the laboured description 
 of the schools could never supply to it, except when 
 illustrating this principle. 
 
 The disposal of the muscular around the osseous 
 elements of the shoulder apparatus, forms a study for 
 the surgeon as well in the abnormal condition of these 
 parts, as in their normal arrangement; for in practice 
 he discovers that that very mechanical principle upon 
 which both orders of structures (the osseous and mus¬ 
 cular) are grouped together for normal articular action, 
 becomes, when the parts are deranged by fracture or, 
 other accident, the chief cause whereby rearrangement 
 is prevented, and the process of reunion obstructed. 
 When a fracture happens in the shaft of the humerus, 
 above or below the insertions of the pectoral and la- 
 tissimus dorsi muscles, these are the very agents which 
 when the bone possessed its integrity rendered it func¬ 
 tionally fitting, and which, now that the bone is sev¬ 
 ered, produce the displacement of the lower fragment 
 from the upper one. To counteract this source of de¬ 
 rangement, the surgeon becomes the mechanician, and 
 now, for the first time, he recognises the necessity of 
 the study of topographical anatomy. 
 
 When a bone is fractured, or dislocated to a false 
 position and retained there by the muscular force, the 
 surgeon counteracts this force upon mechanical prin¬ 
 ciple ; but while he puts this principle in operation, 
 he also acknowledges to the paramount necessity of 
 ministering to the ease of Nature as much as shall be 
 consistent with the effectual use of the remedial agent; 
 and in the present state of knowledge, it is owned, 
 that that apparatus is most efficient which simply serves 
 both objects, the one no less than the other. And, 
 assuming this to be the principle which should always 
 guide us in our treatment of fractures and dislocations, 
 
36 
 
 COMMENTARY ON PLATES 13 & 14. 
 
 I shall not hesitate to say, that the pad acting as a 
 fulcrum in the axilla, or the perineal band bearing as 
 a counterextending force upon the groin (the suffering 
 body of the patient being, in both instances, subjected 
 for weeks together to the grievous pressure and irrita¬ 
 tion of these members of the apparatus), do not serve 
 both objects, and only one incompletely; I say incom¬ 
 pletely, for out of every six fractures of either clavi¬ 
 cle or thigh-bone, I believe that, as the result of our 
 
 treatment by the present forms of mechanical contri¬ 
 vances, there would not be found three cases of coap¬ 
 tation of the broken ends of the bone so complete 
 as to do credit to the surgeon. The most pliant and 
 portable of all forms of apparatus which constitute 
 the hospital armamentaria, is the judgment; and 
 this cannot give its approval to any plan of in¬ 
 strument which takes effect only at the expense of 
 the patient. 
 
 DESCRIPTION OE PLATES 13 & 14. 
 
 Plate 13. 
 
 A. Axillary vein, drawn apart from the artery, to 
 
 show the nerves lying between both vessels. On 
 the bicipital border of the vein is seen the inter¬ 
 nal cutaneous nerve; on the tricipital border is 
 the nerve of Wrisberg, communicating with some 
 of the intercosto-humeral nerves; a, the common 
 trunk of the vence comites, entering the axillary 
 vein. 
 
 B. Axillary artery, crossed by one root of the median 
 
 nerve; b, basilic vein, forming, with a, the axil¬ 
 lary vein, A. 
 
 C. Coraco-bracliialis muscle. 
 
 D. Coracoid head of the biceps muscle. 
 
 E. Pectoralis major muscle. 
 
 F. Pectoralis minor muscle. 
 
 G. Serratus magnus muscle, covered by g, the axilla¬ 
 
 ry fascia, and perforated, at regular intervals, by 
 the nervous branches called intercosto-humeral. 
 
 H. Conglobate gland, crossed by the nerve called “ ex¬ 
 
 ternal respiratory ” of Bell, distributed to the ser¬ 
 ratus magnus muscle. This nerve descends from 
 the cervical plexus. 
 
 I. Subscapular artery. 
 
 K. Tendon of latissimus dorsi muscle. 
 
 L. Teres major muscle. 
 
 Plate 14. 
 
 A. Axillary vein. 
 
 B. Axillary artery. 
 
 C. Coraco-brachialis muscle. 
 
 D. Short head of the biceps muscle. 
 
 E. Pectoralis major muscle. 
 
 F. Mammary gland, seen in section. 
 
 G. Serratus magnus muscle. 
 
 H. Lymphatic gland; li 7i, other glands of the lym¬ 
 
 phatic class. 
 
 I. Subscapular artery, crossed by the intercosto-hume¬ 
 
 ral nerves and descending parallel to the exter¬ 
 nal respiratory nerve. Beneath the artery is 
 seen a subscapular branch of the brachial plex¬ 
 us, given to the latissimus dorsi muscle. 
 
 K. Locality of the subclavian artery. 
 
 L. Locality of the brachial artery at the bend of the 
 
 elbow. 
 

COMMENTARY ON PLATES 15 & 16. 
 
 THE SURGICAL DISSECTION OF THE BEND OF THE ELBOW AND THE FOREARM, SHOW¬ 
 ING THE RELATIVE POSITION OF THE ARTERIES, VEINS, NERVES, &c. 
 
 The farther the surgical region happens to be re¬ 
 moved from the centre of the body, the less likely is it 
 that all accidents or operations which involve such 
 regions will concern the life immediately. The limbs 
 undergo all kinds of mutilation, both by accident and 
 intention, and yet the patient survives; but when the 
 like happens at any region of the trunk of the body, 
 the life will be directly and seriously threatened. It 
 seems, therefore, that in the same degree as the living 
 principle diverges from the body’s centre into the out¬ 
 standing members, in that degree is the life weakened 
 in intensity; and just as, according to physical laws, 
 the ray of light becomes less and less intense by the 
 square of the distance from the central source, so the 
 vital ray, or vis, loses momentum in the same ratio as 
 it diverges from the common central line to the peri¬ 
 phery. 
 
 The relative anatomy of every surgical region be¬ 
 comes a study of more or less interest to the surgeon, 
 according to the degree of importance attaching to the 
 organs contained, or according to the frequency of 
 such accidents as are liable to occur in each. The 
 bend of the elbow is a region of anatomical importance, 
 owing to the fact of its giving passage to c, Plate 15, 
 the main artery of the limb, and also because in it are 
 located the veins i>, b, e, f, which are frequently the 
 subject of operation. The anatomy of this region be¬ 
 comes, therefore, important; forasmuch as the opera¬ 
 tion which is intended to concern the veins alone, may 
 also, by accident, include the main arterial vessel 
 which they overlie. The nerves, which are seen to 
 accompany the veins superficially, as well as that 
 which accompanies the more deeply-situated artery, 
 are, for the same reason, required to be known. 
 
 The course of the brachial artery along the inner 
 border of the biceps muscle is comparatively super¬ 
 ficial, from the point where it leaves the axilla to the 
 
 bend of the elbow. In the whole of this course it is 
 covered by the fascia of the arm, which serves to iso¬ 
 late it from the superficial basilic vein, b, and the in¬ 
 ternal cutaneous nerve, both of which nevertheless 
 overlie the artery. The median nerve, cl, Plate 15, 
 accompanies the artery in its proper sheath, which is 
 a duplication of the common fascia; and in this sheath 
 are also situated the vence comites, making frequent 
 loops around the artery. The median nerve itself, d, 
 Plate 16, takes a direct course down the arm; and the 
 different relative positions which this nerve holds in 
 reference to the artery, c, at the upper end, the middle, 
 and the lower end of the arm, occur mainly in conse¬ 
 quence of the undulating character of the vessel itself. 
 
 When it is required to ligature the artery in the 
 middle of the arm, the median nerve will be found, in 
 general, at its outer side, between it and the biceps; 
 but as the course of the artery is from the inner side 
 of the biceps to the middle of the bend of the elbow, 
 so we find it passing under the nerve to gain this 
 locality, c, Plate 16, where the median nerve, d, then 
 becomes situated at the inner side of the vessel. The 
 median nerve, thus found to be differently situated in 
 reference to the brachial artery, at the upper, the 
 middle, and the lower part of the arm, is (with these 
 facts always held in memory) taken as the guide to 
 that vessel. An incision made of sufficient length (an 
 inch and a half, more or less) over the course of the ar¬ 
 tery, and to the outer side of the basilic vein, B, Plate 
 16, will divide the skin, subcutaneous adipose mem¬ 
 brane, which varies much in thickness in several in¬ 
 dividuals, and will next expose the common fascial 
 envelope of the arm. When this fascia is opened, by 
 dividing it on the director, the artery becomes exposed; 
 the median nerve is then to be separated from the side 
 of the vessel by the probe or director, and, with the 
 precaution of not including the venm comites, the liga- 
 
 ( 07 ) 
 
 * 
 
38 
 
 COMMENTARY ON PLATES 15 & 16. 
 
 ture may now be passed around tbe vessel. In the 
 lower third of the arm it is not likely that the opera¬ 
 tor will encounter the ulnar nerve, and mistake it for 
 the median, since the former, '/, Plate 16, is consider¬ 
 ably removed from the vessel. If the incision be made 
 precisely in the usual course of the brachial artery, 
 the ulnar nerve will not show itself. It will be well, 
 however, to bear in mind the possible occurrence of 
 some of those anomalies to that normal relative posi¬ 
 tion of the artery, the median, and the ulnar nerve, 
 which the accompanying Plates represent. 
 
 The median nerve, D, Plate 16, is sometimes found 
 to lie beneath the artery in the middle and lower third 
 of the arm. At other times it is found far removed 
 to the inner side of the usual position of the vessel, 
 and lying in close contact with the ulnar nerve, d. 
 Or the brachial artery may take this latter position, 
 while the median nerve stands alone at the position 
 of D, Plate 16. Or both the main artery and the me¬ 
 dian nerve may course much to the inner side of the 
 biceps muscle, A, Plate 16, while in the usual situation 
 of the nerve and vessel there is only to be found a 
 small arterial branch (the radial), which springs from 
 the brachial, high up in the arm. Or the nerve and 
 vessel may be lying concealed beneath a slip of the 
 brachialis anticus muscle, E, Plate 16, in which case 
 no appearance of them will be at all manifested 
 through the usual place of incision made for the liga¬ 
 ture of the brachial vessel. Or, lastly, there may be 
 found more arteries than the single main brachial ap¬ 
 pearing at this place in the arm, and such condition 
 ot a plurality of vessels occurs in consequence of a 
 high division of the brachial artery. Each of these 
 variations from the normal type is more or less fre¬ 
 quent ; and though it certainly is of practical import 
 to bear them in mind, still, as we never can foretell 
 their occurrence by a superficial examination of the 
 limb, or pronounce them to be present till we actually 
 encounter them in operation, it is only when we find 
 them that we commence to reason upon the lacts; but 
 even at this crisis the knowledge of their anatomy 
 may prevent a confusion of ideas. 
 
 That generalization of the facts of such anomalies 
 as are liable to occur to the normal character of the 
 
 brachial artery, represented in Plates 15 and 16, which 
 appears to me as being most inclusive of all their vari¬ 
 ous conditions, is this—viz., that the point of division 
 into radial, ulnar, and interosseous, which f, Plate 16, 
 usually marks, may take place at any part of the 
 member between the bend of the elbow and the cora¬ 
 coid process in the axillary space. 
 
 At the bend of the elbow, the brachial artery usual¬ 
 ly occupies the middle point between e, the inner con¬ 
 dyle of the humerus and the external margin of the 
 supinator radii longus muscle, G. The structures 
 which overlie the arterial vessel, c, Plate 16, at this 
 locality, numbering them from its own depth to the 
 cutaneous surface, are these—viz., some adipose cel¬ 
 lular membrane envelopes the vessel, as it lies on E, 
 the brachialis anticus muscle, and between the two 
 accompanying veins; at the inner side of the artery, 
 but separated from it by a. small interval occupied by 
 one of the veins, is situated the median nerve d, Plate 
 15. Above all three structures is stretched that dense 
 fibrous band of the fascia, h, Plate 16, which becomes 
 incorporated with the common fascial covering of the 
 forearm. Over this fascial process lies the median 
 basilic vein, f b, Plate 15, accompanying which are 
 seen some branches of the internal cutaneous nerve. 
 The subcutaneous adipose tissue and common integu¬ 
 ment cover these latter. If it be required to ligature 
 the artery at this locality, an incision two inches and 
 a half in length, made along the course of the vessel, 
 and avoiding the superficial veins, will expose the fas¬ 
 cia ; and this being next divided on the director, the 
 artery will be exposed resting on the brachialis anti¬ 
 cus, and between the biceps tendon and pronator teres 
 muscle. As this latter muscle differs in width in seve¬ 
 ral individuals, sometimes lying in close contact witli 
 the artery, and at other times leaving a considerable 
 interval between the vessel and itself, its outer mar¬ 
 gin is not, therefore, to be taken as a sure guide to 
 the artery. The inner border of the biceps indicates 
 much more generally the situation of the vessel. 
 
 The bend of the elbow being that locality where the 
 operation of phlebotomy is generally performed, it is 
 therefore required to take exact account of the struc¬ 
 tures which occupy this region, and more especially 
 
COMMENTARY ON PLATES 15 & 16. 
 
 39 
 
 the relation which the superficial veins hold to the 
 deeper seated artery. In Plate 15, the artery, c, is 
 shown in its situation beneath the fascial aponeurosis, 
 which comes off from the tendon of the biceps, a por¬ 
 tion of which has been cut away; and the venous vessel, 
 F B, which usually occupies the track of the artery, is 
 pushed a little to the inner side. While opening any 
 part of the vessel, p b, which overlies the artery, it is 
 necessary to proceed with caution, as well because of 
 the fact that between the artery, 0 , and the vein, p b, 
 the fascia alone intervenes, as also because the ulnar 
 artery is given off rather frequently from the main 
 vessel at this situation, and passes superficial to the 
 fascia and flexors of the forearm, to gain its usual po¬ 
 sition at K, Plate 15. I have met with a well marked 
 example of this occurrence in the living subject. 
 
 The cephalic vein, D, is accompanied by the exter¬ 
 nal cutaneous nerve, which branches over the fascia 
 on the outer border of the forearm. The basilic vein, 
 B, is accompanied by the internal cutaneous nerve, 
 which branches in a similar way over the fascia of 
 the inner and fore part of the forearm. The numerous 
 branches of both these nerves interlace with the super¬ 
 ficial veins, and are liable to be cut when these veins 
 are being punctured. Though the median basilic, r, 
 and the basilic vein, B, are those generally chosen in 
 the performance of the operation of bleeding, it will 
 be seen, in Plate 15, that their contiguity to the arte¬ 
 ry necessarily demands more care and precision in that 
 operation executed upon them, than if n, the cephalic 
 vein, far removed as it is from the course of the artery, 
 were the seat of phlebotomy. 
 
 As it is required, in order to distend the superficial 
 veins, D, b, f, that a band should be passed around the 
 limb at some locality between them and the heart, so 
 that they may yield a free flow of blood on puncture, 
 a moderate pressure will be all that is needful for that 
 end. It is a fact worthy of notice, that the excessive 
 pressure of the ligaturing band around the limb at A e, 
 Plate 15, will produce the same effect upon the veins 
 near f, as if the pressure were defective, for in the for¬ 
 mer case the ligature will obstruct the flow of blood 
 through the artery; and the vein, F, will hence be un¬ 
 distended by the recurrent blood, just as when, in the 
 
 latter case, the ligature, making too feeble a pressure 
 on the vein, b, will not obstruct its current in that 
 degree necessary to distend the vessel, f. 
 
 Whichever be the vein chosen for phlebotomy at 
 the bend of the elbow, it will be seen, from an exam¬ 
 ination of Plates 15 and 16, that the opening may be 
 made with most advantage according to the longitudi¬ 
 nal axis of the vessel; for the vessel while being cut 
 open in this direction, is less likely to swerve from the 
 point of the lancet than if it were to be incised across, 
 which latter mode is also far more liable to implicate 
 the artery. Besides, as the nerves course along the 
 veins from above downwards — making, with each 
 other, and with the vessels, but very acute angles — 
 all incisions made longitudinally in these vessels, will 
 not be so likely to divide any of these nerves as when 
 the instrument is directed to cut crossways. 
 
 The brachial artery usually divides, at the bend of 
 the elbow, into the radial, the ulnar, and the interos¬ 
 seous branches. The point f, Plate 16, is the com¬ 
 mon place of division, and this will be seen in the Plate 
 to be somewhat below the level of the inner condyle, 
 e. From that place, where the radial and ulnar arte¬ 
 ries spring, these vessels traverse the forearm, in gene¬ 
 ral under cover of the muscles and fascia, but occasion¬ 
 ally superficial to both these structures. The radial 
 artery, f n, Plate 16, takes a comparatively superficial 
 course along the radial border of the forearm, and is 
 accompanied, for the upper two-thirds of its length, by 
 the radial branch of the musculo-spiral nerve, seen in 
 Plate 16, at the outer side of the vessel. The supinator 
 radii longus muscle in general overlaps, with its inner 
 border, both the radial artery and nerve. At the situ¬ 
 ation of the radial pulse, i, Plate 15, the artery is not 
 accompanied by the nerve, for this latter will be seen, 
 in plate 16, to pass outward, under the tendon of the 
 supinator muscle, to the integuments. 
 
 The ulnar artery, whose origin is seen near F, Plate 
 16, passes deeply beneath the superficial flexor mus¬ 
 cles, l m k, and the pronator teres, i, and first emerges 
 from under cover of these at the point o, from which 
 point to s, Plate 16, the artery may be felt, in the liv¬ 
 ing body, obscurely beating as the ulnar pulse. On 
 the inner border of the ulnar artery, and in close con- 
 
40 
 
 COMMENTARY ON PLATES 15 & 16. 
 
 nexion with it, the ulnar nerve may he seen looped 
 round by small branches of the vessel. 
 
 The radial and ulnar arteries may be exposed and 
 ligatured in any part of their course; but of the two, 
 the radial vessel can be reached with greater facility, 
 owing to its comparatively superficial situation. The 
 inner border of the supinator muscle, G, Plate 16, is 
 the guide to the radial artery; and the outer margin 
 of the flexor carpi ulnaris muscle, k, Plate 16, indi¬ 
 cates the locality of the ulnar artery. Both arteries, 
 i, k, Plate 15, at the wrist, lie beneath the fascia. If 
 either of these vessels require a ligature in this region 
 of the arm, the operation may be performed with lit¬ 
 tle trouble, as a simple incision over the track of the 
 vessels, through the skin and the fascia, will readily 
 expose each. 
 
 Whenever circumstances may call for placing a ligar 
 ture on the ulnar artery, as it lies between the super¬ 
 ficial and deep flexor muscles, in the region of i l m, 
 Plate 16, the course of the vessel may be indicated by 
 
 a line drawn from a central point of the forearm, an 
 inch or so below the level of the inner condyle—viz., 
 the point f, and carried to the pisiform bone, T. The 
 line of incision will divide obliquely the superficial flex¬ 
 ors ; and, on a full exposure of the vessel in this situa¬ 
 tion, the median nerve will be seen to cross the artery 
 at an acute angle, in order to gain the mid-place in the 
 wrist at Q. The ulnar nerve, d, Plate 16, passing be¬ 
 hind the inner condyle, e, does not come into connex¬ 
 ion with the ulnar artery until both arrive at the place 
 o. It will, however, be considered an awkward pro¬ 
 ceeding to subject to transverse section so large a mass 
 of muscles as the superficial flexors of the forearm, 
 when the vessel may be more readily reached else¬ 
 where, and perhaps with equal advantage as to the 
 locality of the ligature. 
 
 When either the radial or ulnar arteries happen to 
 be completely divided in a wound, both ends of the 
 vessel will bleed alike, in consequence of the free 
 anastomosis of both arteries in the hand. 
 
 DESCRIPTION 0E 
 
 Plate 15. 
 
 A. Fascia covering the biceps muscle. 
 
 B. Basilic vein, with the internal cutaneous nerve. 
 
 C. Brachial artery, with the vence comites. 
 
 D. Cephalic vein, with the external cutaneous nerve; 
 
 d , the median nerve. 
 
 E. A communicating vein, joining the vente comites. 
 
 F. Median basilic vein. 
 
 G. Lymphatic gland. 
 
 H. Radial artery at its middle. 
 
 I. Radial artery of the pulse. 
 
 K. Ulnar artery, with ulnar nerve. 
 
 L. Palmaris brevis muscle. 
 
 Plate 16. 
 
 A. Biceps muscle. 
 
 B. Basilic vein, cut. 
 
 C. Brachial artery. 
 
 D. Median nerve; d, the ulnar nerve. 
 
 PLATES 15 & 16. 
 
 E. Brachialis anticus muscle; e, the internal condyle. 
 
 F. Origin of radial artery. 
 
 G. Supinator radii longus muscle. 
 
 H. Aponeurosis of the tendon of the biceps muscle. 
 
 I. Pronator teres muscle. 
 
 K. Flexor carpi ulnaris muscle. 
 
 L. Flexor carpi radialis muscle. 
 
 M. Palmaris longus muscle. 
 
 N. Radial artery, at its middle, with the radial nerve 
 
 on its outer side. 
 
 O. Flexor digitorum sublimis. 
 
 P. Flexor pollicis longus. 
 
 Q. Median nerve. 
 
 R. Lower end of radial artery. 
 
 S. Lower end of ulnar artery, in company with the 
 
 ulnar nerve. 
 
 T. Pisiform bone. 
 
 U. Extensor metacarpi pollicis. 
 


COMMENTARY ON PLATES 17, 18, & 19. 
 
 THE SURGICAL DISSECTION 
 
 A member of such vast importance as the human 
 nand necessarily claims a high place in regard to sur¬ 
 gery. The hand is typical of the mind. It is the 
 material symbol of the immaterial spirit. It is the 
 prime agent of the will; and it is that instrument by 
 which the human intellect manifests its presence in 
 creation. The human hand has a language of its own. 
 While the tongue demonstrates the thought through 
 the word, the hand realizes and renders visible the 
 thought through the work. This organ, therefore, 
 by whose fitness of form the mind declares its own 
 entity in nature, by the invention and creation of the 
 thing, which is, as it were, the mind’s autograph, 
 claims a high interest in surgical anatomy; and ac¬ 
 cordingly the surgeon lays it down as a rule, strictly 
 to be observed, that when this beautiful and valuable 
 member happens to be seriously mutilated, in any of 
 those various accidents to which it is exposed, the 
 prime consideration should be, not as to the fact of 
 how much of its quantity or parts it can be deprived 
 in operation, but rather as to how little of its quan¬ 
 tity should it be deprived, since no mechanical inge¬ 
 nuity can fashion an apparatus, capable of supplying 
 the loss of a finger, or even of one of its joints. 
 
 The main bloodvessels and nerves of the arm tra¬ 
 verse the front aspect of the wrist, and are distributed 
 chiefly to supply the palmar surface of the hand, 
 since in the palm are to be found a greater variety and 
 number of structures than are met with on the back of 
 the hand. The radial artery, A, Plate 17, occupies (as 
 its name indicates) the radial border of the forepart of 
 the wrist, and the ulnar artery, c, Plate 17, occupies the 
 ulnar border; both vessels in this region of their course 
 lie parallel to each other; both are comparatively su- 
 6 
 
 OF THE WRIST AND HAND. 
 
 perficial, but of the two, the radial artery is the more 
 superficial and isolated, and thereby occasions the radial 
 pulse. The anatomical situation of the radial artery 
 accounts for the fact, why the pulsation of this vessel 
 is more easily felt than that of the ulnar artery. 
 
 The radial vessel, A, Plate 17, at the wrist, is not 
 accompanied by the radial nerve; for this nerve, c, 
 Plate 19, passes from the side of the artery, at a posi¬ 
 tion, c, Plate 19, varying from one to two or more 
 inches above the wrist, to gain the dorsal aspect of 
 the hand. The ulnar artery, c, Plate 17, is attended 
 by the ulnar nerve, d, in the wrist, and both these 
 pass in company to the palm. The ulnar nerve, d e, 
 lies on the ulnar border of the artery, and both are in 
 general to be found ranging along the radial side of 
 the tendon of the flexor carpi ulnaris muscle, t, and 
 the pisiform bone, G. The situation of the radial ar¬ 
 tery is midway between the flexor carpi radialis ten¬ 
 don, i, and the outer border of the radius. The deep 
 veins, called comites, lie in close connexion with the 
 radial and ulnar arteries. When it is required to lay 
 bare the radial or ulnar artery, at the wrist, it will be 
 sufficient for that object to make a simple longitudinal 
 incision (an inch or two in length) over the course of 
 the vessel A or c, Plate 17, through the integument, 
 and this incision will expose the fascia, which forms 
 a common investment for all the structures at this re¬ 
 gion. When this fascia has been cautiously slit open 
 on the director, the vessels w r ill come into view. The 
 ulnar artery, however, lies somewhat concealed be¬ 
 tween the adjacent muscles, and in order to bring this 
 vessel fully into view, it will be necessary to draw 
 aside the tendon of the flexor ulnaris muscle, T. 
 
 The radial artery, A, Plate 18, passes external to 
 
 ( 41 ) 
 
44 
 
 COMMENTARY ON 
 
 All deep incisions made in the median line of the 
 forepart of the wrist are liable to wound the me¬ 
 dian nerve b, Plate 17. When the thumb, together 
 with its metacarpal bone, is being amputated, the ra- 
 
 PLATES 17, 18, & 19. 
 
 dial artery e, Plate 19, which winds round near the 
 head of that hone, may be wounded. It is possible, 
 by careful dissection, to perform this operation with¬ 
 out dividing the radial vessel. 
 
 DESCRIPTION OF PLATES 17, 18, & 19. 
 
 Plate 17. 
 
 A. Radial artery. 
 
 B. Median nerve; bbbb, its branches to the thumb 
 
 and fingers. 
 
 C. Ulnar artery, forming f, the superficial palmar arch. 
 
 D. Ulnar nerve; e e e, its continuation branching to 
 
 the little and ring fingers, &c. 
 
 G. Pisiform hone. 
 
 H. Abductor muscle of the little finger. 
 
 I. Tendon of flexor carpi radialis muscle. 
 
 K. Opponens pollicis muscle. 
 
 L. Flexor brevis muscle of the little finger. 
 
 M. Flexor brevis pollicis muscle. 
 
 N. Abductor pollicis muscle. 
 
 OOOO. Lumbricales muscles. 
 
 PPPP. Tendons of the flexor digitorum sublimis 
 muscle. 
 
 Q. Tendon of the flexor longus pollicis muscle. 
 
 R. Tendon of extensor metacarpi pollicis. 
 
 S. Tendons of extensor digitorum sublimis; ppp, 
 
 their digital prolongations. 
 
 T. Tendon of flexor carpi ulnaris. 
 
 U. Union of the digital arteries at the tip of the 
 finger. 
 
 Plate 18. 
 
 A. Radial artery. 
 
 B. Tendons of the extensors of the thumb. 
 
 C. Tendon of extensor carpi radialis. 
 
 D. Annular ligament. 
 
 E. Deep palmar arch, formed by radial artery giving 
 
 off e, the artery of the thumb. 
 
 F. Pisiform bone. 
 
 G. Ulnar artery, giving off the branch i to join the 
 
 deep palmar arch e of the radial artery. 
 
 H. Ulnar nerve ; 7i, superficial branches given to the 
 
 fingers. Its deep palmar branch is seen lying on 
 the interosseous muscles, m m. 
 
 K. Abductor minimi digiti. 
 
 L. Flexor brevis minimi digiti. 
 
 M. Palmar interosseal muscles. 
 
 N. Tendons of flexor digitorum sublimis and profun¬ 
 
 dus, and the lumbricales muscles cut and turned 
 down. 
 
 O. Tendon of flexor pollicis longus. 
 
 P. Carpal end of the metacarpal bone of the thumb. 
 
 Plate 19. 
 
 AAA. Tendons of extensor digitorum communis; A*, 
 tendon overlying that of the indicator muscle. 
 
 B. Dorsal part of the annular ligament. 
 
 C. End of the radial nerve distributed over the back 
 
 of the hand, to two of the fingers and the thumb. 
 
 D. Dorsal branch of the ulnar nerve supplying the 
 
 back of the hand and the three outer fingers. 
 
 E. Radial artery turning round the carpal end of the 
 
 metacarpal hone of the thumb. 
 
 F. Tendon of extensor carpi radialis brevis. 
 
 G. Tendon of extensor carpi radialis longus. 
 
 H. Tendon of third extensor of the thumb. 
 
 I. Tendon of second extensor of the thumb. 
 
 K. Tendon of extensor minimi digiti joining a ten¬ 
 don of extensor communis. 
 

Base 
 
 - 
 
 

COMMENTARY ON PLATES 20 & 21. 
 
 THE RELATIVE POSITION OF THE CRANIAL, NASAL, ORAL, AND PHARYNGEAL 
 
 CAVITIES, &c. 
 
 On making a section (vertically through the median 
 line) of the cranio-facial and cervico-hyoid apparatus, 
 the relation which these structures bear to each other 
 in the osseous skeleton reminds me strongly of the 
 great fact enunciated by the philosophical anatomists, 
 that the facial apparatus manifests in reference to the 
 cranial structures the same general relations which 
 the hyoid apparatus bears to the cervical vertebras, 
 and that these relations are similar to those which the 
 thoracic apparatus bears to the dorsal vertebras. To 
 this anatomical fact I shall not make any further allu¬ 
 sions, except in so far as the acknowledgment of it 
 shall serve to illustrate some points of surgical import. 
 
 The cranial chamber, A A h, Plate 20, is continuous 
 with the spinal canal c. The osseous envelope of the 
 brain, called calvarium, z b, holds serial order with the 
 cervical spinous processes, e i, and these with the 
 dorsal spinous processes. The dura-matral lining 
 membrane, A A A*, ’of the cranial chamber is continu¬ 
 ous with the lining membrane, C, of the spinal canal. 
 The brain is continuous with the spinal cord. The 
 intervertebral foramina of the cervical spine are mani¬ 
 festing serial order with the cranial foramina. The 
 nerves which pass through the spinal region of this 
 series of foramina above and below c are continuous 
 with the nerves which pass through the cranial region. 
 The anterior boundary, d i, of the cervical spine is 
 continuous with the anterior boundary, Y f, of the 
 cranial cavity. And this common serial order of os¬ 
 seous parts—viz., the bodies of vertebras, serves to 
 isolate the cranio-spinal compartment from the facial 
 and cervical passages. Thus the anterior boundary, 
 
 y f d i, of the cranio-spinal canal is also the posterior 
 boundary of the facial and cervical cavities. 
 
 Now as the cranio-spinal chamber is lined by the 
 common dura-matral membrane, and contains the com¬ 
 mon mass of nervous structure, thus inviting us to fix 
 attention upon this structure as a whole, so we find 
 that the frontal cavity, z, the nasal cavity, x w, the 
 oral cavity, 4, 5, s, the pharyngeal and oesophageal 
 passages 8 Q, are lined by the common mucous mem¬ 
 brane, and communicate so freely with each other 
 that they may be in fact considered as forming a com¬ 
 mon cavity divided only by partially formed septa, 
 such as the one, u v, which separates to some extent 
 the nasal fossa from the oral fossa. 
 
 As owing to this continuity of structure, visible be¬ 
 tween the head and spine, we may infer the liability 
 which the affections of the one region have to pass 
 into and implicate the other, so likewise by that con¬ 
 tinuity apparent between all compartments of the face, 
 fauces, oesophagus, and larynx, we may estimate how 
 the pathological condition of the one region will con¬ 
 cern the others. 
 
 The cranium, owing to its comparatively superficial 
 and undefended condition, is liable to fracture. When 
 the cranium is fractured, in consequence of force ap¬ 
 plied to its anterior or posterior surfaces, A or b, Plate 
 20, the fracture will, for the most part, be confined to 
 the place whereat the force has been applied, provided 
 the point opposite has not been driven against some 
 resisting body at the same time. Thus when the 
 point b is struck by a force sufficient to fracture the 
 bone, while the point A is not opposed to any resisting 
 
 ( 45 ) 
 
46 
 
 COMMENTARY ON PLATES 20 & 21. 
 
 body, then b alone will yield to the force applied; and 
 fracture thus occurring at the point b, will have hap¬ 
 pened at the place where the applied force is met by 
 the force, or weight, or inertia of the head itself. But 
 when b is struck by any ponderous body, while A is at 
 the same moment forced against a resisting body, then 
 A is also liable to suffer fracture. If fracture in one 
 place be attended with counter-fracture in another 
 place, as at the opposite points A and b, then the frac¬ 
 ture occurs from the force impelling, while the counter¬ 
 fracture happens by the force resisting. 
 
 Now in the various motions which the cranium aab 
 performs upon the top of the cervical spine c, motions 
 backwards, forwards, and to either side, it will follow 
 that, taking c as a fixed point, almost all parts of the 
 cranial periphery will be brought vertical to c in 
 succession, and therefore whichever point happens at 
 the moment to stand opposite to c, and has impelling 
 force applied to it, then c becomes the point of resist¬ 
 ance, and thus counter-fractures at the cranial base 
 occur in the neighbourhood of c. When force is ap¬ 
 plied to the cranial vertex, whilst the body is-in the 
 erect posture, the top of the cervical spine, edc, 
 becomes the point of resistance. Or if the body fall 
 from a height upon its cranial vertex, then the pro¬ 
 pelling force will take effect at the junction of the 
 spine with the cranial base, whilst the resisting force 
 will be the ground upon which the vertex strikes. In 
 either case the cranial base, as well as the vertex, will 
 be liable to fracture. 
 
 The anatomical form of the cranium is such as to 
 obviate a frequent liability to fracture. Its rounded 
 shape diffuses, as is the case with all rotund forms, 
 the force which happens to strike upon it. The mode 
 in which the cranium is set upon the cervical spine 
 serves also to diffuse the pressure at the points where 
 the two opposing forces meet—viz., at the first cervical 
 vertebra e and the cranial basilar process f. This fact 
 might be proved upon mechanical principle. 
 
 The tegumentary envelope of the head, as well as 
 the dura-matral lining, serves to damp cranial vibration 
 consequent upon concussion ; while the sutural isola¬ 
 
 tion of the several component bones of the cranium 
 also prevents, in some degree, the extension, of frac¬ 
 tures and the vibrations of concussion. The contents 
 of the head, like the contents of all hollow forms, 
 receive the vibratory influence of force externally ap¬ 
 plied. The brain receives the concussion of the force 
 applied to its osseous envelope ; and when this latter 
 happens to be fractured, the danger to life is not in 
 proportion to the extent of the fracture here, any more 
 than elsewhere in the skeleton fabric, but is solely in 
 proportion to the amount of shock or injury sustained 
 by the nervous centre. 
 
 When it is required to trephine any part of the 
 cranial envelope, the points which should be avoided, 
 as being in the neighbourhood of important blood¬ 
 vessels, are the following—the occipital protuberance, 
 b, within which the “ torcular Herophili” is situated, 
 and from this point passing through the median line 
 of the vertex forwards to z the frontal sinus, the tre¬ 
 phine should not be applied, as this line marks the 
 locality of the superior longitudinal sinus. The great 
 lateral sinus is marked by the superior occipital ridge 
 passing from the point b outwards to the mastoid pro¬ 
 cess. The central point, b of the side of the head, 
 Plate 21, marks the locality of the root of the menin¬ 
 geal artery within the cranium, and from this point 
 the vessel branches forwards and backwards over the 
 interior of the cranium. 
 
 The nasal fossse are situated on either side of the 
 median partition formed by the vomer and cartilagi¬ 
 nous nasal septum. Both nasal fossce are open ante¬ 
 riorly and posteriorly; but laterally they do not, in 
 the normal state of these parts, communicate. The 
 two posterior nares answering to the two nasal fossm 
 open into the upper part of the bag of the pharynx 
 at 8, Plate 20, which marks the opening of the Eusta¬ 
 chian tube. 
 
 The structures observable in both the nasal fossm 
 absolutely correspond, and the foramina which open 
 into each correspond likewise. All structures situated 
 on either side of the median line are similar. And 
 the structure which occupies the median line is itself 
 
COMMENTARY ON PLATES 20 & 21. 
 
 47 
 
 double, or duality fused into symmetrical unity. The 
 osseous nasal septum is composed of two laminm laid 
 side by side. The spongy bones, xw, are attached to 
 the outer wall of the nasal fossa, and are situated one 
 above the other. These bones are three in number, 
 the uppermost is the smallest. The outer wall of each 
 naris is grooved by three fossae, called meatuses, and 
 these are situated between the spongy bones. Each 
 meatus receives one or more openings of various canals 
 and cavities of the facial apparatus. The sphenoidal 
 sinus near f opens into the upper meatus. The fron¬ 
 tal, z, and maxillary sinuses open into the middle 
 meatus, and the nasal duct opens into the inferior sinus 
 beneath the anterior inferior angle of the lower spongy 
 bone, w. 
 
 In the living body the very vascular fleshy and 
 glandular Schneiderian membrane which lines all parts 
 of the nasal fossa almost completely fills this cavity. 
 When polypi or other growths occupy the nasal fossm, 
 they must gain room at the expense of neighbouring 
 parts. The nasal duct may have a bent probe intro¬ 
 duced into it by passing the instrument along the outer 
 side of the floor of the nasal fossa as far back as the 
 anterior inferior angle of the lower spongy bone, w, 
 at which locality the duct opens. An instrument of 
 sufficient length, when introduced into the nostrils in 
 the same direction, will, if passed backwards through 
 the posterior nares, reach the opening of the Eusta¬ 
 chian tube, 8. 
 
 While the jaws are closed, the tongue, r, Plate 20, 
 occupies the oral cavity almost completely. When 
 the jaws are opened they form a cavity between them 
 equal in capacity to the degree at which they are sun¬ 
 dered from each other. The back of the pharynx can 
 be seen when the jaws are widely opened if the tongue 
 be depressed, as r, Plate 20. The hard palate, u, 
 which forms the roof of the mouth, is extended further 
 backwards by the soft palate, v, which hangs as the 
 loose velum of the throat between the nasal fossm 
 above and the fauces below. Between the velum pa- 
 
 lati, v, and the root of the tongue, we may readily 
 discern, when the jaws are open, two ridges of arching 
 form, 5, 6, on either side of the fauces. These promi¬ 
 nent arches and their fellows are named the pillars of 
 the fauces. The anterior pillar, 5, is formed by the 
 submucous palato-glossus muscle ; the posterior pillar, 
 6, is formed by the palato-pharyngeus muscle. Be¬ 
 tween these pillars, 5 and 6, is situated the tonsil, s, 
 beneath the mucous membrane. When the tonsils of 
 opposite sides become inflamed and suppurate, an in¬ 
 cision may be made into either gland without much 
 chance of wounding the internal carotid artery; for, 
 in fact, this vessel lies somewhat removed from it 
 behind. In Plate 21, that point of the superior con¬ 
 strictor of the pharynx, marked d, indicates the situa¬ 
 tion of the tonsil gland; and a considerable interval 
 will be seen to exist between d and the internal carotid 
 vessel f. 
 
 If the head be thrown backwards the nasal and oral 
 cavities will look almost vertically towards the pha¬ 
 ryngeal pouch. When the juggler is about to “swal¬ 
 low the sword,” he throws the head back so as to bring 
 the mouth and fauces in a straight line with the 
 pharynx and oesophagus. And when the surgeon 
 passes the probang or other instruments into the oeso¬ 
 phagus, he finds it necessary to give the head of the 
 person on whom he operates the same inclination back¬ 
 wards. When instruments are being passed into the 
 oesophagus through the nasal fossa, they are not so 
 likely to encounter the rima glottidis below the epi¬ 
 glottis, 9, as when they are being passed into the 
 oesophagus by the mouth. The glottis may be always 
 avoided by keeping the point of the instrument press¬ 
 ing against the back of the pharynx during its passage 
 downwards. 
 
 When in suspended animation we endeavour to 
 inflate the lungs through the nose or mouth, we 
 should press the larynx, 10,11,12, backwards against 
 the vertebral column, so as to close the oesophageal 
 tube. 
 
DESCRIPTION OF PLATES 20 & 21. 
 
 Plate 20. 
 
 A A. The dura-matral falx ; a*, its attachment to the tentorium. 
 
 B. Torcular Herophili. 
 
 C. Dura-mater lining the spinal canal. 
 
 D D*. Axis vertebra. 
 
 E E*. Atlas vertebra. 
 
 F F*. Basilar processes of the sphenoid and occipital bones. 
 
 G. Petrous part of the temporal bone. 
 
 II. Cerebellar fossa. 
 
 11*. Seventh cervical vertebra. 
 
 K K*. First rib surrounding the upper part of the pleural sac. 
 L L*. Subclavian artery of the right side overlying the pleural 
 sac. 
 
 M M*. Right subclavian vein. 
 
 N. Right common carotid artery cut at its origin. 
 
 O. Trachea. 
 
 P. Thyroid body. 
 
 Q. (Esophagus. 
 
 R. Genio-hyo-glossus muscle. 
 
 S. Left tonsil beneath the mucous membrane. 
 
 T. Section of the lower maxilla. 
 
 U. Section of the upper maxilla. 
 
 V. Velum palati in section. 
 
 W. Inferior spongy bone. 
 
 X. Middle spongy bone. 
 
 Y. Crista galli of cethmoid bone. 
 
 Z. Frontal sinus. 
 
 2. Anterior cartilaginous part of nasal septum. 
 
 3. Nasal bone. 
 
 4. Last molar tooth of the left side of lower jaw. 
 
 5. Anterior pillar of the fauces. 
 
 6. Posterior pillar of the fauces. 
 
 7. Genio-hyoid muscle. 
 
 8. Opening of Eustachian tube. 
 
 9. Epiglottis. 
 
 10. Hyoid bone. 
 
 11. Thyroid bone. 
 
 12. Cricoid bone. 
 
 13. Thyroid axis. 
 
 14. Part of anterior scalenus muscle. 
 
 15. Humeral end of the clavicle. 
 
 16. Part of posterior scalenus muscle. 
 
 Plate 21. 
 
 A. Zygoma. 
 
 B. Articular glenoid fossa of temporal bone. 
 
 C. External pterygoid process lying on the levator and tensor 
 
 palati muscles. 
 
 D. Superior constrictor of pharynx. 
 
 E Transverse process of the Atlas. 
 
 F. Internal carotid artery. Above the point f, is seen the 
 
 glosso-pharyngeal nerve ; below f, is seen the hypoglossal 
 nerve. 
 
 G. Middle constrictor of pharynx. 
 
 H. Internal jugular vein. 
 
 I. Common carotid cut across. 
 
 K. Rectus capitis major muscle. 
 
 L. Inferior constrictor of pharynx. 
 
 M. Levator anguli scapulas muscle. 
 
 N. Posterior scalenus muscle. 
 
 O. Anterior scalenus muscle. 
 
 P. Brachial plexus of nerves. 
 
 Q. Trachea. 
 
 R R*. Subclavian artery. 
 
 S. End of internal jugular vein. 
 
 T. Bracheo-cephalic artery. 
 
 UU*. Roots of common carotid arteries. 
 
 V. Thyroid body. 
 
 W. Thyroid cartilage. 
 
 X. Hyoid bone. 
 
 Y. Hyo-glossus muscle. 
 
 Z. Upper maxillary bone. 
 
 2. Inferior maxillary branch of fifth cerebral nerve. 
 
 3. Digastric muscle cut. 
 
 4. Styloid process. 
 
 5. External carotid artery. 
 
 6 6. Lingual artery. 
 
 7. Roots of cervical plexus of nerves. 
 
 8. Thyroid axis; 8*, thyroid artery, between which and q, tne 
 trachea, is seen the inferior laryngeal nerve. 
 
 9. Omo-hyoid muscle cut. 
 
 10. Sternal end of clavicle. 
 
 11. Upper rings of trachea, which may with most safety be di¬ 
 vided in tracheotomy. 
 
 12. Cricoid cartilage. 
 
 13. Crico-thyroid interval where laryngotomy is performed. 
 
 14. Genio-hyoid muscle. 
 
 15. Section of lower maxilla. 
 
 16. Parotid duct. 
 
 17. Lingual attachment of styloglossus muscle, with part of the 
 gustatory nerve seen above it. 
 
 ( 48 ) 
 
PJWK f K.'-.iuta t.t. . 
 
COMMENTARY ON 
 
 PLATE 22 . 
 
 THE RELATIVE POSITION OF THE SUPERFICIAL ORGANS OF THE THORAX AND 
 
 ABDOMEN. 
 
 In the osseous skeleton, the thorax and abdomen 
 constitute a common compartment. We cannot, 
 while we contemplate this skeleton, isolate the one re¬ 
 gion from the other by fact or fancy. The only differ¬ 
 ence which I can discover between the regions called 
 thorax and abdomen, in the osseous skeleton, (consid¬ 
 ering this body morphologically,) results, simply, from 
 the circumstance that the ribs, which enclose thoracic 
 space, have no osseous counterparts in the abdomen 
 enclosing abdominal space, and this difference is mere¬ 
 ly histological. In man and the mammalia the costal 
 arches hold relation with the pulmonary organs, and 
 these costm Tail at that region where the ventral organs 
 are located. In birds, and many reptiles, the costal 
 arches enclose the common thoracico-abdominal region, 
 as if it were a common pulmonary region. ‘In fishes 
 the costal arches enclose the thoracico-abdominal re¬ 
 gion, just as if it were a common abdominal region. 
 I merely mention these general facts to show that cos¬ 
 tal enclosure does not actual^ serve to isolate the 
 thorax from the abdomen in the lower classes of ani¬ 
 mals ; and on turning to the human form, I find that 
 this line of separation between the two compartments 
 is so very indefinite, that, as pathologists, we are very 
 liable to err in our diagnosis between the diseased and 
 the healthy organs of either region, as they lie in re¬ 
 lation with the moveable diaphragm or septum in the 
 living bod}-. The contents of the whole trunk of the 
 body from the top of the sternum to the perineum are 
 influenced by the respiratory motions; and it is most 
 true that the diaphragmatic line, n f h*, is alternately 
 occupied by those organs situated immediately above 
 
 and below it during the performance of these motions, 
 even in health. 
 
 The organs of the thoracic region hold a certain 
 relation to each other and to the thoracic walls. The 
 organs of the abdomen hold likewise a certain relation 
 to each other and to the abdominal parietes. The 
 organs of both the thorax and the abdomen have a 
 certain relation to each other, as they lie above and 
 below the diaphragm. In dead nature these relations 
 are fixed and readily ascertainable, but in living, 
 moving nature, the organs influence this relative po¬ 
 sition, not only of each other, but also of that which 
 they bear to the cavities in which they are contained. 
 This change of place among the organs occurs in the 
 normal or healthy state of the living body, and, 
 doubtless, raises some difficulty in the way of our as¬ 
 certaining, with mathematical precision, the actual 
 state of the parts which we question, by the physical 
 signs of percussion and auscultation. In disease this 
 change of place among these organs is increased, and 
 the difficulty of making a correct diagnosis is increased 
 also in the same ratio. For when an emphysematous 
 lung shall fully occupy the right thoracic side from b 
 to l, then G, the liver, will protrude considerably into 
 the abdomen beneath the right asternal ribs, and yet 
 will not be therefore proof positive that the liver is 
 diseased and abnormally enlarged. Whereas, on the 
 other hand, when G, the liver, is actually diseased, it 
 may occupy a situation in the right side as high as 
 the fifth or sixth ribs, pushing the right lung upwards 
 as high as that level; and, therefore, while percussion 
 elicits a dull sound over this place thus occupied, such 
 
 (49) 
 
50 
 
 COMMENTARY ON PLATE 22. 
 
 sound will not be owing to a hepatized lung, but to the 
 absence of the lung caused by the presence of the 
 liver. 
 
 In the healthy adult male body, Plate 22, the two 
 lungs, dd* whilst in their ordinary expanded state, 
 may be said to range over all that region of the trunk 
 of the body which is marked by the sternal and aster¬ 
 nal ribs. The heart, E, occupies the thoracic centre, 
 and part of the left thoracic side. The heart is al¬ 
 most completely enveloped in the two lungs. The 
 only portion of the heart and pericardium, which 
 appears uncovered by the lung on opening the thorax, 
 is the base of the right ventricle, E, situated immedi¬ 
 ately behind the lower end of the sternum, where this 
 bone is joined by the cartilages of the sixth and seventh 
 ribs. The lungs range perpendicularly from points an 
 inch above b, the first rib, downwards to L, the tenth 
 rib, and obliquely downwards and backwards to the 
 vertebral ends of the last ribs. This space varies in 
 capacity, according to the degree in which the lungs 
 are expanded within it. The increase in thoracic 
 space is attained, laterally, by the expansion of the 
 ribs, 0 I; and vertically, by the descent of the dia¬ 
 phragm, H, which forces downwards the mass of ab¬ 
 dominal viscera. The contraction of thoracic space 
 is caused by the approximation of all the ribs on each 
 side to each other ; and by the ascent of the dia¬ 
 phragm. The expansion of the lungs around the 
 heart would compress this organ, were it not that the 
 costal sides yield laterally while the diaphragm itself 
 descends. The heart follows the ascent and descent 
 of the diaphragm, both in ordinary and forced respi- 
 ration. 
 
 But however much the lungs vary in capacity, or 
 the heart as to position in the respiratory motions, 
 still the lungs are always closely applied to the tho¬ 
 racic walls. Between the pleura costalis and pulmo- 
 nalis there occurs no interval in health. The thoracic 
 parietes expand and contract to a certain degree; and 
 to that same degree, and no further, do the lungs 
 within the thorax expand and contract. By no effort 
 of expiration can the animal expel all the air com¬ 
 
 pletely from its lungs, since by no effort of its own, 
 can it contract thoracic space beyond the natural 
 limit. On the other hand, the utmost degree of ex¬ 
 pansion of which the lungs are capable, exactly equals 
 that degree in which the thoracic walls are dilatable 
 by the muscular effort; and, therefore, between the 
 extremes of inspiration and expiration, the lungs still 
 hold closely applied to the costal parietes. The air 
 within the lungs is separated from the air external to 
 the thorax, by the thoracic parietes. The air within 
 and external to the lungs communicate at the open 
 glottis. When the glottis closes and cuts off the com¬ 
 munication, the respiratory act ceases—the lungs be¬ 
 come immovable, and the thoracic walls are (so far as 
 the motions of respiration are concerned) rendered 
 immovable also. The muscles of respiration cannot, 
 therefore, produce a vacuum between the pulmonic 
 and costal pleura, either while the external air has or 
 has not access to the lungs. Upon this fact the me¬ 
 chanism of respiration mainly depends ; and we may 
 see a still further proof of this in the circumstance 
 that, when the thoracic parietes are pierced, so as to 
 let the external air into the cavity of the pleura, the 
 lung collapses and the thoracic side ceases to exert an 
 expansile influence over the lung. When in cases of 
 fracture of the rib the lung is wounded, and the air 
 of the lung enters the pleura, the same effect is pro¬ 
 duced as when the external air was admitted through 
 an opening in the side. 
 
 When serous or purulent effusion takes place -within 
 the cavity of the pleura, the capacity of the lung be¬ 
 comes lessened according to the quantity of the effu¬ 
 sion. It is more reasonable to expect that the soft 
 tissue of the lung should yield to the quantity of fluid 
 within the pleural cavity, than that the rigid costal 
 walls should give way outwardly; and, therefore, it 
 seldom happens that the practitioner can discover by 
 the eye any strongly-marked difference between the 
 thoracic walls externally, even when a considerable 
 quantity of either serum, pus, or air, occupies the 
 pleural sacs. 
 
 In the healthy state of the thoracic organs, a sound 
 
COMMENTARY ON PLATE 22. 
 
 51 
 
 characteristic of the presence of the lung adjacent to 
 the walls of the thorax may be elicited by percussion, 
 or heard during the respiratory act through the ste¬ 
 thoscope, over all that costal space ranging anteriorly 
 between b, the first rib, and i k, the eight and ninth 
 ribs. The respiratory murmur can be heard below 
 the level of these ribs posteriorly, for the lung descends 
 behind the arching diaphragm as far as the eleventh 
 rib. 
 
 When fluid is effused into the pleural cavity, the 
 ribs are not moved by the intercostal muscles opposite 
 the place occupied by the fluid, for this has separated 
 the lung from the ribs. The fluid has compressed the 
 lung; and in the same ratio as the lung is prevented 
 from expanding, the ribs become less moveable. The 
 presence of fluid in the pleural sac is discoverable by 
 dulness on percussion, and, as might be expected, by 
 the absence of the respiratory murmur at that locality 
 which the fluid occupies. Fluid, when effused into 
 the pleural sac, will of course gravitate; and its po¬ 
 sition will vary according to the position of the patient. 
 The sitting or standing posture will therefore suit best 
 for the examination of the thorax in reference to the 
 presence of fluid. 
 
 Though the lungs are closely applied to the costal 
 sides at all times in the healthy state of these organs, 
 still they slide freely within the thorax during the 
 respiratory motions—forwards and backwards—over 
 the serous pericardium, e, and upwards and downwards 
 along the pleura costalis. The length of the adhesions 
 which supervene upon pleuritis gives evidence of the 
 extent of these motions. When the lung becomes in 
 part solidified and impervious to the inspired air, the 
 motions of the thoracic parietes opposite to the part 
 are impeded. Between a solidified lung and one 
 which happens to be compressed by effused fluid it re¬ 
 quires no small experience to distinguish a difference, 
 either by percussion or the use of the stethoscope. 
 It is great experience alone that can diagnose hydro¬ 
 pericardium from hypertrophy of the substance of the 
 heart by either of these means. 
 
 The thoracic viscera gravitate according to the po¬ 
 
 sition of the body. The heart in its pericardial 
 envelope sways to either side of the sternal median 
 line according as the body lies on this or that side. 
 The two lungs must, therefore, be alternately affected 
 as to their capacity according as the heart occupies 
 space on either side of the thorax. In expiration, 
 the heart, e, is more uncovered by the shelving edges 
 of the lungs than in inspiration. In pneumothorax 
 of either of the pleural sacs the air compresses the 
 lung, pushes the heart from its normal position, and 
 the space which the air occupies in the pleura yields 
 a clear hollow sound on percussion, whilst, by the ear 
 or stethoscope applied to a corresponding part of the 
 thoracic walls, we discover the absence of the respira¬ 
 tory murmur. 
 
 The transverse diameter of the thoracic cavity 
 varies at different levels from above downwards. The 
 diameter which the two first ribs,B b*, measure, is the 
 least. That which is measured by the two eighth ribs, 
 11 *, is the greatest. The perpendicular depth of the 
 thorax, measured anteriorly, ranges from A, the top 
 of the sternum, to f, the xyphoid cartilage. Poste¬ 
 riorly, the perpendicular range of the thoracic cavity 
 measures from the spinous process of the seventh cer¬ 
 vical vertebra above, to the last dorsal spinous process 
 below. In full, deep-drawn inspiration in the healthy 
 adult, the ear applied to the thoracic walls discovers 
 the respiratory murmur over all the space included 
 within the above mentioned bounds. After extreme 
 expiration, if the thoracic walls be percussed, this 
 capacity will be found much diminished; and the ex¬ 
 treme limits of the thoracic space, which during full 
 inspiration yielded a clear sound, indicative of the 
 presence of the lung, will now, on percussion, manifest 
 a dull sound, in consequence of the absence of the 
 lung, which has receded from the place previously oc¬ 
 cupied. 
 
 Owing to the conical form of the thoracic space, the 
 apex of which is measured by the first ribs, b b*, and 
 the basis by 1 i*, it will be seen that if percussion be 
 made directly from before, backwards, over the pectoral 
 masses, R R*, the pulmonic resonance will not be elicited. 
 
COMMENTARY ON PLATE 22. 
 
 When we raise the arms from the side and percuss the 
 thorax between the folds of the axilla?, where the ser- 
 ratns magnus muscle alone intervenes between the ribs 
 and the skin, the pulmonic sound will answer clearly. 
 
 At the hypochondriac angles formed between the 
 points f, l, n, on either side the lungs are absent both 
 in inspiration and expiration. Percussion, when made 
 over the surface of the angle of the right side, discovers 
 the presence of the liver, g gA When made over the 
 median line, and on either side of it above the umbil¬ 
 icus, n, we ascertain the presence of the stomach, M mA 
 In the left hypochondriac angle, the stomach may also 
 be found to occupy this place wholly. 
 
 Beneath the umbilicus, N, and on either side of it 
 as far outwards as the lower asternal ribs, k l, thus 
 ranging the abdominal parietes transversely, percus¬ 
 sion discovers the transverse colon, o, p, oA The small 
 intestines, s s*, covered by the omentum, p*, occupy 
 the hypogastric and iliac regions. 
 
 The organs situated within the thorax give evidence 
 that they are developed in accordance to the law of 
 symmetry. The lungs form a pair, one placed on either 
 
 side of the median line. The heart is a double organ, 
 formed of the right and left heart. The right lung 
 differs from the left, inasmuch as we find the former 
 divided into three lobes, while the latter has only two. 
 That place which the heart now occupies in the left 
 thoracic side is the place where the third or middle 
 lobe of the left lung is wanting. In the abdomen we 
 find that most of its organs are single. The liver, 
 stomach, spleen, colon, and small intestine form a 
 series of single organs : each of these may be cleft 
 symmetrically. The kidneys are a pair. 
 
 The extent to which the ribs are bared in the figure 
 Plate 22, marks exactly the form and transverse ca¬ 
 pacity of the thoracic walls. The diaphragm, n h*, 
 has had a portion of its forepart cut off, to show how 
 it separates the thin edges of both lungs above from 
 the liver, G, and the stomach, m, below. These latter 
 organs, although occupying abdominal space, rise to 
 a considerable height behind k l, the asternal ribs, 
 a fact whicli should be borne in mind when percus¬ 
 sing the walls of the thorax and abdomen at this 
 region. 
 
 DESCRIPTION 
 
 A. Upper bone of the sternum. 
 
 B BA Two first ribs. 
 
 C C*. Second pair of ribs. 
 
 D DA Right and left lungs. 
 
 E. Pericardium, enveloping the heart—the right ven¬ 
 
 tricle. 
 
 F. Lower end of the sternum. 
 
 G GA Lobes of the liver. 
 
 II HA Right and left halves of the diaphragm in 
 section. The right half separating the right lung 
 from the liver; the left half separating the left 
 lung from the broad cardiac end of the stomach. 
 
 OF PLATE 22. 
 
 IIA Eighth pair of ribs. 
 
 K KA Ninth pair of ribs. 
 
 L LA Tenth pair of ribs. 
 
 M MA The stomach; m, its cardiac bulge ; M*, its py¬ 
 loric extremity. 
 
 N. The umbilicus. 
 
 0 OA The transverse colon. 
 
 P PA The omentum, covering the transverse colon 
 and small intestines. 
 
 Q. The gall bladder. 
 
 R RA The right and left pectoral prominences. 
 
 S SA Small intestines. 
 
COMMENTARY ON PLATE 23. 
 
 THE RELATIVE POSITION OF THE DEEPER ORGANS OF THE THORAX AND THOSE OF 
 
 THE ABDOMEN. 
 
 The size or capacity of the thorax in relation to that 
 of the abdomen varies in the individual at different 
 periods of life. At an early age, the thorax, compared 
 to the abdomen, is less in proportion than it is at 
 adult age. The digestive organs in early age pre¬ 
 ponderate considerably over the respiratory organs; 
 whereas, on the contrary, in the healthy and well- 
 formed adult, the thoracic cavity and organs of respi¬ 
 ration manifest a greater relative proportion to the 
 ventral cavity and organs. At the adult age, when 
 sexual peculiarities have become fully marked, the 
 thoracic organs of the male body predominate over 
 those of the abdomen, whilst in the female form the 
 ventral organs take precedence as to development and 
 proportions. This diversity in the relative capacity 
 of the thorax and abdomen at different stages of 
 development, and also in persons of different sexes, 
 stamps each individual with characteristic traits of 
 physical conformation; and it is required that we 
 should take into our consideration this normal diver¬ 
 sity of character, while conducting our examinations 
 of individuals in reference to the existence of disease. 
 
 The heart varies in some measure, not only as to 
 size and weight, but also as to position, even in 
 healthy individuals of the same age and sex. The 
 level at which the heart is in general found to be 
 situated in the thorax is that represented in Plate 
 23, where the apex points to the sixth intercostal 
 space on the left side above k, while the arch of the 
 aorta rises to a level with c, the second costal carti¬ 
 lage. In some instances, the heart may be found to 
 occupy a much lower position in the thorax than the 
 
 one above mentioned, or even a much higher level. 
 The impulse of the right ventricle, f, has been noticed 
 occasionally as corresponding to a point somewhat 
 above the middle of the sternum and the intercostal 
 space between the fourth and fifth left costal carti¬ 
 lages; while in other instances its beating was ob¬ 
 servable as low down as an inch or more below the 
 xiphoid cartilage, and these variations have existed 
 in a state of health. 
 
 Percussion over the region of the heart yields a 
 dull flat sound. The sound is dullest opposite the 
 right ventricle, f ; whilst above and to either side of 
 this point, where the heart is overlapped by the ante¬ 
 rior shelving edges of both lungs, the sound is modi¬ 
 fied in consequence of the lung’s resonant qualities. 
 The heart-sounds, as heard through the stethoscope, 
 in valvular disease, will, of course, be more distinctly 
 ascertained at the locality of f, the right ventricle, 
 which is immediately substernal. While the body 
 lies supine, the heart recedes from the forepart of the 
 chest; and the lungs during inspiration expanding 
 around the heart will render its sounds less distinct. 
 In the erect posture, the heart inclines forwards and 
 approaches the anterior wall of the thorax. When 
 the heart is hypertrophied, the lungs do not overlap 
 it to the same extent as when it is of its ordinary 
 size. In the latter state, the elastic cushion of the 
 lung muffles the heart’s impulse. In the former state, 
 the lung is pushed aside by the overgrown heart, the 
 strong muscular walls of which strike forcibly against 
 the ribs and sternum. 
 
 The thorax is separated from the abdomen by the 
 
 ( 53 ) 
 
54 
 
 COMMENTARY ON PLATE 23. 
 
 moveable diaphragm. The heart, f e, lies upon the 
 diaphragm, l L*. The liver, m, lies immediately 
 beneath the right side of this muscular septum, l*, 
 while the bulging cardiac end of the stomach, o, is in 
 close contact with it on the left side, l. As these 
 three organs are attached to the diaphragm — the 
 heart by its pericardium, the stomach by the tube of 
 the oesophagus, and the liver by its suspensory liga¬ 
 ments— it must happen that the diaphragm while 
 descending and ascending in the motions of inspiration 
 and expiration will communicate the same alternate 
 motions to the organs which are connected with it. 
 
 In ordinary respiration the capacity of the thorax 
 is chiefly affected by the motions of the diaphragm; 
 and the relative position which this septum holds with 
 regard to the thoracic and abdominal chambers will 
 cause its motions of ascent and descent to influence 
 the capacity of both chambers at the same time. 
 When the lungs expand, they follow the descent of 
 the diaphragm, which forces the abdominal contents 
 downwards, and thus what the thorax gains in space 
 the abdomen loses. When the lungs contract, the 
 diaphragm ascends, and by this act the abdomen gains 
 that space which the thorax loses. But the organs 
 of the thoracic cavity perform a different office in the 
 economy from those of the abdomen. The air which 
 lills the lungs is soon again expired, whilst the ingesta 
 of the abdominal viscera are for a longer period re¬ 
 tained ; and as the space, which by every inspiration 
 the thorax gains from the abdomen, would cause 
 inconvenient pressure on the distended organs of this 
 latter cavity, so we find that to obviate this inconve¬ 
 nience, nature has constructed the anterior parietes 
 of the abdomen of yielding material. The muscular 
 parietes of the abdomen relax during every inspira¬ 
 tion, and thus this cavity gains that space which it 
 loses by the encroachment of the dilating lungs. 
 
 The mechanical principle upon which the abdominal 
 chamber is constructed, enables it to adjust its capacity 
 to such exigence or pressing necessity as its own vis¬ 
 ceral organs impose on it, from time to time; and the 
 relation which the abdominal cavity bears to the 
 
 thoracic chamber, enables it also to be compensatory 
 to this latter. When the inspiratory thorax gains 
 space from the abdomen, or when space is demanded 
 for the increasing bulk of the alimentary canal, or for 
 the enlarging pregnant uterus; or when, in conse¬ 
 quence of disease, such as dropsical accumulation, 
 more room is wanted, then the abdominal chamber 
 supplies the demand by the anterior bulge or swell 
 of its expansile muscular parietes. 
 
 The position of the heart itself is affected by the 
 expansion of the lungs on either side of it. As the 
 expanding lungs force the diaphragm downwards, the 
 heart follows it, and all the abdominal viscera yield 
 place to the descending thoracic contents. In strong 
 muscular efforts the diaphragm plays an important 
 part, for, previously to making forced efforts, the lungs 
 are distended with air, so as to swell and render fixed 
 the thoracic walls into which so many powerful mus¬ 
 cles of the shoulders, the neck, back, and abdomen, 
 are inserted; at the same time the muscular dia¬ 
 phragm l iA, becomes tense and unbent from its 
 arched form, thereby contracting abdominal space, 
 which now has no compensation for this loss of space, 
 since the abdominal parietes are also rendered firm 
 and unyielding. It is at this crisis of muscular effort 
 that the abdominal viscera become impacted together; 
 and, acting by their own elasticity against the muscu¬ 
 lar force, make an exit for themselves through the 
 weakest parts of the abdominal walls, and thus hernia 2 
 of various kinds are produced. The most common 
 situations of abdominal herniae are at the inguinal 
 regions, towards which the intestines, t t, naturally 
 gravitate; and at these situations the abdominal 
 parietes are weak and membranous. 
 
 The contents of a hernial protrusion through the 
 abdominal parietes, correspond in general with those 
 divisions of the intestinal tube, which naturally lie 
 adjacent to the part where the rupture has taken 
 place. In the umbilical hernia it is either the trans¬ 
 verse colon s*, or some part of the small intestine 
 occupying the median line, or both together, with 
 some folds of the omentum, which will be found to 
 
COMMENTARY ON PLATE 23. 
 
 55 
 
 form the contents of this swelling. When the dia¬ 
 phragm itself sustains a rupture in its left half, the 
 upper portion of the descending colon, s, protrudes 
 through the opening. A diaphragmatic hernia, has 
 not, so far as I am aware, been seen to occur in the 
 right side; and this exemption from rupture of the 
 right half of the diaphragm may be accounted for 
 anatomically, by the fact that the liver, m, defends 
 the diaphragm at this situation. The liver occupies 
 the whole depth of the right hypochondrium; and 
 intervenes between the diaphragm L*, and the right 
 extremity of the transverse colon, s**. 
 
 The contents of a right inguinal hernia consist 
 of the small intestine, t. The contents of the right 
 crural hernia are formed by either the small intestine, 
 t, or the intestinum caecum, s***. I have seen a few 
 cases in which the caecum formed the right crural 
 hernia. Examples are recorded in which the intes¬ 
 tine caecum formed the contents of a right inguinal 
 hernia. The left inguinal and crural herniae contain 
 most generally the small intestine, t, of the left side. 
 
 The right lung, i*, is shorter than the left; for the 
 liver, m, raises the diaphragm, l, to a higher level 
 within the thorax, on the right side, than it does on 
 the left. When the liver happens to he diseased and 
 enlarged, it encroaches still more on thoracic space; 
 but, doubtless, judging from the anatomical connexions 
 of the liver, we may conclude that when it becomes 
 increased in volume it will accommodate itself as 
 much at the expense of abdominal space. The liver, 
 in its healthy state and normal proportions, protrudes 
 for an inch (more or less) below the margins of the 
 right asternal ribs. The upper or convex surface of 
 the liver rises beneath the diaphragm to a level cor¬ 
 responding with the seventh or sixth rib, but this 
 position will vary according to the descent and ascent 
 of the diaphragm in the respiratory movements. The 
 ligaments by which the liver is suspended do not pre¬ 
 vent its full obedience to these motions. 
 
 The left lung, i, descends to a lower level than the 
 right; and the left diaphragm upon which it rests is 
 itself supported by the cardiac end of the stomach. 
 
 When the stomach is distended, it does not even then 
 materially obstruct the expansion of the left lung, or 
 the descent of the left diaphragm, for the abdominal 
 walls relax and allow of the increasing volume of the 
 stomach to accommodate itself. The spleen, r, is 
 occasionally subject to an extraordinary increase of 
 bulk; and this organ, like the enlarged liver and the 
 distended stomach, will, to some extent, obstruct the 
 movements of the diaphragm in the act of respiration, 
 but owing to its free attachments it admits of a change 
 of place. The abdominal viscera, one and all, admit 
 of a change of place; the peculiar forms of those 
 mesenteric bonds by which they are suspended, allow 
 them to glide freely over each other; and this circum¬ 
 stance, together with the yielding nature of the abdo¬ 
 minal parietes, allows the thoracic organs to have full 
 and easy play in the respiratory movements performed 
 by agency of the diaphragm. 
 
 The muscles of respiration perform with ease so 
 long as the air has access to the lungs through the 
 normal passage, viz., the trachea. While the prin¬ 
 ciple of the thoracic pneumatic apparatus remains 
 underanged, the motor powers perform their functions 
 capably. The physical or pneumatic power acts in 
 obedience to the vital or muscular power, while both 
 stand in equilibrium; but the ascendancy of the one 
 over the other deranges the whole thoracic machine. 
 When the glottis closes by muscular spasm and 
 excludes the external air, the respiratory muscles 
 cease to exert a motor power upon the pulmonary 
 cavity; their united efforts cannot cause a vacuum in 
 thoracic space in opposition to the pressure of the 
 external air. When, in addition to the natural 
 opening of the glottis, a false opening is made in the 
 side at the point K, the air within the lung at i, and 
 external to it in the now open pleural cavity, will 
 stand in equilibrio; the lung will collapse as having 
 no muscular power by which to dilate itself, and the 
 thoracic dilator muscles will cease to affect the capa¬ 
 city of the lung, so long as by their action in expand¬ 
 ing the thoracic walls, the air gains, access through 
 the side to the pleural sac external to the lung. 
 
56 
 
 COMMENTARY ON PLATE 23. 
 
 Whether the air be admitted into the pleural sac, 
 by an opening made in the side from without, or by 
 an opening in the lung itself, the mechanical principle 
 of the respiratory apparatus will be equally deranged. 
 Pneumo-thorax will be the result of either lesion; 
 and by the accumulation of air in the pleura the 
 lung will suffer pressure. This pressure will be per¬ 
 manent so long as the air has no egress from the 
 cavity of the pleura. 
 
 The permanent distention of the thoracic cavity, 
 caused by the accumulation of air in the pleural sac, 
 or by the diffusion of air through the interlobular 
 cellular tissue consequent on a wound of the lung 
 itself, will equally obstruct the breathing; and though 
 the situation of the accumulated air is in fact anatom¬ 
 ically different in both cases, yet the effect produced 
 is similar. Interlobular pressure and interpleural 
 
 pressure result in the same thing, viz., the permanent 
 retention of the air external to the pulmonary cells, 
 which, in the former case, are collapsed individually; 
 and, in the latter case, in the mass. Though the 
 emphysematous lung is distended to a size equal to 
 the healthy lung in deep inspiration, yet we know 
 that emphysematous distention, being produced by 
 extrabronchial air accumulation, is, in fact, obstructive 
 to the respiratory act. The emphysematous lung 
 will, in the same manner as the distended pleural 
 sac, depress the diaphragm and render the thoracic 
 muscles inoperative. The foregoing observations 
 have been made in reference to the effect of wounds 
 of the thorax, the proper treatment of which will 
 be obviously suggested by our knowledge of the 
 state of the contained organs which have suffered 
 lesion. 
 
 DESCRIPTION 
 
 A. Upper end of the sternum. 
 
 B B.* First pair of ribs. 
 
 C C.* Second pair of ribs. 
 
 D. Aorta, with left vagus and phrenic nerves crossing 
 
 its transverse arch. 
 
 E. Root of pulmonary artery. 
 
 F. Right ventricle. 
 
 G. Right auricle. 
 
 II. Vena cava superior, with right phrenic nerve on 
 its outer border. 
 
 11*. Right and left lungs collapsed, and turned out¬ 
 wards, to show the heart’s outline. 
 
 K K*. Seventh pair of ribs. 
 
 L L*. The diaphragm in section. 
 
 M. The liver in section. 
 
 N. The gall bladder with its duct joining the hepatic 
 
 duct to form the common bile duct. The hepatic 
 
 OF PLATE 23. 
 
 artery is seen superficial to the common duct; 
 the vena portm is seen beneath it. The patent 
 orifices of the hepatic veins are seen on the cut 
 surface of the liver. 
 
 O. The stomach. 
 
 P. The coeliac axis dividing into the coronary, splenic 
 
 and hepatic arteries. 
 
 Q. Inferior vena cava. 
 
 R. The spleen. 
 
 S S* S**. The transverse colon, between which and 
 the lower border of the stomach is seen the 
 gastro-epiploic artery, formed by the splenic and 
 hepatic arteries. 
 
 S***. Ascending colon in the right iliac region. 
 
 T. Convolutions of the small intestines distended 
 with air. 
 

 
 \ 
 
 I 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 ■ 
 
 . 
 
 
 
 
 
 
 
 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COMMENTARY ON PLATE 24 
 
 THE RELATIONS OF THE PRINCIPAL BLOODVESSELS TO THE VISCERA OF THE 
 THORACICO-ABDOMINAL CAVITY. 
 
 The median line of the body is occupied by the cen¬ 
 tres of the four great systems of organs which serve 
 in the processes of circulation, respiration, inner vation, 
 and nutrition. These organs being fashioned in ac¬ 
 cordance with the law of symmetry, we find them 
 arranged in close connexion with the vertebrate centre 
 of the osseous fabric, which is itself symmetrical. In 
 this symmetrical arrangement of the main organs of 
 the trunk of the body, a mechanical principle is 
 prominently apparent; for as the centre is the least 
 moveable and most protected region of the form, so 
 have these vitally important structures the full benefit 
 of this situation. The aortal trunk, G, of the arterial 
 system is disposed along the median line, as well for 
 its own safety as for the fitting distribution of those 
 branches which spring symmetrically from either side 
 of it to supply the lateral regions of the body. 
 
 The visceral system of bloodvessels is moulded upon 
 the organs which they supply. As the thoracic vis¬ 
 cera differ in form and functional character from those 
 of the abdomen, so we find that the arterial branches 
 which are supplied by the aorta to each set, differ like¬ 
 wise in some degree. In the accompanying figure, 
 which represents the thoracic and abdominal visceral 
 branches of the aorta taken in their entirety, this 
 difference in their arrangement may be readily recog¬ 
 nised. In the thorax, compared with the abdomen, 
 we find that not only do the aortic branches differ in 
 form according to the variety of those organs contained 
 in either region, but that they differ numerically ac¬ 
 cording to the number of organs situated in each. 
 The main vessel itself, however, is common to both 
 
 regions. It is the one thoracico-abdominal vessel, and 
 this circumstance calls for the comparison, not only of 
 the several parts of the great vessel itself, but of all 
 the branches which spring from it, and of the various 
 organs which lie in its vicinity in the thorax and ab¬ 
 domen, and hence we are invited to the study of these 
 regions themselves connectedly. 
 
 In the thorax, the aorta, G G*, is wholly concealed 
 by the lungs in their states both of inspiration and 
 expiration. The first part of the aortic arch, as it 
 springs from the left ventricle of the heart, is the most 
 superficial, being almost immediately sub-sternal, and 
 on a level with the sternal junctions of the fourth ribs. 
 By applying the ear at this locality, the play of the 
 aortic valves may be distinctly heard. From this 
 point the aorta, G, rises and arches from before, back¬ 
 wards, to the left side of the spine, G*. The arch of 
 the vessel lies more deeply between the two lungs than 
 does its ventricular origin. The descending thoracic 
 aorta lies still more deeply situated at the left side of 
 the dorsal spine. At this latter situation it is in im¬ 
 mediate contact with the posterior thick part of the 
 left lung; whilst on its right are placed, t, the thoracic 
 duct; i, the oesophagus; K, the vena azygos, and the 
 vertebral column. In Plate 26 may be seen the rela¬ 
 tion which the superior vena cava, H, bears to the 
 aortic arch, A. 
 
 In the span of the aortic arch will be found, H* the 
 left bronchus, together with the right branch of the 
 pulmonary artery, and the right pulmonary veins. 
 The pneumo-gastric and phrenic nerves descend on 
 either side of the arch. The left pneumo-gastric 
 
 ( 57 ) 
 
58 
 
 COMMENTARY ON PLATE 24. 
 
 
 nerve winds round beneath the arch at the point 
 where the obliterated ductus arteriosus joins it. See 
 Plates 12 & 26. 
 
 The pulmonary artery, b, Plates 1 & 2, lies close upon 
 the fore part, and conceals the origin, of the systemic 
 aorta. Whenever, therefore, the semilunar valves of 
 either the pulmonary artery or the systemic aorta 
 become diseased, it must be extremely difficult to dis¬ 
 tinguish by the sounds alone, during life, in which of 
 the two the derangement exists. The origins of both 
 vessels being at the fore part of the chest, it is in this 
 situation, of course, that the state of their valves is to 
 be examined. The descending part of the thoracic 
 aorta, G*, being at the posterior part of the chest, and 
 lying on the vertebral ends of the left thoracic ribs, 
 will therefore require that we should examine its con¬ 
 dition in the living body at the dorsal aspect of the 
 thorax. As the arch of the aorta is directed from be¬ 
 fore backwards—that is, from the sternum to the spine, 
 it follows that when an aneurism implicates this region 
 of the vessel, the exact situation of the tumour must 
 be determined by antero-posterior examination ; and 
 we should recollect, that though on the fore part of the 
 chest the cartilages of the second ribs, where these 
 join the sternum, mark the level of the aortic arch, 
 on the back of the chest its level is to be taken from 
 the vertebral ends of the third or fourth ribs. This 
 difference is caused by the oblique descent of the ribs 
 from the spine to the sternum. The first and second 
 dorsal vertebras, with which the first and second ribs 
 articulate, are considerably above the level of the first 
 and second pieces of the sternum. 
 
 In a practical point of view, the pulmonary artery 
 possesses but small interest for us; and in truth the 
 trunk of the systemic aorta itself may be regarded in 
 the same disheartening consideration, forasmuch as 
 when serious disease attacks either vessel, the “ tree 
 of life” may be said to be lopped at its root. 
 
 When an aneurism arises from the aortic arch it 
 implicates those important organs which are gathered 
 together in contact with itself. The aneurismal tu¬ 
 mour may press upon and obstruct the bronchi, h n*; 
 
 the thoracic duct, l; the oesophagus, i; the superior 
 vena cava, n, Plate 26, or wholly obliterate either of 
 the vagi nerves. The aneurism of the arch of the 
 aorta may cause suffocation in two ways—viz., either 
 by pressing directly on the tracheal tube, or by com¬ 
 pressing and irritating the vagus nerve, whose recur¬ 
 rent branch will convey the stimulus to the laryngeal 
 muscles, and cause spasmodic closure of the glottis. 
 This anatomical fact also fully accounts for the 
 constant cough which attends some forms of aortic 
 aneurism. The pulmonary arteries and veins are also 
 liable to obstruction from the tumour. This will oc¬ 
 cur the more certainly if the aneurism spring from the 
 right or the inferior side of the arch, and if the tumour 
 should not break at an early period, slow absorption, 
 caused by pressure of the tumour, may destroy even 
 the vertebral column, and endanger the spinal nervous 
 centre. If the tumour spring from the left side or 
 the fore part of the arch, it may in time force a pas¬ 
 sage through the anterior wall of the thorax. 
 
 The principal branches of the thoracic aorta spring 
 from the upper part of its arch. The innominate ar¬ 
 tery, 2, is the first to arise from it; the left common 
 carotid, 6, and the left subclavian artery, 5, spring in 
 succession. These vessels being destined for the head 
 and upper limbs, we find that the remaining branches 
 of the thoracic aorta are comparatively diminutive 
 and of little surgical interest. The intercostal arteries 
 occasionally, when wounded, call for the aid of the 
 surgeon; these arteries, like all other branches of the 
 aorta, are largest at their origin. Where these vessels 
 spring from g, the descending thoracic aorta, they pre¬ 
 sent considerable caliber ; but at this inaccessible 
 situation, they seldom or never call for surgical inter¬ 
 ference. As the intercostal arteries pass outwards, 
 traversing the intercostal spaces with their accompany¬ 
 ing nerves, they diminish in size. Each vessel divides 
 at a distance of about two inches, more or less, from 
 the spine; and the upper larger branch lies under 
 cover of the inferior border of the adjacent rib. When 
 it is required to perform the operation of paracentesis 
 thoracis, this distribution of the vessel should be borne 
 
 \ 
 
COMMENTARY ON PLATE 24. 
 
 59 
 
 in mind; and also, that the farther from the spine this 
 operation is performed, the less in size will the vessels 
 be found. The intercostal artery is sometimes wounded 
 by the fractured end of the rib, in which case, if the 
 pleura be lacerated, an effusion of blood takes place 
 within the thorax, compresses the lung, and obstructs 
 respiration. 
 
 The thoracic aorta descends along the left side of 
 the spine, as far as the last dorsal vertebra, at which 
 situation the pillars of the diaphragm overarch the 
 vessel. From this place the aorta passes obliquely in 
 front of the five lumbar vertebras, and on arriving op¬ 
 posite the fourth, it divides into the two common iliac 
 branches. The aorta, for an extent included between 
 these latter boundaries, is named the abdominal aorta, 
 and from its fore part arise those branches, which sup¬ 
 ply the viscera of the abdomen. 
 
 The branches which spring from the abdominal aorta 
 to supply the viscera of this region, are considerable ? 
 both as to their number and size. They are, however, 
 of comparatively little interest in practice. To the 
 anatomist they present many peculiarities of distribu¬ 
 tion and form worthy of notice, as, for example, their 
 frequent anastomosis, their looping arrangement, and 
 their large size and number compared with the actual 
 bulk of the organs which they supply. As to this 
 latter peculiarity, we interpret it according to the fact 
 that here the vessels serve other purposes in the econ¬ 
 omy besides that of the support and repair of struc¬ 
 ture. The vessels are large in proportion to the great 
 quantity of fluid matter secreted from the whole extent 
 of the inner surface of this glandular apparatus—the 
 gastro-intestinal canal, the liver, pancreas, and kidneys. 
 
 As anatomists, we are enabled, from a knowledge of 
 the relative position of the various organs and blood¬ 
 vessels of both the thorax and abdomen, to account 
 for certain pathological phenomena which, as practi¬ 
 tioners, we possess as yet but little skill to remedy. 
 Thus it would appear most probable that many cases 
 of anasarca of the lower limbs, and of dropsy of the 
 belly, are frequently caused by diseased growths of the 
 liver, p, obstructing the inferior vena cava, R, and vena 
 
 portm, rather than by what we are taught to be the 
 “want of balance between secreting and absorbing 
 surfaces.” The like occurrence may obstruct the gall- 
 ducts, and occasion jaundice. Over-distention of any 
 of those organs situated beneath the right hypoclion- 
 drium, will obstruct neighbouring organs and vessels. 
 Mechanical obstruction is doubtless so frequent a 
 source of derangement, that we need not on many 
 occasions essay a deeper search for explaining the 
 mystery of disease. 
 
 In the right hypochondriac region there exists a 
 greater variety of organs than in the left; and disease 
 is also more frequent on the right side. Affections of 
 the liver will consequently implicate a greater number 
 of organs than affections of the spleen on the left side, 
 for the spleen is comparatively isolated from the more 
 important bloodvessels and other organs. 
 
 The external surface of the liver, p, lies in contact 
 with the diaphragm, n, the costal cartilages, m, and the 
 upper and lateral parts of the abdominal parietes; and 
 when the liver becomes the seat of abscess, this, ac¬ 
 cording to its situation, will point and burst either 
 into the thorax above, or through the side between or 
 beneath the false ribs, m. The hepatic abscess has 
 been known to discharge itself through the stomach, 
 the duodenum, t, and the transverse colon, facts which 
 are readily explained on seeing the close relationship 
 which these parts hold to the under surface of the 
 liver. When the liver is inflamed, we account for the 
 gastric irritation, either from the inflammation having 
 extended to the neighbouring stomach, or by this lat¬ 
 ter organ- being affected by “reflex action.” The 
 hepatic cough is caused by the like phenomena disturb¬ 
 ing the diaphragm, n, with which the liver, p, lies in 
 close contact. 
 
 When large biliary concretions form in s, the gall¬ 
 bladder, or in the hepatic duct. Nature, failing in her 
 efforts to discharge them through the common bile-duct, 
 into the duodenum, t, sets up inflammation and ulcera¬ 
 tive absorption, by aid of which processes they make 
 a passage for themselves through some adjacent part 
 of the intestine, either the duodenum or the transverse 
 
60 
 
 COMMENTARY ON PLATE 24. 
 
 colon. In these processes the gall-bladder, which con¬ 
 tains the calculus, becomes soldered by effused lymph 
 to the neighbouring part of the intestinal tube, into 
 which the stone is to be discharged, and thus its escape 
 into the peritoneal sac is prevented. When the he¬ 
 patic abscess points externally towards M, the like pro¬ 
 cess isolates the matter from the cavities of the chest 
 and abdomen. 
 
 In wounds of any part of the intestine, whether of 
 
 x, the CEecum, w, the sigmoid flexure of the colon, or 
 z, the small bowel, if sufficient time be allowed for 
 Nature to establish the adhesive inflammation, she 
 does so, and thus fortifies the peritoneal sac against an 
 escape of the intestinal matter into it by soldering the 
 orifice of the wounded intestine to the external open¬ 
 ing. In this mode is formed the artificial anus. The 
 surgeon on principle aids Nature in attaining this re¬ 
 sult. 
 
 DESCBIE TION OE PLATE 24. 
 
 A. The thyroid body. 
 
 B. The trachea. 
 
 C C*. The first ribs. 
 
 D D*. The clavicles, cut at their middle. 
 
 E. Humeral part of the great pectoral muscle, cut. 
 
 F. The coracoid process of the scapula. 
 
 G. The arch of the aorta. G*. Descending aorta in 
 
 the thorax. 
 
 H. Right bronchus. H*. Left bronchus. 
 
 I. (Esophagus. 
 
 K. Yena azygos receiving the intercostal veins. 
 
 L. Thoracic duct. 
 
 M M*. Seventh ribs. 
 
 N N. The diaphragm, in section. 
 
 O. The cardiac orifice of the stomach. 
 
 P. The liver, in section, showing the patent orifices of 
 
 the hepatic veins. 
 
 Q. The coeliac axis sending off branches to the liver, 
 
 stomach, and spleen. The stomach has been re¬ 
 moved, to show the looping anastomosis of these 
 vessels around the superior and inferior borders 
 of the stomach. 
 
 R. The inferior vena cava about to enter its notch in 
 
 the posterior thick part of the liver, to receive 
 the hepatic veins. 
 
 S. The gall-bladder, communicating by its duct vfith 
 
 the hepatic duct, which is lying upon the vena 
 ports®, and by the side of the hepatic artery. 
 
 T. The pyloric end of the stomach, joining T :;: , the 
 
 duodenum. 
 
 U. The spleen. 
 
 Y Y. The pancreas. 
 
 W. The sigmoid flexure of the colon. 
 
 X. The caput coli. 
 
 Y. The mesentery supporting the numerous looping 
 
 branches of the superior mesenteric artery. 
 
 Z. Some coils of the small intestine. 
 
 2. Innominate artery. 
 
 3. Right subclavian artery. 
 
 4. Right common carotid artery. 
 
 5. Left subclavian artery. 
 
 6. Left common carotid artery. 
 
 7 . Left axillary artery. 
 
 8. Coracoid attachment of the smaller pectoral muscle. 
 
 9. Subscapular muscle. 
 
 10. Coracoid head of the biceps muscle. 
 
 11. Tendon of the latissimus dorsi muscle. 
 
 12. Superior mesenteric artery, with its accompanying 
 vein. 
 
 13. Left kidney. 
 
COMMENTARY ON PLATE 25. 
 
 THE RELATION OF THE PRINCIPAL BLOODVESSELS OF THE THORAX AND 
 ABDOMEN TO THE OSSEOUS SKELETON, ETC. 
 
 The arterial system of vessels assumes, in all cases, 
 somewhat of the character of the forms upon which 
 they are distributed, or of the organs which they sup¬ 
 ply. This mode of distribution becomes the more 
 apparent, according as we rise from particulars to take 
 a view of the whole. With the same ease that any 
 piece of the osseous fabric, taken separately, may be 
 known, so may any one artery, taken apart from the 
 rest, be distinguished as to the place which it occupied, 
 and the organs which it supplied in the economy. The 
 vascular skeleton, whether taken as a whole or in 
 parts, exhibits characteristics as apparent as are those 
 of the osseous skeleton itself. The main bloodvessel, 
 A b c, of the trunk of the body, possesses character, 
 sui generis, just as the vertebral column itself mani¬ 
 fests. The main arteries of the head or limbs are as 
 readily distinguishable, the one from the other, as are 
 the osseous fabrics of the head and limbs. The vis¬ 
 ceral arteries are likewise moulded upon the forms 
 which they supply. But evidently the arterial system 
 of vessels conforms most strictly with the general de¬ 
 sign of the osseous skeleton. 
 
 In Plate 25, viewed as a whole, we find that as the 
 vertebral column stands central to the osseous skele¬ 
 ton, so does the aorta, ABC, take the centre of the 
 arterial skeleton. As the ribs jut symmetrically from 
 either side of the vertebral column, so do the inter¬ 
 costal arteries follow them from their own points of 
 origin in the aorta. The one side of the osseous sys¬ 
 tem is not more like the other than is the system of 
 vessels on one side like that of the other. And in 
 addition to this fact of a similarity of sides in the 
 vascular as in the osseous skeleton, I also remark that 
 
 both extremities of the aorta divide into branches 
 which are similar to one another above and below, 
 thereby conforming exactly with the upper and lower 
 limbs, which manifest unmistakable points of analogy. 
 
 The branches which spring from the aortic arch 
 above are destined to supply the head and upper limbs. 
 They are, h, the innominate artery, and i k, the left 
 common carotid and subclavian arteries. The branches 
 which spring from the other extremity of the aorta 
 are disposed for the support of the pelvis and lower 
 limbs ; they are the right and left common iliac arte¬ 
 ries, l M. These vessels exhibit, at both ends of the 
 main aortic trunk, a remarkable analogy; and as the 
 knowledge of this fact may serve to lighten the dry 
 and weary detail of descriptive anatomy, at the same 
 time that it points directly to views of practical im¬ 
 port, I may be allowed briefly to remark upon it as 
 follows : — 
 
 The vessels which spring from both ends of the 
 aorta, as seen in Plate 25, are represented in what is 
 called their normal character—that is, while three 
 vessels, hik, spring separately from the aortic arch 
 above, only two vessels, l and m, arise from the aorta 
 below. Let the anatomist now recall to mind the “pe¬ 
 culiarities” which at times appear amongst the vessels, 
 hik, above, and he will find that some of them abso¬ 
 lutely correspond to the normal arrangement of the 
 vessels, l m, below. And if he will consider the 
 “ peculiarities” which occur to the normal order of the 
 vessels, l m, below, he will find that some of these 
 correspond exactly to the normal order of the vessels 
 above. Thus, when i k of the left side join into a 
 common trunk, this resembles the innominate artery, 
 
 ( 61 ) 
 
COMMENTARY ON PLATE 25. 
 
 62 
 
 n, of the right side, and then both these vessels per¬ 
 fectly correspond with the two common iliac arteries 
 below. When, on the other hand, l and m, the com¬ 
 mon iliac arteries, divide, immediately after leaving 
 the aortic trunk, into two pairs of branches, they cor¬ 
 respond to the abnormal condition of the vessels, hik, 
 above; where h, immediately after leaving the aortic 
 arch, divides into two branches, like i k. With this 
 generalization upon the normal and abnormal facts of 
 arrangement, exhibited among the vessels arising from 
 both ends of the aorta, I furnish to the reader the idea 
 that the vessels, n i k, above may present of the same 
 figure as the vessels, l m, below, and these latter may 
 assume the character of hik, above. Whenever, 
 therefore, either set of vessels becomes the subject of 
 operation, such as having a ligature applied to them, 
 we must be prepared to meet the “ varieties.” 
 
 The veins assume an arrangement similar to that 
 of the arteries, and the above remarks will therefore 
 equally apply to the veins. In the same way as the 
 arteries, hik, may present in the condition of two 
 common or brachio-ceplialic trunks, and thereby simu¬ 
 late the condition of-the common iliac arteries, so we 
 find that the normal forms of the veins above and 
 below actually and permanently exhibit this very 
 type. The brachio-ceplialic veins, d b, Plate 26, ex¬ 
 actly correspond to each other, and to the common 
 iliac veins, s t ; and as these latter correspond precisely 
 with the common iliac arteries, so may we infer that 
 the original or typical condition of the vessels i k, 
 Plate 25, is a brachio-ceplialic or commQn-trunk union 
 corresponding with its brachio-ceplialic vein. When 
 the vessels, i K, therefore present of the bracliio-ceplia- 
 lic form as the vessel n, we have a perfect correspond¬ 
 ence between the two extremes of the aorta, both as 
 regards the arteries arising from it, and the veins 
 which accompany these arteries; and this condition 
 of the vascular skeleton I regard as the typical uni¬ 
 formity. The separate condition of the vessels i k, 
 notwithstanding the frequency of the occurrence of 
 such, may be considered as a special variation from 
 the original type. 
 
 The length of the aorta is variable in two or more 
 
 bodies; and so, likewise, is the length of the trunk of 
 each of those great branches which springs from its 
 arch above, and of those into which it divides below. 
 The modes in which these variations as to length oc¬ 
 cur, are numerous. The top of the arch of the aorta 
 is described as being in general on a level with the 
 cartilages of the second ribs, from which point it de¬ 
 scends on the left side of the spinal column ; and after 
 having wound gradually forwards to the forepart of 
 the lumbar spine at c, divides opposite to the fourth 
 lumbar vertebra into the right and left common iliac 
 arteries. The length of that portion of the aorta 
 which is called thoracic, is determined by the position 
 of the pillars of the diaphragm f, which span the ves¬ 
 sel ; and from this point to where the aorta divides 
 into the two common iliac arteries, the main vessel is 
 named abdominal. The aorta, from its arch to its 
 point of division on the lumbar vertebrae, gradually 
 diminishes in caliber, according to the number and 
 succession of the branches derived from it. 
 
 The varieties as to length exhibited by the aorta 
 itself, and by the principal branches which spring from 
 it, occur under the following mentioned conditions :— 
 When the arch of the aorta rises above or sinks below 
 its ordinary position or level,—namely, the cartilages 
 of the second ribs, as seen in Plate 25,—it varies not 
 only its own length, but also that of the vessels hik; 
 for if the arch of the aorta rises above this level, the 
 vessels hik become shortened; and as the arch sinks 
 below this level, these vessels become lengthened. 
 Even when the aortic arch holds its proper level in 
 the thorax, still the vessels hik may vary as to 
 length, according to the height to which they rise in 
 the neck previously to their division. When the aorta 
 sinks below its proper level at the same time that the 
 vessels hik rise considerably above that point at 
 which they usually arch or divide in the neck, then 
 of course their length becomes greatly increased. 
 When, on the other hand, the aortic arch rises above 
 its usual level, whilst the vessels hik arch and divide 
 at a low position in the neck, then their length be¬ 
 comes very much diminished. The length of the 
 artery h may be increased even though the arch of 
 
63 
 
 COMMENTARY 
 
 the aorta holds its proper level, and though the vessels 
 n i K occupy their usual position in the neck ; for it is 
 true that the vessel n may spring from a point of the 
 aortic arch A nearer to the origin of this from the 
 ventricle of the heart, whilst the vessel i may be 
 shortened, owing to the fact of its arising from some 
 part of n, the innominate vessel. All these circum¬ 
 stances are so obvious, that they need no comment, 
 were it not for the necessity of impressing the surgeon 
 with the fact that uncertainty as to a successful result 
 must always attach to his operation of including in a 
 ligature either of the vessels n i k, so as to affect an 
 aneurismal tumour. 
 
 Now whilst the length of the aorta and that of the 
 principal branches springing from its arch may be 
 varied according to the above-mentioned conditions, 
 so may the length of the aorta itself, and of the two 
 common iliac vessels, vary according to the place 
 whereat the aorta, c, bifurcates. Or, even when this 
 point of division is opposite the usual vertebra,—viz., 
 the fourth lumbar,—still the common iliac vessels 
 may be short or long, according to the place where 
 they divide into external and internal iliac branches. 
 
 ON PLATE 25. 
 
 The aorta may bifurcate almost as high up as where 
 the pillars of the diaphragm overarch it, or as low 
 down as the fifth lumbar vertebra. The occasional 
 existence of a sixth lumbar vertebra also causes a 
 variety in the length, not only of the aorta, but of the 
 two common iliac vessels and their branches.*)* 
 
 The difference between the perpendicular range of 
 the anterior and posterior walls of the thoracic cavity 
 may be estimated on a reference to Plate 25, in which 
 the xyphoid cartilage, e, joined to the seventh pair of 
 ribs, bounds its anterior wall below, while f, the pil¬ 
 lars of the diaphragm, bound its posterior wall. The 
 thoracic cavity is therefore considerably deeper in its 
 posterior than in its anterior wall; and this occasions 
 a difference of an opposite kind in the anterior and 
 posterior walls of the abdomen; for while the abdo¬ 
 men ranges perpendicularly from e to w, its posterior 
 range measures only from f to the ventra of the iliac 
 bones, r. The arching form of the diaphragm, and 
 the lower level which the pubic symphysis occupies 
 compared with that of the cristm of the iliac bones, 
 occasion this difference in the measure of both the 
 thorax and abdomen. 
 
 f Whatever may be the number of variations to which the 
 branches arising from both extremes of the aorta are liable, all 
 anatomists admit that the arrangement of these vessels, as ex¬ 
 hibited in riate 25, is by far the most frequent. The surgical 
 anatomist, therefore, when planning his operation, takes this 
 arrangement as the standard type. Haller asserts this order 
 of the vessels to be so constant, that in four hundred bodies 
 which he examined, he found only one variety —namely, that in 
 which the left vertebral artery arose from the aorta. Of other 
 varieties described by authors, he observes—“ Rara vero h®c 
 omnia esse si dixero cum quadringenta nunc cadavera humana 
 dissecuerim, fidem forte inveniam.” (Iconum Anatom.) This 
 variety is also stated by J. F. Meckel (Handbuch der Mensch 
 Anat.), Soemmerring (De Corp. Hum Fabrica), Boyer (Tr. 
 d’Anat.), and Mr. Harrison (Surg. Anat. of Art.), to be the most 
 frequent. Tiedemann figures this variety amongst others (Ta- 
 bulte Arteriarum). Mr. Quain regards as the most frequent 
 change which occurs in the number of the branches of the 
 aortic arch, “ that in which the left carotid is derived from the 
 innominate.” (Anatomy of the Arteries, &c.) A case is re¬ 
 corded by Petsche (quoted in Haller), in which he states the 
 
 bifurcation of the aorta to have taken place at the origin of the 
 renal arteries: (query) are we to suppose that the renal arteries 
 occupied their usual position 1 Cruveilhier records a case (Anat. 
 Descript.) in which the right common iliac was wanting, in con¬ 
 sequence of having divided at the aorta into the internal and 
 external iliac branches. Whether the knowledge of these and 
 numerous other varieties of the arterial system be of much 
 practical import to the surgeon, he will determine for himself. 
 To the scientific anatomist, it must appear that the main object 
 in regard to them is to submit them to a strict analogical rea¬ 
 soning, so as to demonstrate the operation of that law which 
 has produced them. To this end I have pointed to that analogy 
 which exists between the vessels arising from both extremities 
 of the aorta. “ Itaque convertenda plane est opera ad inquiren- 
 das et notandas rerum similitudines et analoga tarn integralibus 
 quam partibus; ill® enim sunt, qu® naturam uniunt, et consti- 
 tuere scientias incipiunt.” “Natura enim non nisi parendo 
 vincitur; et quod in contemplatione instar caus® est; id in 
 operatione instar regul® est.” (Novum Organum Scientiarum, 
 Aph. xxvii-iii, lib. i.) 
 
64 
 
 COMMENTARY 
 
 The usual position of the kidneys, G G*, is on either 
 side of the lumbar spine, between the last ribs and 
 the cristm of the iliac bones. The kidneys lie on the 
 fore part of the quadratus lumborum and psoce muscles. 
 They are sometimes found to have descended as low 
 as the iliac fosste, r, in consequence of pressure, occa¬ 
 sioned by an enlarged liver on the right, or by an 
 enlarged spleen on the left. The length of the ab¬ 
 dominal part of the aorta may be estimated as being 
 a third of the entire vessel, measured from the top of 
 its arch to its point of bifurcation. So many and such 
 large vessels arise from the abdominal part of the 
 aorta, and these are set so closely to each, other, that 
 it must in all cases be very difficult to choose a proper 
 
 ON PLATE 25. 
 
 locality whereat to apply a ligature on this region of 
 the vessel. If other circumstances could fairly justify 
 such an operation, the anatomist believes that the 
 circulation might be maintained through the anasto¬ 
 mosis of the internal mammary and intercostal arteries 
 with the epigastric; the branches of the superior me¬ 
 senteric with those of the inferior; and the branches 
 of this latter with the perineal branches of the pubic. 
 The lumbar, the gluteal, and the circumflex ilii arte¬ 
 ries, also communicate around the hip-bone. The 
 same vessels would serve to carry on the circulation 
 if either L, the common iliac, v, the external iliac, or 
 the internal iliac vessel, were the subject of the oper¬ 
 ation by ligature. 
 
 DESCRIPTION OE PLATE 25. 
 
 A. The arch of the aorta. 
 
 B B. The descending thoracic part of the aorta, giv¬ 
 ing off b b, the intercostal arteries. 
 
 C. The abdominal part of the aorta. 
 
 D D. First pair of ribs. 
 
 E. The xyphoid cartilage. 
 
 G G*. The right and left kidneys. 
 
 H. The brachio-cephalic artery. 
 
 I. Left-common carotid artery. 
 
 K. Left subclavian artery. 
 
 L. Right common iliac artery at its place of division. 
 
 M. Left common iliac artery, seen through the meso- 
 
 rectum. 
 
 N. Inferior vena cava. 
 
 0 0. The sigmoid flexure of the colon. 
 
 P. The rectum. 
 
 Q. The urinary bladder. 
 
 R. The right iliac fossa. 
 
 S S. The right and left ureters. 
 
 T. The left common iliac vein, joining the right under 
 
 the right common iliac artery to form the inferior 
 vena cava. 
 
 U. Fifth lumbar vertebra. 
 
 Y. The external iliac artery of right side. 
 
 W. The symphysis pubis. 
 
 X. An incision made over the locality of the femoral 
 
 artery. 
 
 b b. The dorsal intercostal arteries. 
 
 c. The coeliac axis 
 
 d. The superior mesenteric artery. 
 
 //. The renal arteries. 
 
 g. The inferior mesenteric artery. 
 
 h. The vas deferens bending over the epigastric artery 
 
 and the os pubis, after having passed through the 
 internal abdominal ring. 
 
FI. 25. 
 
 
 
COMMENTARY ON PLATE 26. 
 
 THE RELATION OF THE INTERNAL PARTS TO THE EXTERNAL SURFACE OF THE BODY. 
 
 An exact acquaintance with the normal character 
 of the external form, its natural prominences and 
 depressions, produced by the projecting swell of mus¬ 
 cles and points of hone, &c., is of great practical 
 importance to the surgeon. These several marks 
 described on the superficies he takes as certain guides 
 to the precise locality and relations of the more deeply 
 situated organs. And as, by dissection, Nature reveals 
 to him the fact that she holds constant to these rela¬ 
 tions, so, at least, may all that department of practice 
 whicli he bases upon this anatomical certainty be 
 accounted as rooted in truth and governed by fixed 
 principles. The same organ bears the same special 
 and general relations in all bodies, not only of the 
 human, but of all other species of vertebrata; and 
 from this evidence we conclude that the same marks 
 on surface indicate the exact situation of the same 
 organs in all similar bodies. 
 
 The surface of the well-formed human body presents 
 to our observation certain standard characters with 
 which we compare all its abnormal conditions. Every 
 region of the body exhibits fixed character proper to 
 its surface. The neck, the axilla, the thorax, the 
 abdomen, the groin, have each their special marks, 
 by which we know them; and the eye, well versed 
 in the characters proper to the healthy state of each, 
 will soonest discover the nature of all effects of injury 
 —such as dislocations, fractures, tumours of various 
 kinds, &c. By our acquaintance with the perfect, we 
 discover the imperfect; by a comparison with the 
 geometrically true rectangled triangle, or circle, w r e 
 estimate the error of these forms when they have 
 become distorted; and in the same way, by a know¬ 
 ledge of what is the healthy normal standard of human 
 form, we diagnose correctly its slightest degree of 
 9 
 
 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 con¬ 
 ceals 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, whicli 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 na¬ 
 ture, is he prepared to estimate the conditions of 
 disease, or interfere for its removal. 
 
 When fluid accumulates on either side of the tho¬ 
 racic compartment to such an excess that an opening 
 
 (65) 
 
66 
 
 COMMENTARY ON PLATE 26. 
 
 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, gakn, 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, akn, 
 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 possi¬ 
 bility of wounding the heart. The intercostal artery 
 at k is not of any considerable size. 
 
 In the normal state of the thoracic organs, the peri¬ 
 cardial 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 pericar¬ 
 dium, for the escape of its fluid contents, if such pro- ! 
 
 ceeding 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 cathar¬ 
 tic, 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 sym¬ 
 physis pubis. The anatomist chooses this median 
 line as the safest place in which to perform paracen¬ 
 tesis 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 pro¬ 
 priety 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 drop¬ 
 sical accumulation to such an extent as to distend the 
 abdomen very considerably. Ovarian dropsy is dis¬ 
 tinguished 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 
 
COMMENTARY ON PLATE 26. 
 
 67 
 
 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 accord¬ 
 ing to the line of gravitation. 
 
 Now, though the above-mentioned circumstances 
 be anatomically true respecting dropsical effusion 
 within the general peritonceal 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 peritonceal 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 liga¬ 
 ments. The spleen occupies the left side, 12. The 
 ccecum and the sigmoid flexure of the colon occupy, 
 e R :i: , 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 what¬ 
 ever 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 abdomi¬ 
 
 nal 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 sym¬ 
 physis. 
 
 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,-j* f, may 
 press upon the veins, n or d, and cause an cedematous 
 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 obstruc¬ 
 tion 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.J An abscess or 
 
 
 
 t 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 circum¬ 
 stances which render the operation of tying the vessel in cases 
 of aneurism very doubtful as to a successful issue. The opera¬ 
 tion (so far as I know) has hitherto failed. Anatomical rela¬ 
 
 tions, 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. # 
 
 J The effusion of fluid into the pleural sac (from whatever 
 cause it may arise) sometimes takes place to a very I’emarkable 
 extent. I have had opportunities of examining patients, in 
 whom the heart appeared to be completely dislocated, from the 
 
 
68 
 
 COMMENTARY ON PLATE 26. 
 
 other tumour of the liver may, by pressing on the 
 vena ports, cause serous effusion into the peritonmal 
 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 press¬ 
 
 ing 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 disadvanta¬ 
 geous right angle, into the left renal vein. 
 
 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 brachio-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. CEsophagus. 
 
 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. 
 
 Y. 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 sym¬ 
 physis. 
 
 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. 
 
 left to the right side, owing to the large collection of serous | contracted in their abnormal position, did not immediately 
 
 fluid in the left pleural sac. The heart’s pulsations could be resume their proper situation when the fluid was withdrawn 
 
 felt distinctly under the right nipple. Paracentesis thoracis from the chest. Nor is it to be expected that they should 
 was performed at the point indicated in Plate 26. In these ever return to their normal character and position, when the 
 
 cases, and another observed at the Hotel Dieu, the heart and disease which caused their displacement has been of long 
 
 lung, in. consequence of the extensive adhesions which they standing. 
 

 
 
 
 . 
 
 
 
 ! 
 
 
 
 
 
 
 
 
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 sur¬ 
 geon 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 hernia3, 
 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 evi¬ 
 dence. And it would seem that nothing can more 
 directly tend to this simplification, than that of view¬ 
 ing 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 hernias 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 
 hernias 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 ab¬ 
 dominal hernias 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 ad¬ 
 dition 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 gravi¬ 
 tation 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. 
 
 Hernias 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 pecu¬ 
 liarities do not serve to distinguish hernias, 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 hernias happen at those 
 localities where the abdominal walls are traversed by 
 the bloodvessels on their way to the outstanding or¬ 
 gans, 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 ]x>int 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 im¬ 
 mediately beneath this, the crural arch, which gives 
 
TO 
 
 COMMENTARY 
 
 exit to the crural vessels. Hernise may happen at 
 other localities, such as at the thyroid aperture, which 
 transmits the thyroid vessels; and at the greater sacro- 
 sciatic notch, through which the gluteal vessels pass; 
 and all regions of the abdominal walls may give exit 
 to intestinal protrusion in consecpiencc of malforma¬ 
 tions, disease, or injury. But as the more frequent 
 varieties of hernias are those which traverse the 
 localities, A, d, e, and as these, fortunately, are the 
 most manageable under the care of the surgical ana¬ 
 tomist, 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 de¬ 
 monstrates to us the fact, that where the spermatic 
 cord, D f, and the femoral vessels, pass from the abdo¬ 
 men 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 
 hernise which follow the passages made by the sper¬ 
 matic cord, and the crural vessels, must necessarily 
 carry with them the like investments, and these are 
 what constitute the coverings of the hernias them¬ 
 selves. 
 
 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 undulat¬ 
 ing 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 exter¬ 
 nal 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 
 
 ON PLATE 27. 
 
 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 in¬ 
 vesting membrane called the superficial fascia. This 
 fascia, a a a, stretches over the lower part of the ab¬ 
 domen 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 over- 
 lies 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, 
 
COMMENTARY ON PLATE 27. 
 
 71 
 
 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 ilio¬ 
 pubic 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,”j* 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 mem¬ 
 branes form the two outermost envelopes for the in¬ 
 testine in its new and abnormal situation. 
 
 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 in¬ 
 guinal hernia descends from d to f, it approaches the 
 
 f On referring to the works of Sir Astley Cooper, Hessel- 
 bach, 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 struc¬ 
 tures 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 super¬ 
 ficial 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 considera¬ 
 tions 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 are absolutely of no mo¬ 
 
 situation of the saphenous opening, e, which is the 
 seat of the femoral or crural hernia, and both varie¬ 
 ties 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 inguinofemoral 
 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 sa¬ 
 phenous 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 sa¬ 
 phenous 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, 7i-, the external cutaneous, which is given off from 
 
 ment, and in a purely scientific view, they are, so far as re¬ 
 gards the substance of the truth which they would reveal, 
 wholly beneath the notice of the rational mind. The prac¬ 
 titioner 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 aponeuro- 
 tica?” 
 
72 
 
 COMMENTARY ON PLATE 27. 
 
 tlie 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 subcutane¬ 
 ous, 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 sa- 
 phenous opening. The former group receive the 
 lymphatic vessels of the generative organs; and the 
 glands of which it is composed are those which sup¬ 
 purate 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 bifur¬ 
 cates 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 pul¬ 
 sating under the pressure of the hand; for the verte¬ 
 brae 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 bifur¬ 
 cation. 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 ex¬ 
 ternal 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 
 
 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 mani¬ 
 
 fested 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. 
 
 OF TLATE 27. 
 
 II. 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 sper¬ 
 
 matic 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. 
 
 /. The middle cutaneous nerve, derived from the an¬ 
 terior crural nerve. 
 
 g. Femoral lymphatic glands. 
 
 h. Superficial external iliac vein. 
 
 i. Superficial epigastric vein. 
 
 Jc. External cutaneous branches of nerves from the 
 lumbar plexus. 
 
COMMENTARY ON PLATES 28 & 29. 
 
 THE SURGICAL DISSECTION OF THE FIRST, SECOND, TniRD, AND FOURTH LAYERS OF 
 THE INGUINAL REGION IN CONNEXION WITH THOSE OF THE THIGH. 
 
 The common integument or first layer of the in- 
 guino-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 correspond¬ 
 ing with this line the fascia is devoid of adipous sub¬ 
 stance, 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 gene¬ 
 rally loaded with a considerable quantity of adipous 
 tissue, will account for the permanency and distinct¬ 
 ness of the fold of the groin. As this fold corresponds 
 with Poupart’s ligament, it is taken as a guide to dis¬ 
 tinguish between the inguinal and femoral forms of 
 hernice. 
 
 The general relations of the superficial fascia are 
 well described by Camper in the following sentence : 
 “ Musculus obliquus igitur externus abdominis, qua 
 parte cameus est, membrana quadam propria, quali 
 omnes musculi, tegitur, quse 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 mus¬ 
 culo cremasteri, ac aponeuroseos speciem musculis 
 anterioribus femoris, qua glandulse inguinales, ac 
 cruris vasa majora obteguntur.” (leones 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, 
 10 
 
 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, PI. 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 inguinoffemoral region, as being the seat of 
 hernial protrusions, may in this stage of the dissec¬ 
 tion 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, bcd, 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 hernim occur immediately above the line, 
 c d, while the femoral varieties of hernim take place 
 below this line. The hernijn 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, bcd, 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 for¬ 
 wards 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 
 
 ( 73 ) 
 

 
 
 74 
 
 COMMENTARY ON PLATES 2S & 29. 
 
 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 n, 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 liga¬ 
 ment 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 flex¬ 
 ing 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 hernioe. 
 
 Immediately above the middle of Poupart’s liga¬ 
 ment, at the point e, PI. 28, we observe the commence¬ 
 ment 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 identi¬ 
 fies 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 simi¬ 
 lar 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, PI. 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 pen¬ 
 dulous as far outwards as the point e, PI. 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 tra¬ 
 versing the inguinal parietes, these parts are fortified 
 against the occurrence of hernia. In PI. 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 PI. 29, the 
 upper band of fibres (“ internal pillar of the ring”) 
 may be seen proceeding to its insertion into the sym¬ 
 physis 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, PI. 28, together with its spermatic elon¬ 
 gation, E, we expose the internal oblique, F E, PI. 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, 
 
COMMENTARY ON PLATES 28 & 29. 
 
 75 
 
 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 to¬ 
 tality. Cloquet (R4clierches anatomiques sur les 
 Hernies de l’Abdomen) first demonstrated the cor¬ 
 rectness of this idea. 
 
 The oblique and serial arrangement of the mus¬ 
 cular fibres of the internal oblique, f, PI. 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 scro¬ 
 tum, carried with it a muscular covering, at the ex¬ 
 pense of the internal oblique muscle. The cremas¬ 
 ter, 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 there¬ 
 fore necessarily become invested by cremasteric fibres. 
 
 The fascia lata, n, PL 28, being strongly connected 
 and continuous with Poupart’s ligament along its in¬ 
 ferior border, the-boundary line, which Poupart’s liga¬ 
 ment 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., n, the iliac part, and l, 
 
 the pubic. The iliac part, h, which is external, and 
 occupying a higher plane than the pubic part, is at¬ 
 tached to Poupart’s ligament along its whole extent, 
 from c to D, PI. 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 fas¬ 
 cia 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 in¬ 
 terval 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, 7i, 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 be¬ 
 neath 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 super¬ 
 ficial 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 
 
76 
 
 COMMENTARY ON PLATES 28 & 29. 
 
 sheatli, lie immediately beneath the iliac part of the 
 fascia lata, in that angle which is expressed by Pou- 
 part’s ligament, along the line c d above; by the sar- 
 torius muscle in the line c m externally; and by a 
 line drawn from d to n, corresponding to the pec- 
 tineus 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 7i, PI. 28, the dense falciform process, h, em¬ 
 
 braces 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, PI. 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 distinc- 
 I tive 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 mus¬ 
 cle 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 indi¬ 
 
 cates 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. 
 
 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. 
 
 II. The iliac part of the fascia lata; Ji, 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; its upper 
 
 part. 
 
 O. The saphena vein. 
 
 P. The pubic part of the fascia lata. 
 
__-____ 7 ' 
 

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 cremas¬ 
 ter muscles, we expose the transverse muscle, which 
 may be regarded as the fifth inguinal layer , f, PI. 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, Pou- 
 part’s ligament. The fleshy fibres of these two mus¬ 
 cles 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 apo¬ 
 neurotic 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 be¬ 
 tween 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 out¬ 
 wards to its insertion into the pectineal ridge of the 
 
 pubic bone, as to occupy a situation immediately be¬ 
 hind 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, to¬ 
 gether 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 explana¬ 
 tion 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 tes¬ 
 ticles has been arrested in the inguinal canal, the 
 muscles, e f, do not present a defined arched margin, 
 
 (77) 
 
78 
 
 COMMENTARY ON PLATES 30 & 31. 
 
 above the vacant space l 7i, 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 spaoe 
 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 cre¬ 
 master. 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 compara¬ 
 tively, 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 cre¬ 
 masteric elongation of these muscles, and then de¬ 
 scribe 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 in¬ 
 guinal layer, L 7i, 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 peritonceum, 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 be¬ 
 tween them and the serous membranes, and afford 
 sbeaths or envelopes for these vessels in their passage 
 from the interior to the external parts. The sheath, 
 n 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 trans¬ 
 versalis. 
 
 In the groin, the transversalis fascia, k l', 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 peritonceum, 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 low'er posterior aspect of the rec¬ 
 tus muscle, where this is devoid of its sheath; and it 
 is incorporated with /, the conjoined tendon, thereby 
 fencing the external abdominal ring. Immediately 
 above the middle of Poupart’s ligament, this mem¬ 
 brane, 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 infundibuli- 
 form” (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 
 
COMMENTARY ON PLATES 30 & 31. 
 
 79 
 
 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 trans¬ 
 versals join along the line of Poupart’s ligament, A c. 
 The iliac vessels, in their passage to the thigh, en¬ 
 counter 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 transver- 
 salis — 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 sub- 
 serous cellular membrane, which serves as a connect¬ 
 ing medium between the fascia and the peritonaeum. 
 This cellular membrane may be considered as the 
 seventh inguinal layer. It is described by Scarpa 
 (suir Ernie) as forming an investment for the sper¬ 
 matic 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 hernia}. 
 
 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 sper¬ 
 matic 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 peritonmum, 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 be¬ 
 fore 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 hernias 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 re¬ 
 marks 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 peritonmum, 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 con¬ 
 tinued 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. 
 
so 
 
 COMMENTARY ON PLATES 30 & 31. 
 
 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 con¬ 
 dition 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 de¬ 
 termining the precise relative position of the several 
 parts of the inguinal region. 
 
 DESCRIPTION OF TIIE EI( 
 
 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; /, its tendon, forming, 
 
 with e, the conjoined tendon. 
 
 * G. The rectus muscle enclosed in its sheath. 
 
 II. 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. 
 
 Y. The iliac portion attached to Poupart’s ligament. 
 W. The lower part of the iliacus muscle. 
 
 Plate 31. 
 
 A. The anterior superior iliac spine. 
 
 B. The umbilicus. 
 
 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 hernim than others. 
 
 rURES 0E PLATES 30 & 31. 
 
 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; /, 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; 7c, its pubic part. 
 
 L. The epigastric artery and veins. 
 
 M. The spermatic artery, veins, and vas deferens 
 
 bending round the epigastric artery at the inter¬ 
 nal 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. 
 
 Y. The iliac part of the fascia lata. 
 
 W. The lower part of the iliacus muscle. 
 

 lithUH Che snutV Phil 
 
COMMENTARY ON PLATES 32, 33, & 34. 
 
 THE DISSECTION OF THE OBLIQUE OR EXTERNAL AND THE DIRECT OR INTERNAL 
 
 INGUINAL HERNUE. 
 
 The order in which the herniary bowel takes its in¬ 
 vestments 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 peri- 
 ton teum, 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 hernise are said to be enveloped 
 in a sac, or elongation of the peritoneum. This is 
 accounted as the general rule. The exceptions to the 
 rule are mentioned as occurring in the following 
 modes: 1st, the cecum and sigmoid flexure of the 
 colon, which are devoid of mesenteries, and only 
 partially covered by the peritoneum, may slip down 
 behind this membrane, and become hernial; 2nd, the 
 inguinal part of the peritoneum may suffer rupture, 
 and allow the intestine to protrude through the open¬ 
 ing. When a hernia occurs under either of these 
 circumstances, it will be found deprived of a sac. 
 
 All the bloodvessels and nerves of the abdomen lie 
 external to the peritoneum. Those vessels which 
 traverse the abdomen on their way to the external 
 organs course outside the peritoneum; 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 peritoneum which lines the ingui¬ 
 nal 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. ( 
 11 
 
 It is in these places, where the membrane happens to 
 be unsupported, that hernie 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 fosse, by an intervening crescentic fold of 
 the peritoneum, 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 peritoneum, 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 op¬ 
 posite 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 peritoneal fosse being named external and 
 internal, in reference to the situation of the epigastric 
 vessels, we find that the two varieties of inguinal 
 hernie which occur in these fosse are named external 
 and internal also, in reference to the same part. 
 
 The external inguinal hernia, so called from its 
 commencing in the outer peritoneal fossa, on the 
 outer side of the epigastric artery, takes a covering 
 from the peritoneum of this place, and pushes forward 
 into the internal abdominal ring at the point marked 
 p, Plate 32. In this place, the incipient hernia 
 
 ( 81 ) 
 
 or 
 
82 
 
 COMMENTARY ON PLATES 32, 33, & 34. 
 
 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 sper¬ 
 matic vessels, anterior, while the protruded intestine 
 itself is separated from actual contact with either of 
 these vessels by its proper sac. The bubonocele, pro¬ 
 jecting 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 di¬ 
 rectly forwards becomes arrested by the tense resists 
 ing 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, pur¬ 
 sued 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 exter¬ 
 nal ring, n, so as to form a tumour of the size and in 
 the situation of f<j, it is named “complete.” When, 
 lastly, the hernia has extended itself so far as to oc¬ 
 cupy 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, how¬ 
 ever, 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, comparar 
 lively 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 accompa¬ 
 nies 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 mus¬ 
 cular 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 pro¬ 
 cess has taken place, and where a cremaster does not 
 exist at the expense of the internal oblique and trans¬ 
 verse 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 peritoneal 
 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, carry- 
 
83 
 
 COMMENTARY ON 
 
 ing investments from each of such structures as it 
 meets with in this locality of the groin. As the exter¬ 
 nal ring, h, Plate 34, is opposite the inner peri tomcat 
 fossa, Q e, 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, F and R, 
 Plate 32, within the abdomen, arrive at the same 
 place—viz., the external ring, B, 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 struc¬ 
 tures ; these are, 1 st, the peritonaeum, g, which forms 
 its sac; 2 nd, 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 
 
 PLATES 32, 33, & 34. 
 
 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 transver¬ 
 salis in all instances* 
 
 The variety in the number of investments of the 
 internal inguinal hernia (especially as regards the 
 presence or absence of the conjoined tendon and cre¬ 
 master) appears to me to be dependent, 1 st, upon the 
 position whereat this hernia occurs ; 2 nd, upon the 
 state of the parts through which it passes; and 3 rd, 
 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 nar¬ 
 row, and removed from it nearer to the median line. 
 At the external ring, h, (Plate 34,) the sac of this 
 hernia, < 7 , 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, 1 , the crista pubis. At the ring, h, (Plate 34,) 
 the investments, gf of the direct hernia are not 
 always distinct from those of the oblique hernia, <7 /, 
 (Plate 33); for whilst in both varieties the intestine 
 
 * Mr. Lawrence (Treatise on Ruptures) remarks, “ How 
 often it may be invested by a protrusion of the fascia transver¬ 
 salis, 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 her¬ 
 nia 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 abdom- 
 inali 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, qua: involucre adeo inhserent, ut pro lubitu musculum 
 (membranam) eflormare queas unde magnam illam inter ana- 
 tomicos discrepantiam ortam conjicio.” (Camper. leones 
 Herniarum.) 
 
84 
 
 COMMENTARY ON PLATES 
 
 33, & 34. 
 
 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, 
 & 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 com¬ 
 pletely 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. Hiacus muscle. 
 
 II. Psoas magnus muscle supporting the spermatic 
 vessels. 
 
 I. Transversalis muscle. 
 
 K. Termination of the sheath of the rectus muscle. 
 L 1 L 2 L 3 . The iliac, transverse and pelvic portions of 
 the transversalis fascia. 
 
 M M. The peritonmum lining the groin. 
 
 N. The epigastric vessels lying between the perito¬ 
 
 neum, M, and the transversalis fascia, L 2 . 
 
 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 liga¬ 
 ment 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. 
 
 Y. External iliac artery covered by the peritonaeum. 
 
 W. Internal iliac artery. 
 
 X. Common iliac artery. 
 
 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 /. The funnel-shaped sheath of the spermatic ves¬ 
 sels covering the external hernia; upon it are 
 seen the cremasteric fibres. 
 
 G g. The peritoneal covering or sac of the external 
 hernia within the sheath. 
 
 H. The external abdominal ring. 
 
 I. The crista pubis. 
 
 K h. 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. 
 
 Plate 34.— The Internal Inguinal Hernia. 
 
 The letters indicate the same parts as in Plate 33 
 
'_ 
 

COMMENTARY ON PLATES 35, 36, 37, & 38. 
 
 THE DISTINCTIVE DIAGNOSIS BETWEEN EXTERNAL AND INTERNAL INGUINAL 
 HEENIxE, THE TAXIS, THE SEAT OF STRICTURE, AND THE OPERATION. 
 
 A comparison of the relative position of these two 
 varieties of hernias 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 hernise 
 occur at the situations commonly described, and where 
 they manifest their broadest contrast, that the follow¬ 
 ing 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, n, 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 direc¬ 
 tion of this hernia is immediately from behind for¬ 
 wards, 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 ex¬ 
 ternal 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 hernise, 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 hernias 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, n, 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 exter¬ 
 nal 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 hernise 
 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 exter¬ 
 nal hernia, G, not having descended the canal as far 
 
 ( 85 ) 
 
86 
 
 COMMENTARY ON PLATES 35, 36, 3 7, & 38. 
 
 as tlie external ring, T, allows the internal hernia, h, 
 to assume its usual position with respect to the 
 cord, q* 
 
 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 gravita¬ 
 tion, the obliquity of the inguinal canal to such a 
 degree as to bring the internal, n, 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 reduc¬ 
 tion 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 alway 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 reduc¬ 
 tion 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 ex¬ 
 ternal 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, /, Plate 38, this struc¬ 
 ture 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 cremas¬ 
 teric 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 hernias, the neck of the 
 sac is described as being occasionally the seat of stric¬ 
 ture, and it certainly is so; but never from a cause 
 
 * 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 in¬ 
 guinal hernias in each inguinal region. (Ing. et Congenit. Hernia?.) 
 
87 
 
 COMMENTARY ON P] 
 
 originating in itself per se, or independently of adja¬ 
 cent 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, 
 n, 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 con¬ 
 stricting 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 pro¬ 
 ceeding 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 replace¬ 
 ment 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 in¬ 
 vagination ; 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. 
 
 ATES 35, 36, 37, & 38. 
 
 The operation for the division of the stricture by 
 the knife is conducted in the following way : an inci¬ 
 sion 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 
 , 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 constric¬ 
 tion 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 pro¬ 
 duced by either of the muscles which lie beneath the 
 aponeurosis of the external oblique, it will be neces- 
 sary 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 adhe¬ 
 sions which it may have contracted with some part 
 of the sac, it then becomes necessary to open this en¬ 
 velope. 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, re¬ 
 quires the incision to be made outwards from the ex¬ 
 ternal 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 
 m 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 
 
88 
 
 COMMENTARY ON PLATES 35, 36, 37, & 38. 
 
 case of this kind with positive certainty, it is there-1 ring to Plates 32, 33, 34, 35, 36, 37, & 38, that an in- 
 fore recommended to incise the stricture at the neck cision carried obliquely upwards towards the umbilicus 
 of the sac in a line carried directly upwards. (Sir would be much more likely to avoid the epigastric 
 Astley Cooper.) It will be seen, however, on refer- 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 situa- j 
 
 tion of the middle of Poupart’s ligament. 
 
 B. Symphysis pubis. 
 
 C. Rectus abdominis muscle covered by the fascia transversalis. 
 
 D. The peritonseum 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 epigas¬ 
 
 tric 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. 
 
 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 ar¬ 
 tery 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. 
 
 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. 
 
 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 re 
 
 ceiving 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 di¬ 
 rect inguinal hernia. 
 

_ 
 


 

COMMENTARY ON PLATES 39 & 40. 
 
 DEMONSTRATIONS OF THE NATURE OF CONGENITAL AND INFANTILE INGUINAL 
 IIERNIjE, 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 ab¬ 
 dominal 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 peri¬ 
 tonaeum is reflected from it, a small membranous fold 
 or mesentery (mesorchium, Seiler ) is formed, and be¬ 
 tween the layers of this the nerves and vessels enter 
 the organ, the nerves being derived from the neigh¬ 
 bouring 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 (pro¬ 
 cessus 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* 
 
 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.f The testis in the loins has a cover¬ 
 ing from both membranes, and is still found to be en¬ 
 closed 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 re¬ 
 spectively the tunica albuginea and tunica vaginalis 
 when the gland occupies the scrotal cavity. 
 
 Plate 39, Fig. 2.— The testicle in the scrotum .— 
 
 * 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 contrac¬ 
 tion of the gubernaculum, since that does not contain any 
 fibrous structure until after the lowering of the testis has com¬ 
 menced.” Dr. Sharpey (Quain’s Anatomy, 5th edition) 
 observes, that “ the office of the gubernaculum is yet imper¬ 
 fectly 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 
 12 
 
 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. 
 
 f 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.) 
 
 ( 89 ) 
 
92 
 
 COMMENTARY ON PLATES 39 & 40. 
 
 ing pervious, a congenital hernia is formed .—When the 
 testicle, 7, has descended to the scrotum, if the com¬ 
 munication between the peritonreum, 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 tunicas vaginalis, Cooper) , the intestine 
 is in front of, and in immediate contact with, the tes¬ 
 ticle. 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 congen¬ 
 ital 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 trans¬ 
 parency and fluctuation. The impulse which is com¬ 
 municated 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 hydro¬ 
 cele. But in hydrocele of the separate tunica vagi¬ 
 nalis, 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. 
 
 Plate 40, Eig. 5. — Infantile hernia .—When the 
 serous spermatic tube becomes merely closed, or oblit¬ 
 erated at the inguinal ring, 6 h, 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 peritonasum, 6 a, near the 
 closed ring, 6 h, 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 perito¬ 
 neum 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 h, and will thus invest and 
 obscure the descending herniary sac, 13. This form 
 of hernia is named infantile (Hey), owing to the con¬ 
 genital 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. 
 
 Plate 40, Fig. G.— Oblique inguinal hernia in the 
 adult. —This variety of hernia occurs not in conse¬ 
 quence 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, de¬ 
 rived anew from the inguinal peritonasum, 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. G, 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 en¬ 
 tered 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 hernias have happened. 
 
COMMENTARY ON PLATES 41 & 42. 
 
 DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF INGUINAL HERNIH3 
 
 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.* 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 peritonceum, which it dilates and pouches be¬ 
 fore itself. As the epigastric artery, 9, bends in gen¬ 
 eral 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. 
 
 Plate 41, Fig. 2—When the serous spermatic tube, 
 11, remains pervious between the internal ring, 1, 
 (where it communicates with the general peritonmal 
 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 infan¬ 
 tile 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 
 hernia?, forasmuch as it will lie in immediate contact 
 with the testicle.-)- 
 
 Plate 41, Fig. 3.—The infantile serous spermatic 
 tube, 11, sometimes remains pervious in the neigh¬ 
 bourhood of the internal ring, 1, and a narrow taper¬ 
 ing 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 
 
 * Mr. Lawrence (op. cit.) remarks, “ When we consider the 
 texture of the peritonasum, and the mode of its connexion to 
 the abdominal parietes, we cannot fancy the possibility of tear¬ 
 ing the membrane by any attitude or motion.” Cloquet and Scar¬ 
 pa have also expressed themselves to the effect, that the perito¬ 
 naeum suffers a gradual distention before the protruding bowel. 
 
 t A hernia may he 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 tra¬ 
 verses the open internal inguinal ring and pervious tube will not 
 enter the tunica vaginalis. 
 
 ( 93 ) 
 
94 
 
 COMMENTARY ON PLATES 41 & 42. 
 
 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 ves¬ 
 sels is the same as that mentioned above. 
 
 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 peritonceal 
 membrane; and if, at the same time, it remain per¬ 
 vious from this point above to the tunica vaginalis 
 below, then the herniary bowel, when about to pro¬ 
 trude at the point 1, must force and dilate the perito¬ 
 naeum, 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 ori¬ 
 ginal state of the parts may, however, suffer modifica¬ 
 tion 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 
 
 * 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 
 
 tunica vaginalis still exist in communication. In 
 either case, the hernia will hold the same relative 
 position in regard to the epigastric artery and sper¬ 
 matic vessels, as stated of Fig. 1, Plate 41. 
 
 Plate 41, Fig. 5.—Sudden rupture of the peritonteum 
 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 peritonamm suffers dila¬ 
 tation at the internal ring, 1, it advances gradatim 
 and pa/r% 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. 
 
 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 pro¬ 
 cesses, 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 in¬ 
 fundibuliform manner* 
 
 Plate 41. Fig. 7. —When an external inguinal 
 
 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 philo- 
 
COMMENTARY ON PLATES 41 & 42. 
 
 95 
 
 hernia, 11, dilates and protrudes the peritoneum from 
 the closed internal ring, 1, and descends the ingui¬ 
 nal 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 inter¬ 
 nal 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 perito¬ 
 neum 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. 
 
 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 re¬ 
 ceived into the original serous infantile tube. The 
 possibility of these occurrences is self-evident, even if 
 they were never as yet experienced.* 
 
 Plate 42, Fig. 1.—The epigastric artery, 9, being 
 covered by the fascia transversalis, can lend no sup¬ 
 port to the internal ring, 2, 2, nor to the tube pro¬ 
 longed from it. The herniary bowel may, therefore, 
 dilate the peritomeum 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. 
 
 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 epi¬ 
 gastric 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.+ 
 
 sophic 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 elon¬ 
 gates their fibres. 
 
 * According to Mr. Lawrence and M. Cloquet, most of the 
 
 serous cysts found around hernial tumours are ancient sacs oblit 
 erated at the neck, and adhering to the new swelling (opera cit.) 
 
 t 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.) 
 
96 
 
 COMMENTARY ON PLATES 41 & 42. 
 
 It is impossible for any internal hernia to assume the 
 congenital form, because the neck of the original se¬ 
 rous 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. 
 
 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 onty 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. 
 
 Plate 42, Fig. 4.—The external hernia, from hav¬ 
 ing 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 pro¬ 
 jects directly from behind forwards, through, 4, the 
 external ring. The conjoined tendon, 6, when weak, 
 becomes bent upon itself. The change of place per¬ 
 formed 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 in¬ 
 guinal 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.* 
 
 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 po¬ 
 sition. This obliquity is caused by a change of place, 
 performed rather by the internal than the external 
 ring.-j- 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 trans¬ 
 mits the round ligament, 14, accounts anatomically 
 for the fact, that this sex is less liable to the occur¬ 
 rence of rupture in this situation. 
 
 * 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 exter¬ 
 nal ring. 
 
 ■f M. Velpeau (Nouveaux Elemens de med. Operat.) states 
 the length of the inguinal canal in a well-formed adult, mea¬ 
 
 sured from the internal to the external ring, to be 1£ 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 measure¬ 
 ment, from any given point whatever. The judgment alone 
 must fix the general average. 
 
f 1.12. 
 
 I’iinclaiis litilCl Cfcu^.ui S' 1 Phil 
 
 
COMMENTARY ON PLATES 43 & 44. 
 
 THE DISSECTION OF FEMORAL HERNIA, AND THE SEAT OF STRICTURE. 
 
 Whilst all forms of inguinal hernias 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 immedi¬ 
 ately 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 hernias, 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 hernias 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 hernias, 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 
 hernias 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 an¬ 
 terior 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 extrem¬ 
 ity appear the external ring and the saphenous open¬ 
 ing. On cutting through the falciform process, F, 
 Fig. 1, Plate 44, we find Gimbernat’s ligament, r, a 
 13 
 
 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, corres¬ 
 ponding 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, h, the conjoined tendon. This 
 tendon is inserted with the ligament into the pecti¬ 
 neal 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 con¬ 
 strict the femoral hernia. 
 
 The sheath, ef, of the femoral vessels, e f, Fig. 1, 
 Plate 43, passes from beneath the middle of the 
 
 (97) 
 
98 
 
 COMMENTARY ON PLATES 43 & 44. 
 
 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 compart¬ 
 ments 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 occfb- 
 sionally, 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, n, Fig. 2, Plate 43, is, in the 
 natural state of the parts, closed over by the perito- 
 nasum, in the same manner as this membrane shuts 
 the internal inguinal ring. There is, however, corre¬ 
 sponding to each ring, a depression in the peritoneal 
 covering; and here it is that the bowel first forces 
 the membrane and forms of this part its sac. 
 
 On removing the peritoneum 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 corre¬ 
 sponding canal. The ring is the point of union be¬ 
 tween 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) be¬ 
 neath the peritoneum. 
 
 The femoral ring, n, 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 con¬ 
 joined 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 liga¬ 
 ment, &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, 
 
COMMENTARY ON PLATES 43 & 44. 
 
 99 
 
 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, n, 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 gene¬ 
 rally accompanies the artery. These peculiarities in 
 the origin and course of the obturator artery, espe¬ 
 cially that of passing on the pubic side of the ring, 
 behind Gimbernat’s ligament and the conjoined ten¬ 
 don, 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, n, 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.f 
 Its further progress through the saphenous opening, 
 b f, Fig. 1, Plate 44, must be made either by rup¬ 
 turing the weak inner wall of the canal, or by dilating 
 this part; in one or other of these modes, the her¬ 
 niary sac emerges from the canal through the saphe¬ 
 nous 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,J and ultimately rests upon the iliac 
 fascia lata, below the pubic third of Poupart’s liga¬ 
 ment. 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§ 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. 
 
 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 
 
 f 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. 
 
 X The “ upper cornu of the saphenous opening,” the “ falci¬ 
 form 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! 
 
 § The neck of the sac at the femoral ring lies very deep, in 
 the undissected state of the parts (Lawrence). 
 
100 
 
 COMMENTARY ON PLATES 43 & 44. 
 
 sac.* This hernia suffers stricture of the passive 
 kind always ; for the dense fibrous bands in its neigh¬ 
 bourhood 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. 
 
 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, /, 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. 
 
 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. 
 
 PLATE 44. 
 
 Figure 1. 
 
 A. Anterior superior iliac spine. 
 
 B. The crural hernia. 
 
 C. Round ligament of the uterus. 
 
 D. External oblique muscle; cl, Fig. 2, its aponeurosis. 
 
 E. Saphsena 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; 7c, 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 liga¬ 
 
 ment. 
 
 H. Glands in the neighbourhood of the saphenous 
 
 opening. 
 
 I. The sartorius muscle seen through its fascia. 
 
 * Sir A. Cooper (Crural Hernia) is of opinion that the 
 stricture is generally in the neck of the sheath. Mr. Law¬ 
 rence 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.) 
 
' ____ • _ 
 
• n'U 
 
COMMENTARY ON PLATES 45 & 46. 
 
 DEMONSTRATIONS OP THE ORIGIN AND 
 DIAGNOSIS, THE TAXIS, 
 
 Plate 45, Pig. 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 peculiar¬ 
 ities in the courses of these two herni®; and they 
 are readily accounted for by the anatomical relations 
 of the parts concerned. 
 
 Plate 45, Pig. 2. — There exists a very evident 
 analogy between the canals through which both 
 hernias pass. The infundibuliform fascia, 3, 3, of the 
 spermatic vessels is like the infundibuliform sheath, 
 9, 9, of the femoral vessels. Both sheaths are pro¬ 
 ductions 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 
 
 PROGRESS OF FEMORAL HERNIA —ITS 
 AND THE OPERATION. 
 
 of union between the oblique aponeurosis of the 
 abdominal muscle and the fascia lata, merely over¬ 
 arches the femoral sheath, and does not separate it 
 absolutely from the spermatic sheath. 
 
 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 repre¬ 
 sented 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. 
 
 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 re¬ 
 moved 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. 
 
 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 
 
 ( 101 ) 
 
102 
 
 COMMENTARY ON PLATES 45 & 46. 
 
 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.f The bowel, therefore, 
 enters the femoral canal, 9, and herein it lies covered 
 by its peritonmal 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 inci¬ 
 pient 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. 
 
 Plate 45, Fig. G. —The hernia, 2,12, increasing gra¬ 
 dually 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 con¬ 
 tinuous 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. 
 
 f 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 
 
 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 in¬ 
 guinal 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 respec¬ 
 tive hernim 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 im¬ 
 pulse which on coughing is felt at a place above the 
 femoral arch, will serve to indicate, by negative evi¬ 
 dence, that it is not a femoral hernia. 
 
 Plate 46, Fig. 2.—When the inguinal and femoral 
 hernim are fully produced, they best explain their 
 
 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.) 
 
COMMENTARY ON PLATES 45 & 46. 
 
 103 
 
 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 he 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. 
 
 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 epi¬ 
 gastric, 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 he 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 situa¬ 
 tion 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 ob¬ 
 turator artery,f 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 ana¬ 
 tomical knowledge, at the call of the most dexterous 
 operator, can render the vessel safe from danger ? 
 
 The taxis, in a case of crural hernia, should be 
 conducted in accordance with anatomical principles. 
 The fascia lata, Poupart’s ligament, and the abdo¬ 
 minal 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 liga¬ 
 ment 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 he effected by the 
 taxis, and the stricture still remains, the cutting ope¬ 
 ration is required. 
 
 The precise seat of the stricture cannot be known 
 
 f M. Velpeau (Medecine Operatoire), in reference to the re¬ 
 lative frequency of cases in which the obturator artery is de¬ 
 rived from the epigastric, remarks, “ L’examen que j’ai pu en 
 faire sur plusieurs milliers de cadavres, ne me permet pas de 
 dire qu’elie se rencontre un fois sur trois, ni sur cinq, ni rm'ine 
 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), 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 V’ 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 ? 
 
 
 
104 
 
 COMMENTARY ON PLATES 45 & 46. 
 
 except during the operation. But it is to be pre¬ 
 sumed that the sac and contained intestine suffer con¬ 
 striction throughout the whole length of the canal * 
 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 Gimber¬ 
 nat’s ligament be the structure which causes it. 
 
 An incision commencing a little way above Pou- 
 part’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 sub¬ 
 cutaneous 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 mem¬ 
 brane contained between the two layers of the super¬ 
 ficial 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 inter¬ 
 poses 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 directorf 
 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 up¬ 
 wards 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 ; Gim¬ 
 bernat’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 con¬ 
 tents. 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. 
 
 * “ The seat of the stricture is not the same in all cases, 
 though, in by far the greater number of instances, the constric¬ 
 tion 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 
 peritonasal membranes where they lie within the circumference 
 
 of the crural ring .”—Morton (Surgical Anatomy of the Grom 
 p. 148). 
 
 f 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 re 
 quired. 
 

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 prin¬ 
 cipal bloodvessels and nerves are transmitted to the 
 corresponding limb. The main artery of the lower 
 limb frequently becomes the subject of a surgical ope¬ 
 ration. 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 con¬ 
 sider 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 de¬ 
 scribed as follows:—The abdominal aorta, A, bifurcates 
 on the body of the fourth lumbar verteba. 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 imme¬ 
 diately 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 sym¬ 
 metrically 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 
 14 
 
 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 affect¬ 
 ing the vessel are attended with more difficulty and 
 danger than elsewhere, in its course. 
 
 The artery of the lower limb, arising at the bifurca¬ 
 tion of the aorta on the fourth lumbar vertebra, de¬ 
 scends obliquely outwards to the sacro-iliac junction, 
 and here it gives off its first branch, G, (internal iliac,) 
 to the pelvic organs. The main vessel is named com¬ 
 mon 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 
 
 105 
 
106 
 
 COMMENTARY ON PLATE 4 7. 
 
 this course, the artery is accompanied by the vein, 
 n 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 he 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 com¬ 
 mencement 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, y, crosses it, and thence de¬ 
 scends to the bladder. The internal iliac branch sub¬ 
 divides 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, agi, in approaching Poupart’s 
 ligament along the border of the true pelvis, are sup¬ 
 ported 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 sper¬ 
 matic artery and vein, together with the genito-crural 
 nerve, descend along the outer border of the iliac ar¬ 
 tery. 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 ante¬ 
 rior 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 
 
107 
 
 COMMENTARY 
 
 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 anastomotic 
 branch. The profundus branch, x, springs from the 
 outer side of the femoral artery usually at a distance 
 of from one to two inches (seldom more) below Pou- 
 part’s ligament, and soon subdivides:* The femoral 
 artery in a few instances has been found double. 
 
 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 expe¬ 
 dient 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.f 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 circu¬ 
 lation 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 else¬ 
 where 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 
 
 ON PLATE 47. 
 
 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 (an¬ 
 terior 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. 
 
 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 in¬ 
 terval between the epigastric and profundus branches. 
 In addition to this, it must be noticed, that occasion¬ 
 ally 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.| 
 
 * The ordinary length of each part of the main artery is 
 stated on the authority of Mr. Quain. See “ Anatomy of the 
 Arteries,” &c. 
 
 t 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. 
 
 t The main artery (Plate 47) has been exposed in the 
 iliac and femoral regions with the object of showing the rela¬ 
 tion which its parts bear to each other and to the whole; all 
 
108 
 
 COMMENTARY ON PLATE 47. 
 
 The external iliac part of the artery, G i, when re¬ 
 quiring 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 neces¬ 
 sary. The skin and the three abdominal muscles 
 having been successively incised, the fibrous transver- 
 salis 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 ad¬ 
 hering 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,* 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 equidis¬ 
 tant 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 opera¬ 
 tion of so serious a nature, that it can in this respect 
 be exceeded only by tying the aorta itself. The com¬ 
 mon 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 peri¬ 
 tonaeum would have to be disturbed to an equal extent. 
 
 DESCRIPTION 
 
 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 de¬ 
 ferens and spermatic vessels. 
 
 EE*. The right and left iliac muscles covered by the perito¬ 
 neum ; 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; gg, the right 
 and left ureters. 
 
 HH*. The right and left common iliac veins. 
 
 II*. The right and left external iliac arteries, each is crossed 
 by the circumflex ilii vein. 
 
 OF PLATE 47 . 
 
 IvK*. The right and left external iliac veins. 
 
 L. The urinary bladder covered bv the peritonaeum. 
 
 M. The rectum intestinum. 
 
 N. The profundus branch of the femoral artery. 
 
 O. The femoral vein; o, 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. 
 
 Y. 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. 
 
 the other dissections have been made upon the same plan, the 
 practical tendency of which will be illustrated when consider¬ 
 ing the subject of arterial anastomosis. 
 
 * 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 peritoneum. I have once seen a very dis¬ 
 tinguished surgeon, whilst performing this operation on the 
 living body, at fault ow'ing to the same cause. 
 
•n 
 
COMMENTARY ON PLATES 48 & 49. 
 
 THE RELATIVE ANATOMY OF 
 
 As the abdomen and pelvis form one general cavity, 
 the organs contained in both regions are thereby inti¬ 
 mately related. The viscera of the abdomen com¬ 
 pletely 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 con¬ 
 traction 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 peri¬ 
 neum to be protruded or sustained voluntarily accord¬ 
 ing 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 
 perineal 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 moie 
 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 pro¬ 
 cesses in which they serve, are sufficiently explained 
 by pathological facts. The same system of muscles 
 comprising those of the thorax, abdomen and peri¬ 
 neum, performs consentaneously the acts of respira¬ 
 tion, 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, how¬ 
 ever, the effect of such an injury upon the pelvic 
 
 THE MALE PELVIC ORGANS. 
 
 organs alone, these may be regarded as being abso¬ 
 lutely excluded from the pale of voluntary influence 
 in consequence of the paralysis of the diaphragm, the 
 abdominal and perinjeal 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 para¬ 
 lysed, 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 abdo¬ 
 minal walls and the perineeal muscles, the downward 
 pressure of the diaphragm alone could not evacuate 
 the pelvic organs voluntarily, for the abdominal mus¬ 
 cles 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 involun¬ 
 tarily. Again, as the muscular apparatus which occu¬ 
 pies the pelvic outlet acts antagonistic to the abdomen 
 and thorax, when by an injury to the cord in the sacral 
 spine the perineeal 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” urinm, as 
 applied to the muscular coat investing the bladder, is 
 as much a misnomer (if it be meant that the act of 
 
 109 
 
110 
 
 COMMENTARY ON PLATES 4S & 49. 
 
 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, espe¬ 
 cially to those in connexion with its summit, vary also 
 considerably. When empty, the back and upper sur¬ 
 face 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 sur¬ 
 face, 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 indivi¬ 
 duals. 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 intes¬ 
 tines now gravitate upon it. When the body is recum¬ 
 bent, 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 dis¬ 
 tension. Its summit, back, and upper sides are free 
 
 and covered by the elastic peritoneum, whilst its front, 
 lower sides, and base are adherent to adjacent parts, 
 and divested of the serous membrane. On tracing the 
 peritoneum 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 ad¬ 
 herent, that the bladder when much distended, raises 
 the peritoneum 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 blad¬ 
 der is collapsed, the peritoneum 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, ad, Plate 48, to¬ 
 gether 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 peritomeum, 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 mem¬ 
 brane, h n, 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 rec¬ 
 tum. 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 apposi¬ 
 tion with the rectum, w, the serous membrane not in¬ 
 tervening. 
 
 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 
 
COMMENTARY ON PLATES 48 & 49. 
 
 Ill 
 
 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 ligar 
 meri ts.” 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 ure¬ 
 ters, 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 to¬ 
 wards 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 up¬ 
 wards 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 perinseal fascia, x. The an¬ 
 terior 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 Cj at its middle and upper parts, oc¬ 
 cupies the hollow of the sacrum, aq, and is behind 
 
 the bladder. The lower third of the rectum, w, not 
 being covered by the peritonmum, is that part on which 
 the various surgical operations are performed. At its 
 upper three-fifths, the rectum describes a curve corre¬ 
 sponding 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 sa¬ 
 crum, bear the rectum, w, forwards against the base 
 of the bladder, and give to this part a degree of obli¬ 
 quity upwards and backwards, in respect to the peri- 
 nasum and anus. From the point where the prostate, 
 y, lies in contact with the rectum, w, this latter curves 
 downwards, and slightly backwards, to the anus, r. 
 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.* 
 
 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. 171160 
 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, Ss, 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 
 
 * 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 perinteum, as it is termed, is fre¬ 
 quently met with. This may be occasioned either by an unusual 
 quantity of fat in the perineum, 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 circum¬ 
 stances, the prostate and bladder become situated higher in the 
 pelvis than naturally, and consequently at a greater distance 
 from the perinajum."— On the Lateral Operation of Lithotomy. 
 
112 
 
 COMMENTARY ON PLATES 48 & 49. 
 
 I 
 
 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 mem¬ 
 brane (obturator fascia), between which and the obtu¬ 
 rator muscle, it courses obliquely downwards and for¬ 
 wards to the forepart of the perinseum. At the place 
 where the vessel re-enters the pelvis, it lies removed 
 at an interval of an inch and a half from the peri¬ 
 neum, but becomes more superficial as it approaches 
 the subpubic space, n. The levator ani muscle sepa¬ 
 rates 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 perinceal; 
 (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.* 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 perinmal aspect. 
 
 DESCRIPTION OE 
 
 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 peri¬ 
 
 tonaeum. 
 
 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. 
 
 * The pudic artery, or some one of its branches, occasion¬ 
 ally 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 
 
 TLATES 48 & 49. 
 
 Y. The gluteal artery. 
 
 W. The small gluteus muscle. 
 
 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 peri¬ 
 
 toneum; G*, its side, not covered by the 
 membrane. 
 
 HH. The recto-vesical peritoneal pouch, 
 
 I. The vas deferens. 
 
 K. The ureter. 
 
 L. The vesicula seminalis. 
 
 M. N, 0, P, Q, R, S, T, U, refer to the same parts as in 
 
 Plate 48. 
 
 Y. The prostate. 
 
 W. The lower part of the rectum. 
 
 X. The deep perineal fascia. 
 
 incision made in the lateral operation of lithotomy. In another 
 figure is seen a vessel (“ accessory pudic”), which, passing be¬ 
 tween the base of the bladder and the levator ani muscle, 
 crosses in contact with the left lobe of the prostate. 
 

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 situa¬ 
 tion where the opposite halves unite and constitute a 
 perfect symmetrical figure. Every structure — super¬ 
 ficial 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 grada¬ 
 tions 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 perinseum respectively 
 into equal and similar sides. The umbilicus is a cica¬ 
 trix 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 I 
 15 
 
 surface, are of the same nature — namely, o mis sions 
 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. Spii^i 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 fulfil¬ 
 ment, as, for example, when the urethra, the vagina, 
 or the anus are found to be imperforate. As the me¬ 
 dian line of union thus seems to influence the form 
 of the hypogastrium, the genitals, and the perinseum, 
 the dissection of these parts has been conducted ac¬ 
 cordingly. 
 
 By removing the skin and subjacent adipose mem¬ 
 brane from the hypogastrium, we expose the superfi¬ 
 cial fascia. This membrane, eee*, 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 testi¬ 
 cles, 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, coin¬ 
 ciding with the linea alba, they form by that union 
 the suspensory ligament of the penis, which is a struc¬ 
 ture precisely median. 
 
 113 
 
114 
 
 COMMENTARY ON PLATES 50 & 51. 
 
 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 perinceum, Fig. 1, 
 Plate 51, the fascia, A, may be traced from the back 
 of the scrotum to the anus. In this region the mem¬ 
 brane is found to adhere laterally to the rami of the 
 ischium and pubes; whilst along the median perinmal 
 line the two sacs of which the membrane is composed 
 unite, as in the scrotum, and form an imperfect sep¬ 
 tum. 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 
 iscliio-rectal space, whilst its deeper and stronger layer 
 unites with the deep perinatal fascia, and by this con¬ 
 nexion separates the urethral from the anal spaces. 
 The superficial fascia of the hypogastrium, the scro¬ 
 tum, and the perinaeum forming a continuous mem¬ 
 brane, and being adherent to the several parts above- 
 noticed, may be regarded as a general double sac, 
 which isolates the inguino-perinceal region from the 
 femoral and anal regions, and hence it happens that 
 when the urethra becomes ruptured, the urine which 
 is extravasated in the perinceum, 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 tunicce 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-peri- 
 nseal 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 sym¬ 
 metrical 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 “ pecti- 
 niformeposteriorly 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 perinceum 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 perinceum, Figs. 1, 2, Plate 51, is that space 
 which is bounded above by the arch of the pubes, be¬ 
 hind by c, the os coccygis, and the lower borders of, 
 11, the glutcei muscles and sacro-sciatic ligaments, and 
 laterally by d d, the ischiatic tuberosities. The osseous 
 boundaries can be felt through the integuments. Be¬ 
 tween the back of the scrotum and the anus the peri¬ 
 nceum swells on both sides of the raphe, ab, Fig. 3, 
 Plate 50, and assumes a form corresponding with the 
 bag of the superficial fascia which encloses the struc¬ 
 tures connected with the urethra. The anus is cen¬ 
 trally situated in the depression formed between d d, 
 the ischiatic tuberosities, and the double folds of the 
 nates. 
 
 The perinceum, Fig. 3, Plate 50, is, for surgical pur¬ 
 poses, 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, add, contains the 
 urethra; the posterior space, ddc, contains the rec¬ 
 tum. The central raphti, ABC, traverses both these 
 spaces. The anterior or urethral space is (while 
 viewed in reference to its osseous boundaries) trian¬ 
 gular 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 indi¬ 
 cates 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 perinceum 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 peri- 
 
COMMENTARY ON PLATES 50 & 51. 
 
 115 
 
 nasal 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, arid the triangle is thereby render¬ 
 ed 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 perinasal 
 centre, the line of incision, be, Fig. 3, Plate 50, is 
 carried obliquely from above downwards and outwards; 
 but in cases where the tuberosity approaches the cen¬ 
 tre, the incision must necessarily be made more verti¬ 
 cal. The posterior perinseal space may be described 
 on the surface by two lines drawn from dd, the ischiatic 
 tuberosities, to c, the point of the coccyx, whilst the 
 transverse fine 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 nrinae, e, Fig. 2, Plate 
 51, which embraces the urethra, and the sphincter 
 ani, b c, which surrounds the anus, n, occupy the me¬ 
 dian line, and are divided each into halves by a central 
 tendon, ebc, which traverses the perinmum from be¬ 
 fore 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 hsemorrhoidal 
 arteries and nerves—branches of the pudic artery and 
 nerve. » 
 
 In front of the anus are seen two small muscles 
 (transverse perinei), GG, Fig. 2, Plate 51, each arising 
 from the tuber ischii of its own side, and the two be¬ 
 coming inserted into, b, the central tendon. These 
 transverse muscles serve to mark the boundary be¬ 
 tween the anterior and posterior perinseal spaces. Be¬ 
 hind each muscle is found a small artery, crossing to 
 the median line. The left transverse muscle and ar¬ 
 tery are always divided in the lateral operation of 
 lithotomy. On the outer sides of the anterior perinseal 
 space are seen the erectores penis muscles, f f, over¬ 
 laying the crura penis. Between each muscle and the 
 
 accelerator urinse, the superficialis perinsei artery and 
 nerve course forwards to the scrotum, &c. 
 
 The perinmal muscles having been brought fully 
 into view, Plate 52, Fig. 1, their symmetrical arrange¬ 
 ment 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 urinse, d, the erector penis, and e, the 
 transverse muscle. Along the surface of this interval, 
 the superficial perinatal 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 ante¬ 
 rior layer of the membrane named the deep perinmal 
 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 perinseal space 
 require to be removed, Fig. 1, Plate 53, in order to 
 expose the urethra, b m, the crus penis, d, and the deep 
 perinmal 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 transverse 
 perinei muscles, it becomes continuous with the super¬ 
 ficial fascia, in the manner before described. The 
 deep perineal fascia (triangular ligament) encloses 
 between its two layers, c e, on either side of the ure¬ 
 thra, 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 urethre” 
 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 
 perinmal space; the rectum occupies the middle in the 
 posterior space. When either of these parts specially 
 
116 
 
 COMMENTARY ON PLATES 50 & 51. 
 
 requires to be incised — the urethra for impassable 
 stricture, &c., and the lower part of the rectum for 
 fistula in ano — the operation maybe performed with¬ 
 out fear of inducing dangerous arterial haemorrhage. 
 With the object of preserving from injury these im¬ 
 portant parts, deep incisions at, or approaching to, the 
 middle line must be avoided. The outer (ischio-pubic) 
 boundary of the perinseum is the line along which the 
 pudic artery passes. The anterior half of this boun¬ 
 dary 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, bmf, Fig. 2, Plate 52, and those in con¬ 
 nexion with the left perinmal boundary, dgl, 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 perinseum 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 perinseal 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 mem¬ 
 branous portion of the urethra, are still concealed by 
 the deep perinmal 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 hsemor- 
 rhoidal arteries and nerves converging towards the 
 anus will be the more likely to escape being wounded. 
 
 DESCRIPTION OE TIIE 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. 
 
 EE**. 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. 
 
 DD. The corpora cavernosa seen in section. 
 
 E. The scrotal raphe and septum scroti. 
 
 Figure 3. 
 
 A B. The perimeal raphA 
 
 C. The place of the coccyx. 
 
 DD. The projections of the ischiatic tuberosities. 
 BE. The line of section in lithotomy. 
 
 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. 
 
 11. The glutei muscles. 
 
 Figure 2. 
 
 A, B,C,D, II, I. The same parts as in Fig. 1. 
 
 E. The accelerator urinrn muscle. 
 
 F F. Right and left erector penis muscle. 
 
 G G. Right and left transverse muscle. 
 

S? id 
 
COMMENTARY ON PLATES 52 & 53. 
 
 THE SURGICAL DISSECTION OF THE DEEP STRUCTURES OF THE MALE PERINEUM. 
 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 perinatal 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 perinceal fascia, the anterior fibres 
 of k, the levator ani muscle, arise from either side of 
 the pubic symphysis posteriorly, and descend obliquely 
 downwards 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 disturb¬ 
 ing the lower end of the rectum from its natural posi¬ 
 tion in the perinceum, its close relation to the prostate 
 and base of the bladder should be noticed. While the 
 anus remains connected with the deep perinseal 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 lithoto- 
 mist 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-dis¬ 
 tended, 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 ena¬ 
 bled 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, be¬ 
 
 comes, 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 intro¬ 
 duced 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 perinseal 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 perinatal space from the 
 pelvic cavity. The prostate occupies the centre of the 
 perineum. If the perinseum 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 
 
 117 
 
118 
 
 COMMENTARY 01 
 
 the pudie artery by the levator ani muscle, and from 
 the artery of the bulb, by the deep perinmal 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 
 urethra 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, qq, are seen to con¬ 
 verge 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 eva¬ 
 cuating the contents of the bladder, when other mea¬ 
 sures 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, pre¬ 
 cisely 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 con¬ 
 verging 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 rela¬ 
 tive position of the neighbouring parts will be found 
 disturbed, and in such case the bladder can be punc¬ 
 tured above the pubes with greater ease and safety. 
 In cases of impassalle 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 effec¬ 
 tual measure, for at the same time that the stricture 
 is divided, the contents of the bladder may be eva¬ 
 cuated through the perinreum. 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 posi¬ 
 tion of the instrument by the finger in the bowel, the 
 perinoeum should be incised, at the middle line, be¬ 
 tween the bulb of the urethra and the anus. The 
 urethra in this situation will be found to curve back- 
 
 PLATES 52 & 53. 
 
 wards at the depth of an inch or more from the sur¬ 
 face. 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 ob¬ 
 struction 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 perinmum in 
 order to determine the situation of the left tuberosity 
 and ischio-pubic ramus, in relation to the perinceal 
 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 peri- 
 nmuro, commencing the incision on the left of the 
 raphe about an inch in front of the anus, and carrying 
 it downwards and outw r ards midway between the anus 
 and ischiatic tuberosity, to a point below these parts. 
 The left fore-finger is then to be passed along the in¬ 
 cision 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 he felt for, 
 and the structures which cover the membranous por¬ 
 tion of the urethra are to be cautiously divided. Re¬ 
 collecting 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 back¬ 
 wards— 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 de¬ 
 pressed 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, 
 
119 
 
 COMMENTARY ON 
 
 and made to divide the membranous part of the ure¬ 
 thra 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 sur¬ 
 rounds 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 blad¬ 
 der along the finger as a guide. The calculus, now in 
 the gripe 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 perinteal space an inch or more 
 below the anus. The wound thus made would depend 
 in relation to the neck of the bladder; the important 
 
 PLATES 52 & 53. 
 
 parts, vessels, &c., in the anterior perinseal space would 
 be avoided where the incision, if extended upwards, 
 would have no effect whatever in facilitating the ex¬ 
 traction 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 out¬ 
 wards, 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 pro¬ 
 ceeding 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.* 
 
 * “ 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 be¬ 
 twixt 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 dimen¬ 
 sions, 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 ex¬ 
 pressed by Scarpa, Le Cat, and others. Sir Benjamin Brodie, 
 Mr. Stanley, and Mr. Syme are also advocates for limited in¬ 
 cisions, extending no farther than a partial division of the pros¬ 
 tate, the rest being effected by dilatation. The experience, 
 however, of Cheselden, Martineau, and Mr. S. Cooper, inclined 
 
COMMENTARY ON PLATES 52 & 53. 
 
 120 
 
 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 perinasum 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 inte¬ 
 rior of the bladder. 
 
 DESCKIPTION OE THE FIGURES OF PLATES 52 & 53- 
 
 PLATE 52. 
 
 Figure 1. 
 
 A. The urethra. 
 
 B. Accelerator urince muscle. 
 
 C. Central perinaeal tendon. 
 
 D D. Right and left erector penis muscle. 
 
 EE. The transverse muscles. 
 
 F. The anus. 
 
 G G. The ischiatic tuberosities. 
 
 H. The coccyx. 
 
 11. The glutei muscles. 
 
 KK. The levator ani muscle. 
 
 L. The left artery of the bulb. 
 
 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 perinceal fascia. 
 
 M. The bulb of the urethra. 
 
 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. 
 
 DD. The two crura penis. 
 
 M. The urethra in section 
 N N. The rectum. 
 
 O. The sacro-sciatic ligament. 
 
 Figure 2. 
 
 A, B, D, G, H, I, K, L, 0 refer to the same parts as in 
 Fig. 1, Plate 53. 
 
 CC. The two lobes of the prostate. 
 
 F. The rectum turned down. 
 
 M. The membranous part of the urethra. 
 
 NN. The vesicuke seminales. 
 
 P. The base of the bladder. 
 
 QQ. The two vasa deferentia. 
 
 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 con¬ 
 tusing 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 Chinirgische Opera- 
 tionen. 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 per¬ 
 haps 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 per¬ 
 formed 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. 
 
COMMENTARY ON PLATES 54, 55, & 56. 
 
 THE SURGICAL DISSECTION OP THE MALE BLADDER AND URETHRA.—LATERAL AND 
 BILATERAL LITHOTOMY COMPARED. 
 
 Haying examined tlie surgical relations of the blad¬ 
 der 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 ope¬ 
 ration and in catheterism. 
 
 Fig. 1, Plate 54, represents the normal relations of 
 the mere important parts concerned in lithotomy as 
 performed at the perinseal region. The median line, 
 A A, drawn from the symphysis pubis above, to the 
 point of the coccyx below, is seen to traverse verti¬ 
 cally the centres of the urethra, the prostate, the base 
 of the bladder, the anus, and the rectum. These se¬ 
 veral parts are situated at different depths from the 
 perinseal surface. The bulb of the urethra and the 
 lower end of the bowel are on the same plane compa¬ 
 ratively 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 mem¬ 
 branous urethra, which intervenes between the two, 
 is according to the axis of the pelvic outlet; the pros¬ 
 tatic end of the membranous urethra being deeper 
 than the part near the bulb. The scalpel of the litho- 
 tomist, 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 
 perimeal 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 
 1G 
 
 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 perinseum 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 per¬ 
 formed in reference to the line A A; the bilateral ope¬ 
 ration 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 perinasum, the lateral 
 incisions are made obliquely in the direction of the 
 lines CD. In the bilateral operation the incision ne¬ 
 cessary to avoid the bulb of the urethra in front, the 
 rectum behind, and the pudic arteries laterally, is re¬ 
 quired to be made of a semicircular form, correspond¬ 
 ing with the forepart of the bowel; the cornua of the 
 incision being directed behind. Ill the lateral opera¬ 
 tion, 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. 
 
 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 ope¬ 
 rations will be divided. If the superficial lateral inci¬ 
 sion 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 
 
 121 
 
122 
 
 COMMENTARY ON PLATES 54, 55, & 56. 
 
 large and pendulous, as to lie in contact with the front 
 of the rectum. 
 
 Fig. 1, Plate 55.—When the pudic artery crosses in 
 contact with the prostate, f, it must inevitably he 
 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 trans¬ 
 verse 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 
 perinceal incision should be made under the like ne¬ 
 cessity. 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, bb, the seminal 
 ducts, g h, which enter the base of this body, are like¬ 
 wise divided; hut by the simple lateral incision d be¬ 
 ing made through the forepart of the left lobe, f, these 
 ducts will escape injury.* On the whole, therefore, 
 the lateral operation appears preferable to the bila¬ 
 teral one. 
 
 Fig. 2, Plate 55. — The muscular structures sur¬ 
 rounding 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 circum¬ 
 stance 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,-}- 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 bcdef. When one or more of 
 them are omitted from the series, there occurs anato¬ 
 mical variety, which of course occasions variety in 
 opinion, fruitless though never ending. By that inter¬ 
 pretation of the parts which I here venture to offer, 
 
 * 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 hesita¬ 
 tion in cutting any part of the gland which seems to offer re¬ 
 sistance, 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. 
 
 f The part c is that alone described by Santorini, who named 
 it “elevator urethrae,” as passing beneath the urethra. The 
 part b is that first observed and described by Mr. Guthrie as 
 passing above the urethra. The part f represents the well- 
 known “ transversalis perinsei,” between which and the part c 
 there occasionally appears the part e, supposed to be the “ trans¬ 
 versalis alter” of Albinus, and also the part d, which is the 
 “ ischio bulbosus” of Cruveilhier. It is possible that I may not 
 have given one or other of these parts its proper name, but this 
 will not affect their anatomy. 
 
COMMENTARY ON PLATES 54, 55, & 56. 
 
 123 
 
 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 —cZ=11 
 are when the mind is devoid of the power of calcu¬ 
 lation. 
 
 Fig. 3, Plate 55. — The membranous urethra A is 
 also in some instances embraced by two symmetrical 
 fasciculi of muscular fibres b b, which arising from the 
 posterior and lower part of the symphysis pubis, de¬ 
 scend on either side of the canal and join beneath it. 
 The muscles b c, Fig. 2, Plate 55, are between the two 
 layers of the deep perinteal fascia, while the muscle 
 B b, Fig. 3, Plate 55, lies like the forepart of the leva¬ 
 tor ani, c C, behind this structure and between it and 
 the anterior ligaments of the bladder. :i: As to the 
 interpretation of the muscle, I, myself, am inclined to 
 believe that it is simply a part of the levator ani, and 
 for these reasons — 1st, it arises from the pubic sym¬ 
 physis, and is inserted into the perinteal median line 
 with the levator ani; 2nd, the fibres of both muscles 
 overlie the forepart of the prostate, and present the 
 same arrangement in parallel order; 3rd, the one is 
 not naturally separable from the other. 
 
 Fig. 1, Plate 56, represents by section the natural 
 forms of the urethra and bladder. The general direc¬ 
 tion of the urethra measured during its relaxed state 
 from the vesical orifice to the glans is usually described 
 as having the form of the letter S laid procumbent to 
 the right side a: or to the left co. But as the ante¬ 
 rior half of the canal is moveable, and liable thereby 
 to obliterate the general form, while the posterior half 
 is fixed, I shall direct attention to the latter half 
 chiefly, since upon its peculiar form and relative posi¬ 
 
 tion depends most of the difficulty in the performance 
 of catlieterism. The portion of the urethra which in¬ 
 tervenes between the neck of the bladder, K, and the 
 point e, where the penis is suspended from the front 
 of the symphysis pubis by the suspensory ligament, 
 assumes very nearly the form of a semicircle, whose 
 anterior half looks towards the forepart, and whose 
 posterior half is turned to the back of the pubis. The 
 pubic arch, A, spans crossways, the middle of this part 
 of the urethra, G, opposite the bulb n. The two ex¬ 
 tremes, fk, of this curve, and the lower part of the 
 symphysis pubis, occupy in the adult the same antero¬ 
 posterior level; and it follows, therefore, that the dis¬ 
 tance to which the urethra near its bulb, n, is removed 
 from the pubic symphysis above must equal the depth 
 of its own curve, which measures about an inch per¬ 
 pendicularly. The urethral aperture of the triangular 
 ligament appears removed at this distance below the 
 pubic symphysis, and that portion of the canal which 
 lies behind the ligament, and ascends obliquely back¬ 
 wards and upwards to the vesical orifice on a level 
 with the symphysis pubis in the adult should be re¬ 
 membered, as varying both in direction and length in 
 individuals of the extremes of age. In the young, 
 this variation is owing to the usual high position of 
 the bladder in the pelvis, whilst in the old it may be 
 caused by an enlarged state of the prostate. The 
 curve of the urethra now described is permanent in 
 all positions of the body, while that portion of the 
 canal anterior to the point f, which is free, relaxed, 
 and moveable, can by traction towards the umbilicus 
 be made to continue in the direction of the fixed curve 
 f k, and this is the general form which the urethra 
 assumes when a bent catheter of ordinary shape is 
 passed along the canal into the bladder; The length 
 of the urethra varies at different ages and in different 
 
 A 
 
 fr' 
 
 *This is the muscle, bb, which is described by Santorini as 
 the “ levator prostatas;” by Winslow as “ le prostatique supe- 
 rieur;” by Wilson as the “ pubo-urethrales;” by Muller as not 
 existing; by Mr. Guthrie as forming (when existing), with the 
 parts bc, Fig. 2, Plate 55, his “compressor isthmi urethrae;” 
 
 and by M. Cruveilhier as being part of the levator ani muscle. 
 “ As in one case,” (observes Mr. Quain,) “ I myself saw a few 
 vertical muscular fibres connected with the transverse com¬ 
 pressor, it has been thought best to retain the muscle in the 
 text.”—Dr. Quain’s Jlnat., Am. Ed. vol. ii. p. 539. 
 
 if 
 
124 
 
 COMMENTARY ON PLATES 54, 55, & 56. 
 
 individuals, and its structure in the relaxed state is so 
 very dilatable that it is not possible to estimate the 
 width of its canal with fixed accuracy. As a general 
 rule, the urethra is much more dilatable, and capable 
 consequently of receiving an instrument of much 
 larger bore in the aged than in the adult. 
 
 The three portions into which the urethra is de¬ 
 scribed as being divisible, are the spongy, the mem¬ 
 branous, and the prostatic. These names indicate the 
 difference in the structure of each part. The spongy 
 portion is the longest of the three, and extending from 
 the glans to the bulb may be said on a rough, but for 
 practical purposes, a sufficiently accurate estimate to 
 comprise seven parts of the whole urethra, which 
 measures nine. The membranous and prostatic por¬ 
 tions measure respectively one part of the whole. 
 These relative proportions of the three parts are main¬ 
 tained in different individuals of the same age, and in 
 the same individual at different ages. The spongy 
 part occupies the inferior groove formed between the 
 two united corpora cavernosa of the penis, and is sub¬ 
 cutaneous as far back as the scrotum under the pubes, 
 between which point and the bulb it becomes embraced 
 by the accelerator urina? muscle. The bulb and glans 
 are expansions or enlargements of the spongy texture, 
 and do not affect the calibre of the canal. When the 
 spongy texture becomes injected with blood, the canal 
 is rendered much narrower than otherwise. The canal 
 of the urethra is uniform-cylindrical. The meatus is 
 the narrowest part of it, and the prostatic part is the 
 widest. At the point of junction between the mem¬ 
 branous and spongy portions behind the bulb, the 
 canal is described as being naturally constricted. Be¬ 
 hind the meatus exists a dilatation (fossa navicularis), 
 and opposite the bulb another (sinus of the bulb). 
 Muscular fibres are said to enter into the structure of 
 the urethra, but whether such be the case or not, it is 
 at least very certain that they never prove an obstacle 
 to the passage of instruments, or form the variety of 
 stricture known as spasmodic. The urethra is lined 
 by a delicate mucous membrane presenting longitudi¬ 
 nal folds, which become obliterated by distention; and 
 
 its entire surface is numerously studded with the ori¬ 
 fices of mucous cells (lacunas), one of which, larger 
 than the rest, appears on the upper side of the canal 
 near the meatus. Some of these lacunas are nearly 
 an inch long, and all of them open in an oblique direc¬ 
 tion forwards. Instruments having very narrow apices 
 are liable to enter these ducts and to make false pas¬ 
 sages. The ducts of Cowper’s glands open by very 
 minute orifices on the sides of the spongy urethra an¬ 
 terior to and near the bulb. On the floor of the pros¬ 
 tatic urethra appears the crest of the veru montanum, 
 upon which the two seminal ducts open by orifices 
 directed forwards. On either side of the veru mon¬ 
 tanum the floor of the prostate maybe seen perforated 
 by the “ excretory ducts” of this so-called gland. The 
 part k, which is here represented as projecting from 
 the floor of the bladder, near its neck, is named the 
 “ uvula vesicce,” (Lieutaud.) It is the same as that 
 which is named the “third lobe of the prostate,” 
 (Home.) The part does not appear as proper to the 
 bladder in the healthy condition, Fig. 2, Plate 56. On 
 either side of the point k may be seen the orifices, m m, 
 of the ureters, opening upon two ridges of fibrous sub¬ 
 stance directed towards the uvula. These are the 
 fibres which have been named by Sir Charles Bell as 
 “ the muscles of the uretersbut as they do not ap¬ 
 pear in the bladder when in a state of health, I do not 
 believe that nature ever intended them to perform the 
 function assigned to them by this anatomist. And the 
 same may be said of the fibres, which surrounding the 
 vesical orifice, are supposed to act as the “ sphincter 
 vesica?.” The form of that portion of the base of the 
 bladder which is named “ trigone vesical” constitutes 
 an equilateral triangle, and may be described by two 
 lines drawn from the vesical orifice to both openings 
 of the ureters, and another line reaching transversely 
 between the latter. Behind the trigone a depression 
 called “bas fond” is formed in the base of the bladder. 
 Fig. 2, Plate 56, represents the prostate of a boy nine 
 years of age. Fig. 3, Plate 56, represents that of a. 
 man aged forty years. A difference as to form and 
 size, &c., is observable between both. 
 
PI .55 
 
 1 Sinclair's Lilt 101 Chestnut ol Plnla, 
 
 
COMMENTARY ON PLATES 57 & 58. 
 
 CONGENITAL AND PATHOLOGICAL DEFORMITIES OF THE PREPUCE AND URETHRA.— 
 STRICTURE AND MECHANICAL OBSTRUCTIONS OF THE URETHRA. 
 
 When any of the central organs of the body pre¬ 
 sents in a form differing from that which we term 
 natural, or structurally perfect and efficient, if the 
 deformity be one which results as a malformation, 
 ascribable to an error in the law of development, it is 
 always characterized as an excess or defect of the 
 substance of the organ at, and in reference to, the 
 median line. And when any of the canals which na¬ 
 turally open upon the external surface at the median 
 line happens to deviate from its proper position, such 
 deviation, if it be the result of an error in the law of 
 development, always occurs, by an actual necessity, at 
 the median line. On the contrary, though deformities 
 which are the results of diseased action in a central 
 organ may and do, in some instances, simulate those 
 which occur by an error in the process of development, 
 the former cannot bear a like interpretation with the 
 latter, for those are the effects of ever-varying circum¬ 
 stances, whereas these are the effects of certain devia¬ 
 tions in a natural process — a law, whose course is 
 serial, gradational, and in the sequent order of a con¬ 
 tinuous chain of cause and effect. 
 
 Fig. 1, Plate 57, represents the prepuce in a state 
 of congenital phymosis. The part hypertrophied and 
 pendent projects nearly an inch in front of the meatus, 
 and forms a canal, continued forwards from this orifice. 
 As the prepuce in such a state becomes devoid of its 
 proper function, and hence must be regarded, not only 
 as a mere superfluity, but as a cause of impediment 
 to the generative function of the whole organ, it should 
 be removed by an operation. 
 
 Fig. 2, Plate 57, represents the prepuce in the con¬ 
 dition of paraphymosis following gonorrhoeal inflam¬ 
 mation. The part appears constricting the penis and 
 urethra behind the corona glandis. This state of the 
 organ is produced in the following-mentioned way: — 
 
 the prepuce, naturally very extensible, becomes, while 
 covering the glans, inflamed, thickened, and its orifice 
 contracted. It is during this state withdrawn forcibly 
 backwards over the glans, and in this situation, while 
 being itself the first cause of constriction, it induces 
 another—namely, an arrest to the venous circulation, 
 which is followed by a turgescence of the glans. In 
 the treatment of such a case, the indication is, first, to 
 reduce by gradual pressure the size of the glans, so 
 that the prepuce may be replaced over it; secondly, 
 to lessen the inflammation by the ordinary means. 
 
 Fig. 3, Plate 57, exhibits the form of a gonorrhoeal 
 phymosis. The orifice of the prepuce is contracted, 
 and the tissue of it infiltrated. If in this state of the 
 part, consequent upon diseased action, or in that of 
 Fig. 1, which is congenital, the foreskin be retracted 
 over the glans, a paraphymosis, like Fig. 2, will be 
 produced. 
 
 Fig. 4, Plate 57, shows a form of phymosis in which 
 the prepuce during inflammation has become adherent 
 to the whole surface of the glans. The orifice of the 
 prepuce being directly opposite the meatus, and the 
 parts offering no obstruction to the flow of urine, an 
 operation for separating the prepuce from the glans 
 would not be required. 
 
 Fig. 5, Plate 57.—In this figure is represented the 
 form of the penis of an adult, in whom the prepuce 
 was removed by circumcision at an early age. The 
 membrane covering the glans and the part which is 
 cicatrised becomes in these cases dry, indurated, and 
 deprived of its special sense. 
 
 Fig. 6, Plate 57.—In this figure the glans appears 
 protruding through the upper surface of the prepuce, 
 which is thickened and corrugated. This state of the 
 parts was caused by a venereal ulceration of the upper 
 part of the prepuce, sufficient to allow the glans to 
 
 125 
 
12G 
 
 COMMENTARY ON PLATES 57 & 58. 
 
 press through the aperture. The prepuce in this con¬ 
 dition being superfluous, and acting as an impediment, 
 should be removed by operation. 
 
 Fig. 7, Plate 57.—In this figure is shown a condi¬ 
 tion of the glans and prepuce resembling that last 
 mentioned, and the effect of a similar cause. By the 
 removal of the prepuce when in the position here 
 represented, or in that of Fig. 6, the organ may be 
 made to assume the appearance of Fig. 5. 
 
 Fig. 8, Plate 57, represents the form of a congenital 
 hypospadias. The corpus spongiosum does not con¬ 
 tinue the canal of the urethra as far forwards as the 
 usual position of the meatus, but has become defective 
 behind the frsenum prseputii, leaving the canal open 
 at this place. In a case of this kind an operation on 
 the taliacotian principle might be tried in order to 
 close the urethra where it presents abnormally patent. 
 
 Fig. 9, Plate 57, represents a congenital hypospadias, 
 in which the canal of the urethra opens by two dis¬ 
 tinct apertures along the under surface of the corpus 
 spongiosum at the middle line. A probe traverses 
 both apertures. In such a case, if the canal of the 
 urethra were perforate as far forwards as the meatus, 
 and this latter in its normal position, the two false 
 openings should be closed by an operation. 
 
 Fig. 10, Plate 57.—The urethra is here represented 
 as having a false opening on its under surface behind 
 the framum. The perforation was caused by a vene¬ 
 real ulcer. The meatus and urethra anterior to the 
 false aperture remained perforate. Part of a bougie 
 appears traversing the false opening and the meatus. 
 In this state of the organ an attempt should be made 
 to close the false aperture permanently. 
 
 Fig. 11, Plate 57, shows a state of the urethra 
 similar to that of Fig. 10, and the effect of the same 
 cause. Part of a bougie is seen traversing the false 
 aperture from the meatus before to the urethra behind. 
 In this case, as the whole substance of the corpus 
 spongiosum was destroyed for half an inch in extent, 
 the taliacotian operation, by which lost quantity is 
 supplied, is the measure most likely to succeed in 
 closing the canal. 
 
 Fig. 12, Plate 57.—Behind the meatus, and on the 
 
 right of the framum, is represented a perforation in 
 the urethra, caused by a venereal ulcer. The meatus 
 and the false opening have approached by the contrac¬ 
 tion of the cicatrix; in consequence of which, also, 
 the apex of the glans is distorted towards the urethra; 
 a bougie introduced by the meatus occupies the ure¬ 
 thral canal. 
 
 Fig. 13, Plate 57.—In this figure the canal of the 
 urethra appears turning upwards and opening at the 
 median line behind the corona glandis. This state of 
 the urethra was caused by a venereal ulcer penetrating 
 the canal from the dorsum of the penis. The proper 
 direction of the canal might be restored by obliterating 
 the false passage, provided the urethra remained per¬ 
 forate in the direction of the meatus. 
 
 Fig. 14, Plate 57, exhibits the form of a congenital 
 epispadias, in which the urethra is seen to open on the 
 dorsal surface of the prepuce at the median line. The 
 glans appears cleft and deformed. The meatus is defi¬ 
 cient at its usual place. The prepuce at the dorsum 
 is in part deficient, and bound to the glans around the 
 abnormal orifice. 
 
 Fig. 15, Plate 57, represents in section a state of 
 the parts in which the urethra opened externally by 
 one fistulous aperture, a, behind the scrotum; and by 
 another, b, in front of the scrotum. At the latter place 
 the canal beneath the penis became imperforate for an 
 inch in extent. Parts of catheters are seen to enter 
 the urethra through the fistulous openings a b; and 
 another instrument, c, is seen to pass by the proper 
 meatus into the urethra as far as the point where this 
 portion of the canal fails to communicate with the 
 other. The under part of the scrotum presents a cleft 
 corresponding with the situation of the scrotal septum. 
 This state of the urinary passage may be the effect 
 either of congenital deficiency or of disease. When 
 caused by disease, the chief features in its history, 
 taking these in the order of their occurrence, are, 1st, 
 a stricture in the anterior part of the urethra; 2ndly, 
 a rupture of this canal behind the stricture; 3rdly, 
 the formation (on an abscess opening externally) of a 
 fistulous communication between the canal and the 
 surface of some part of the perinmum; 4thly, the 
 
COMMENTARY ON PLATES 5 7 & 58. 
 
 127 
 
 habitual escape of the urine by the false aperture; 
 5thly, the obliteration of the canal to a greater or less 
 extent anterior to the stricture; 6thly, the parts situ¬ 
 ated near the urethral fistula become so consolidated 
 and confused that it is difficult in some and impossible 
 in many cases to find the situation of the urethra, 
 either by external examination or by means of the 
 catheter passed into the canal. The original seat of 
 the stricture becomes so masked by the surrounding 
 disease, and the stricture itself, even if found by any 
 chance, is generally of so impassable a kind, that it 
 must be confessed there are few operations in surgery 
 more irksome to a looker-on than is the fruitless effort 
 made, in such a state of the parts, by a hand without 
 a guide, to pass perforce a blunt pointed instrument 
 like a catheter into the bladder. In some instances 
 the stricture is slightly pervious, the urine passing in 
 small quantity by the meatus. In others, the stricure 
 is rendered wholly imperforate, and the canal either 
 contracted or nearly obliterated anteriorly through 
 disuse. Of these two conditions, the first is that in 
 which catheterism may be tried with any reasonable 
 hope of passing the instrument into the bladder. In 
 the latter state, catheterism is useless, and the only 
 means whereby the urethra may be rendered pervious 
 in the proper direction is that of incising the stricture 
 from the perinmum, and after passing a catheter across 
 the divided part into the bladder, to retain the instru¬ 
 ment in this situation till the wound and the fistulm 
 heal and close under the treatment proper for this 
 end. (Mr. Syme.) 
 
 Fig. 1, Plate 58.—In this figure the urethra appears 
 communicating with a sac like a scrotum. A bougie 
 is represented entering by the meatus, traversing the 
 upper part of the sac, and passing into the membranous 
 part of the urethra beyond. This case which was 
 owing to a congenital malformation of the urethra, 
 exhibits a dilatation of the canal such as might be 
 produced behind a stricture wherever situated. The 
 urine impelled forcibly by the whole action of the 
 abdominal muscles against the obstructing part dilates 
 the urethra behind the stricture, and by a repetition 
 of such force the part gradually yields more and more, 
 
 till it attains a very large size, and protrudes at the 
 perinmum as a distinct fluctuating tumour, every time 
 that an effort is made to void the bladder. If the 
 stricture in such a case happen to cause a complete 
 retention of urine, and that a catheter cannot be passed 
 into the bladder, the tumour should be punctured prior 
 to taking measures for the removal of the stricture. 
 (Sir B. Brodie.) 
 
 Fig. 2, Plate 58, represents two close strictures of 
 the urethra, one of which is situated at the bulb, and 
 the other at the adjoining membranous part. These 
 are the two situations in which strictures of the organic 
 kind are said most frequently to occur, (Hunter, Home, 
 Cooper, Brodie, Phillips, Yelpeau.) False passages 
 likewise are mentioned as more liable to be made in 
 these places than elsewhere in the urethral canal. 
 These occurrences — the disease and the accident — 
 would seem to follow each other closely, like cause 
 and consequence. The frequency with which false 
 passages occur in this situation appears to me to be 
 chiefly owing to the anatomical fact, that the urethra 
 at and close to the bulb is the most dependent part 
 of the curve, f k, Fig. 1, Plate 56; and hence, that 
 instruments descending to this part from before push 
 forcibly against the urethra, and are more apt to pro¬ 
 trude through it than to have their points turned so 
 as to ascend the curve towards the neck of the bladder. 
 If it be also true that strictures happen here more 
 frequently than elsewhere, this circumstance will of 
 course favour the accident. An additional cause why 
 the catheter happens to be frequently arrested at this 
 situation and to perforate the canal, is owing to the 
 fact, that the triangular ligament is liable to oppose it, 
 the urethral opening in this structure not happening 
 to coincide with the direction of the point of the in¬ 
 strument. In the figure, part of a bougie traverses the 
 urethra through both strictures and lodges upon the 
 enlarged prostate. Another instrument, after entering 
 the first stricture, occupies a false passage which was 
 made in the canal between the two constricted parts. 
 
 Fig. 3, Plate 58.—A calculus is here represented 
 lodging in the urethra at the bulb. The walls of the 
 urethra around the calculus appear thickened. Behind 
 
 
 
 
 
128 
 
 COMMENTARY ON PLATES 57 & 58. 
 
 the obstructing body the canal has become dilated, and, 
 in front of it, contracted. In some instances the cal¬ 
 culus presents a perforation through its centre, by which 
 the urine escapes. In others, the urine makes its exit 
 between the calculus and the side of the urethra, which 
 it dilates. In this latter way the foreign body becomes 
 loosened in the canal and gradually pushed forwards as 
 far as the meatus, within which, owing to the narrow¬ 
 ness of this aperture, it lodges permanently. If the 
 calculus forms a complete obstruction to the passage of 
 the urine, and its removal cannot be effected by other 
 means, an incision should be made to effect this object. 
 
 Fig. 4, Plate 58, represents the neck of the bladder 
 and neighbouring part of the urethra of an ox, in which 
 a polypous growth is seen attached by a long pedicle to 
 the veru montanum and blocking up the neck of the 
 bladder. Small irregular tubercles of organized lymph, 
 and tumours formed by the lacunae distended by their 
 own secretion, their orifices being closed by inflamma¬ 
 tion, are also found to obstruct the urethral canal. 
 
 Fig. 5, Plate 58.—In. this figure is represented a 
 small calculus impacted in and dilating the membran¬ 
 ous part of the urethra. 
 
 Fig. 6, Plate 58.—Two strictures are here shown to 
 exist in the urethra, one of which is situated imme¬ 
 diately in front of the bulb, and the other at a point 
 midway between the bulb and the meatus. 
 
 Fig. 7, Plate 58.—A stricture is here shown situated 
 at the bulb. 
 
 Fig. 8, Plate 58, represents a stricture of the canal 
 in front of the bulb. 
 
 Fig. 9, Plate 58, represents the form of an old callous 
 stricture half an inch long, situated midway between 
 the bulb and the meatus. This is perhaps the most 
 common site in which a stricture of this kind is found , 
 to exist. In some instances of old neglected cases the 
 corpus spongiosum appears converted into a thick 
 gristly cartilaginous mass, several inches in extent, the 
 passage here being very much contracted, and chiefly 
 so at the middle of the stricture. When it becomes 
 impossible to dilate or pass the canal of such a stricture j 
 
 by the ordinary means, it is recommended to divide 
 the part by the lancetted stilette. (Stafford.) Division 
 of the stricture, by any means, is no doubt the readiest 
 and most effectual measure that can be adopted, pro¬ 
 vided we know clearly that the cutting instrument 
 engages fairly the part to be divided. But this is a 
 knowledge less likely to be attained if the stricture be 
 situated behind than in front of the triangular ligament. 
 
 Fig. 10, Plate 58, exhibits a lateral view of the mus¬ 
 cular parts which surround the membranous portion 
 of the urethra and the prostate; a, the membranous 
 urethra embraced by the compressor urethras muscle; 
 b, the levator prostatm muscle; c, the prostate; d, the 
 anterior ligament of the bladder. 
 
 Fig. 11, Plate 58. — A posterior view of the parts 
 seen in Fig. 10; a, the urethra divided in front of the 
 prostate; b b, the levator prostatas muscle; c c, the 
 compressor urethras; d d, parts of the obturator mus¬ 
 cles ; e e, the anterior fibres of the levator ani muscle; 
 fg, the triangular ligament enclosing between its layers 
 the artery of the bulb, Cowjser’s glands, the membran¬ 
 ous urethra, and the muscular parts surrounding this 
 portion of the canal. The fact that the flow of urine 
 through the urethra happens occasionally to be . sud¬ 
 denly arrested, and this circumstance contrasted with 
 the opposite fact that the organic stricture is of slow 
 formation, originated the idea that the former occur¬ 
 rence arose from a spasmodic muscular contraction. 
 By many this spasm was supposed to be due to the 
 urethra being itself muscular. By others, it was de¬ 
 monstrated as being dependent upon the muscles which 
 surround the membranous part of the urethra, and 
 which act upon this part and constrict it. From my 
 own observations I have formed the settled opinion 
 that the urethra itself is not muscular. And though, 
 on the one hand, I believe that this canal, per se, never 
 causes by active contraction the spasmodic form of 
 stricture, I am far from supposing, on the other, that 
 all sudden arrests to the passage of urine through the 
 urethra are solely attributable to spasm of the muscles 
 which embrace this canal. 
 

COMMENTARY ON PLATES 59 & 60. 
 
 THE VARIOUS FORMS AND POSITIONS OF STRICTURES AND OTHER OBSTRUCTIONS OF 
 THE URETHRA. — FALSE PASSAGES.—ENLARGEMENTS AND DEFORMITIES OF THE 
 
 PROSTATE. 
 
 Impediments to the passage of the urine through the 
 urethra may arise from different causes, such as the 
 impaction of a small calculus in the canal, or any 
 morbid growth (a polypus, &c.) being situated therein, 
 or from an abscess which, though forming externally 
 to the urethra, may press upon this tube so as either 
 to obstruct it partially, by bending one of its sides to¬ 
 wards the other, or completely, by surrounding the 
 canal on all sides. These causes of obstruction may 
 happen in any part of the urethra, but there are two 
 others (the prostatic and the spasmodic) which are, 
 owing to anatomical circumstances, necessarily confined 
 to the posterior two-thirds of the urethra. The por¬ 
 tion of the urethra surrounded by the prostate can 
 alone be obstructed by this body when it has become 
 irregularly enlarged, while the spasmodic stricture can 
 only happen to the membranous portion of the urethra, 
 and to an inch or two of the canal anterior to the 
 bulb, these being the parts which are embraced by 
 muscular structures. The urethra itself not being 
 muscular, cannot give rise to the spasmodic form of 
 stricture. But that kind of obstruction which is com- i 
 
 mon to all parts of the urethra, and which is dependent, 
 as well upon the structures of which the canal is uni¬ 
 formly composed, as upon the circumstance that in¬ 
 flammation may attack these in any situation and 
 produce the same effect, is the permanent or organic 
 stricture. Of this disease the forms are as various as 
 the situations are, for as certainly as it may reasonably 
 be supposed that the plastic lymph, effused in an in¬ 
 flamed state of the urethra from any cause, does not 
 give rise to stricture of any special or particular form, 
 exclusive of all others; so as certainly may it be in¬ 
 ferred that, in a structurally uniform canal, inflamma¬ 
 tion points to no one particular place of it, whereat 
 by preference to establish the organic stricture. The 
 membranous part of the canal is, however, mentioned 
 as being the situation most prone to the disease; but 
 I have little doubt, nevertheless, that owing to general 
 rules of this kind being taken for granted, upon im¬ 
 posing authority, many more serious evils (false pass¬ 
 ages, &c.) have been effected by catheterism than 
 existed previous to the performance of this opera¬ 
 tion.* 
 
 * Home describes “ a natural constriction of the urethra, 
 directly behind the bulb, which is probably formed with a 
 power of contraction to prevent,” &c. This is the part which 
 he says is « most liable to the disease of stricture.” (Strictures 
 of the Urethra .) Now, if any one, even among the acute ob¬ 
 serving microscopists, can discern the structure to which Home 
 alludes, he will certainly prove this anatomist to be a marked 
 exception amongst those who, for the enforcement of any doc¬ 
 trine, can see any thing or phenomenon they wish to see. And, 
 if Hunter were as the mirror from which Home’s mind was 
 reflected, then the observation must be imputed to the Great 
 Original. Upon the question, however, as to which is the most 
 frequent seat of stricture, I find that both these anatomists do 
 
 17 
 
 not agree, Hunter stating that its usual seat is just in front of 
 the bulb, while Home regrets, as it were, to be obliged to differ 
 from “ his immortal friend,” and avers its seat to be an infini¬ 
 tesimal degree behind the bulb. Sir A. Cooper again, though 
 arguing that the most usual situation of stricture is that men¬ 
 tioned by Hunter, names, as next in order of frequency, stric¬ 
 tures of the membranous and prostatic parts of the urethra. 
 Does it not appear strange now, how questions of this import 
 should have occupied so much of the serious attention of our 
 great predecessors, and of those, too, who at the present time 
 form the vanguard of the ranks of science ? Upon what cir¬ 
 cumstance, either anatomical or pathological, can one part of 
 the urethra be more liable to the organic stricture than another ? 
 
 129 
 
130 
 
 COMMENTARY ON PLATES 59 & GO. 
 
 Figs. 1 and 2, Plate 59. — In these figures are pre¬ 
 sented seven forms of organic stricture occurring in 
 different parts of the urethra. In a, Fig. 1, the mu¬ 
 cous membrane is thrown into a sharp circular fold, 
 in the centre of which the canal appears much con¬ 
 tracted; a section of this stricture appears in b, Fig. 2. 
 In b, Fig. 1, the canal is contracted laterally by a 
 prominent fold of the mucous membrane at the oppo¬ 
 site side. In c, Fig. 1, an organized band of lymph is 
 stretched across the canal; this stricture is seen in 
 section in c, Fig. 2. In e, Fig. 1, a stellate band of 
 organized lymph, attached by pedicles to three sides 
 of the urethra, divides the canal into three passages. 
 In d, Fig. 1, the canal is seen to be much contracted 
 towards the left side by a crescentic fold of the lining 
 membrane projecting from the right. In /, the canal 
 appears contracted by a circular membrane, perforated 
 in the centre; a section of which is seen at a, Fig. 2. 
 The form of the organic stricture varies therefore ac¬ 
 cording to the three following circumstances : — 1st. 
 When lymph becomes effused within the canal upon 
 the surface of the lining mucous membrane, and con¬ 
 tracts adhesions across the canal. 2ndly. When lymph 
 is effused external to the lining membrane, and projects 
 this inwards, thereby narrowing the diameter of the 
 canal. 3rdly. When the outer and inner walls of a 
 part of the urethra are involved in the effused organi- 
 zable matter, and on contracting towards each other, 
 encroach at the same time upon the area of the canal. 
 This latter state presents the form, which is known 
 as the old callous tough stricture, extending in many 
 instances for an inch or more along the canal. In 
 cases where the urethra becomes obstructed by tough 
 bands of substance, c e, which cross the canal directly, 
 the points of flexible catheters, especially if these be 
 of slender shape, are apt to be bent upon the resisting 
 part, and on pressure being continued, the operator 
 may be led to suppose that the instrument traverses 
 the stricture, while it is most probably perforating the 
 wall of the urethra. But in those cases where the 
 diameter of the canal is circularly contracted, the 
 stricture generally presents a conical depression in 
 front, which, receiving the point of the instrument, 
 
 allows this to enter the central passage unerringly. 
 A stricture formed by a crescentic septum, such as is 
 seen in bd, Fig. 1, offers a more effectual obstacle to 
 the passage of a catheter than the circular septum 
 like a f. 
 
 Fig. 3, Plate 59.—In this there are seen three se¬ 
 parate strictures, a,b,c , situated in the urethra, an¬ 
 terior to the bulb. In some cases there are many 
 more strictures (even to the number of six or seven) 
 situated in various parts of the urethra; and it is 
 observed that when one stricture exists, other slight 
 tightnesses in different parts of the canal frequently 
 attend it. (Hunter.) When several strictures occur 
 in various parts of the urethra, they may occasion as 
 much difficulty in passing an instrument as if the 
 whole canal between the extreme constrictions were 
 uniformly narrowed. 
 
 Fig. 4, Plate 59.—In this the canal is constricted 
 at the point a, midway between the bulb and glans. 
 A false passage has been made under the urethra by 
 an instrument which passed out of the canal at the 
 point /, anterior to the stricture a, and re-entered the 
 canal at the point c, anterior to the bulb. When a 
 false passage of this kind happens to be made, it will 
 become a permanent outlet for the urine, so long as 
 the stricture remains. For it can be of no avail that 
 we avoid re-opening the anterior perforation by the 
 catheter, so long as the urine prevented from flowing 
 by the natural canal enters the posterior perforation. 
 Measures should be at once taken to remove the 
 stricture. 
 
 Fig. 5, Plate 59.—The stricture a appears midway 
 between the bulb and glans, the area of the passage 
 through the stricture being sufficient only to admit a 
 bristle to pass. It would seem almost impossible to pass 
 a catheter through a stricture so close as this, unless by 
 a laceration of the part, combined with dilatation. 
 
 Fig. G, Plate 59.—Two instruments, a, b, have made 
 false passages beneath the mucous membrane, in a 
 case where no stricture at all existed. The resistance 
 which the instruments encountered in passing out of 
 the canal having been mistaken, no doubt, for that of 
 passing through a close stricture. 
 
COMMENTARY ON PLATES 59 & 60. 
 
 131 
 
 Pig. 7, Plate 59.—A bougie, bb, is seen to perforate 
 the urethra anterior to the stricture c, situated an inch 
 behind the glans, and after traversing the substance 
 of the right corpus cavernosura d, for its whole length, 
 re-enters the neck of the bladder through the body 
 of the prostate. 
 
 Fig. 8, Plate 59.—A bougie, cc, appears tearing and 
 passing beneath the lining membrane, d d, of the pros¬ 
 tatic urethra. It is remarked that the origin of a false 
 passage is in general anterior to the stricture. It may, 
 however, occur at any part of the canal in which no 
 stricture exists, if the hand that impels the instrument 
 be not guided by a true knowledge of the form of the 
 urethra; and perhaps the accident happening from 
 this cause is the more general rule of the two. 
 
 Fig. 9, Plate 59. — Two strictures are represented 
 here, the one, e, close to the bulb d, the other, /, an 
 inch anterior to this part. In the prostate, a b, are 
 seen irregularly shaped abscess pits, communicating 
 with each other, and projecting upwards the floor of 
 this body to such a degree, that the prostatic canal 
 appears nearly obliterated. 
 
 Fig. 10, Plate 59. — Two bougies, d e, are seen to 
 enter the upper wall of the urethra, c, anterior to the 
 prostate, a b. This accident happens when the handle 
 of a rigid instrument is depressed too soon, with the 
 object of raising its point over the enlarged third lobe 
 of the prostate. 
 
 Fig. 11, Plate 59. — Two instruments appear trans¬ 
 fixing the prostate, of which body the three lobes, 
 a, b, c, are much enlarged. The instrument d perfo¬ 
 rates the third lobe, a, while the instrument e pene¬ 
 trates the right lobe, c, and the third lobe, a. This 
 accident occurs when instruments not possessing the 
 proper prostatic bend are forcibly pushed forwards 
 against the resistance at the neck of the bladder. 
 
 Fig. 12, Plate 59.—In this case an instrument, dd, 
 
 * On comparing this series of figures, it must appear that 
 the third lobe of the prostate is the product of diseased action, 
 in so far at least as an unnatural hypertrophy of a part may 
 be so designated. It is not proper to the bladder in the healthy 
 state of this organ, and where it does manifest itself by increase 
 it performs no healthy function in the economy. When Home, 
 
 after passing beneath part of the lining membrane, e e, 
 anterior to the bulb, penetrates b, the right lobe of the 
 prostate. A second instrument, c c, penetrates the left 
 lobe. A third smaller instrument, ff, is seen to pass 
 out of the urethra anterior to the prostate, and after 
 transfixing the right vesicula seminalis external to the 
 neck of the bladder, enters this viscus at a point be¬ 
 hind the prostate. The resistance which the two 
 larger instruments met with in penetrating the pros¬ 
 tate, made it seem, perhaps, that a tight stricture 
 existed in this situation, to match which the smaller 
 instrument, //, was afterwards passed in the course 
 marked out. 
 
 Figs. 1 to 5, Plate 60, represent a series of prostates, 
 in which the third lobe gradually increases in size. 
 In Fig. 1, which shows the healthy state of the neck 
 of the bladder, unmarked by the prominent lines which 
 are said to bound the space named “ trigone vesical,” 
 or by those which indicate the position of the “muscles 
 of the ureters,” the third lobe does not exist. In Fig. 
 2 it appears as the uvula vesicas, a. In Fig. 3 the part 
 a is increased, and under the name now of third lobe 
 is seen to contract and bend upwards the prostatic 
 canal. In Fig. 4 the effect which the growth of the 
 lobe, a, produces upon the form of the neck of the 
 bladder becomes more marked, and the part presenting 
 perforations, ee, produced by instruments, indicates 
 that by its shape it became an obstacle to the egress 
 of the urine as well as to the entrance of instruments. 
 A calculus of irregular form is seen to lodge behind 
 the third lobe, and to be out of the reach of the point 
 of a sound, supposing this to enter the bladder over 
 the apex of the lobe. In Fig. 5 the three lobes are 
 enlarged, but the third is most so, and while standing 
 on a narrow pedicle attached to the floor of the pros¬ 
 tate, completely blocks up the neck of the bladder.* 
 
 Fig. 6, Plate 60. — The prostatic canal is bent up- 
 
 therefore, described this part as a new fact in anatomy, he had 
 in reality as little reason for so doing as he would have had in 
 naming any other tumour, a thing unknown to normal anatomy. 
 Langenbeck (Neue Bibl. b. i. p. 360) denies its existence in the 
 healthy state. Cruveilhier (Anat. Pathog. liv. xxvii.) deems it 
 incorrect to reckon a third lobe as proper to the healthy bladder. 
 
 I 
 
132 
 
 COMMENTARY ON PLATES 59 & 60. 
 
 wards by the enlarged third lobe to such a degree as 
 to form a right angle with the membranous part of 
 the canal. A bougie is seen to perforate the third 
 lobe, and this is the most frequent mode in which, 
 under such circumstances, and with instruments of 
 the usual imperfect form, access may be gained to the 
 bladder for the relief of retention of urine. “The 
 new passage may in every respect be as efficient as 
 one formed by puncture or incision in any other way.” 
 (Fergusson.) 
 
 Fig. 7, Plate 60. — The three lobes of the prostate, 
 a, i, c , are equally enlarged. The prostatic canal is 
 consequently much contracted and distorted, so that 
 an instrument on being passed into the bladder has 
 made a false passage through the third lobe. When a 
 catheter is suspected to have entered the bladder by 
 perforating the prostate, the instrument should be re¬ 
 tained in the newly made passage till such time as 
 this has assumed the cylindrical form of the instru¬ 
 ment. If this be done, the new passage will be the 
 more likely to become permanent. It is ascertained 
 that all false passages and fistulce by which the urine 
 escapes, become after a time lined with a membrane 
 similar to that of the urethra. (Stafford.) 
 
 Fig. 8, Plate 60. — The three lobes, a,b,c, of the 
 prostate are irregularly enlarged. The third lobe, a a, 
 projecting from below, distorts the prostatic canal up¬ 
 wards and to the right side. 
 
 Fig. 9, Plate 60.—The right lobe, acc, of the pros¬ 
 tate appears hollowed out so as to form the sac of an 
 abscess which, by its projection behind, pressed upon 
 the forepart of the rectum, and by its projection in 
 front, contracted the area of the prostatic canal, and 
 thereby caused an obstruction in this part. Not un- 
 frequently when a catheter is passed along the urethra, 
 for the relief of a retention of urine caused by the 
 swell of an abscess in this situation, the sac becomes 
 
 penetrated by the instrument, and, instead of urine, 
 pus flows. The sac of a prostatic abscess frequently 
 opens of its own accord into the neighbouring part of 
 the urethra, and when this occurs it becomes necessary 
 to retain a catheter in the neck of the bladder, so as 
 to prevent the urine entering the sac. 
 
 Fig. 10, Plate 60.—The prostate presents four lobes 
 of equal size, and all projecting largely around the 
 neck of the bladder. The prostatic canal is almost 
 completely obstructed, and an instrument has made a 
 false passage through the lobe a. 
 
 Fig. 11, Plate 60.—The third lobe of the prostate 
 is viewed in section, and shows the track of the false 
 passage made by the catheter, cl, through it, from its 
 apex to its base. The proper canal is bent upwards 
 from its usual position, which is that at present mark¬ 
 ed by the instrument in the false passage. 
 
 Fig. 12, Plate 60.—The prostatic lobes are uniformly 
 enlarged, and cause the corresponding part of the ure¬ 
 thra to be uniformly contracted, so as closely to em¬ 
 brace the catheter, cl d, occupying it, and to offer con¬ 
 siderable resistance to the passage of the instrument. 
 
 Fig. 13, Plate 60.—The prostate, be, is considerably 
 enlarged anteriorly, b, in consequence of which the 
 prostatic canal appears more horizontal even than na¬ 
 tural. The catheter, cl, occupying the canal lies nearly 
 straight. The lower wall, c, of the prostate is much 
 diminished in thickness. A nipple-shaped process, a, 
 is seen to be attached by a pedicle to the back of the 
 upper part, b, of the prostate, and to act like a stopper 
 to the neck of the bladder. The body a being move- 
 able, it will be perceived how, while the bladder is 
 distended with urine, the pressure from above may 
 block up the neck of the organ with this part, and 
 thus cause complete retention, which, on the introduc¬ 
 tion of a catheter, becomes readily relieved by the in¬ 
 strument pushing the obstructing body aside. 
 
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COMMENTARY ON PLATES 61 & 62. 
 
 DEFORMITIES OF THE PROSTATE. — DISTORTIONS AND OBSTRUCTIONS OF THE 
 
 PROSTATIC URETHRA. 
 
 The prostate is liable to such frequent and varied 
 deformities, the consequence of diseased action, whilst, 
 at the same time, its healthy function (if it have any) 
 in the male body is unknown, that it admits at least 
 of one interpretation which may, according to fact, be 
 given of it—namely, that of playing a principal part 
 in effecting some of the most distressing of “ the thou¬ 
 sand natural ills that flesh is heir to.” But heedless 
 of such a singular explanation of a final cause, the 
 practical surgeon will readily confess the fitting appli¬ 
 cation of the interpretation, such as it is, and rest 
 contented with the proximate facts and proofs. As 
 physiologists, however, it behooves us to look further 
 into nature, and search for the ultimate fact in her 
 prime moving law. The prostate is peculiar to the 
 male body, the uterus to the female. With the excep¬ 
 tion of these two organs there is not another which 
 appears iu the one sex but has its analogue in the op¬ 
 posite sex; and thus these two organs, the prostate 
 and the uterus, appear by exclusion of the rest to 
 approach the test of comparison, by which their ana¬ 
 logy becomes as fully manifested as that between the 
 
 two quantities, a — b, and a + b the only difference 
 which exists depends upon the subtraction or the ad¬ 
 dition of the quantity, b. The difference between a 
 prostate and a uterus is simply one of quantity, such 
 as we see existing between the male and the female 
 breast. The prostate is to the uterus absolutely what 
 a rudimentary organ is to its fully developed analogue. 
 The one, as being superfluous, is in accordance with 
 nature’s law of nihil supervacaneum nihil frustra , ar¬ 
 rested in its development, and in such a character 
 appears the prostate. This body is not a gland any 
 more than is the uterus, but both organs being quan¬ 
 titatively, and hence functionally different, I here 
 once more venture to call down an interpretation of 
 the part from the unfrequented bourne of comparative 
 anatomy, and turning it to lend an interest to the ac¬ 
 companying figures even with a surgical bearing, I 
 remark that the prostatic or rudimentary uterus, like 
 a germ not wholly blighted, is prone to an occasional 
 sprouting or increase beyond its prescribed dimen¬ 
 sions— a hypertrophy in barren imitation, as it were, 
 of gestation.* 
 
 * This expression of the fact to which I allude will not, I 
 trust, be extended beyond the limits I assign to it. Though I 
 have every reason to believe, that between the prostate of the 
 male and the uterus of the female, the same amount of analogy 
 exists, as between a coccygeal ossicle and the complete verte¬ 
 bral form elsewhere situated in the spinal series, I am as far 
 from regarding the two former to be in all respects structurally 
 or functionally alike, as I am from entertaining the like idea in 
 respect to the two latter. But still I maintain that between a 
 prostate and a uterus, as between a coccygeal bone and a ver¬ 
 tebra, the only difference which exists is one of quantity, and 
 that hence arises the functional difference. A prostate is part 
 of a uterus, just as a coccygeal bone is part (the centrum) of a 
 
 vertebra. That this is the absolute signification of the prostate 
 I firmly believe, and were this the proper place, I could prove 
 it in detail, by the infallible rule of analogical reasoning. John 
 Hunter has observed that the use of the prostate was not suffi¬ 
 ciently known to enable us to form a judgment of the bad con¬ 
 sequences of its diseased state. When the part becomes mor¬ 
 bidly enlarged, it acts as a mechanical impediment to the 
 passage of urine from the bladder, but from this circumstance 
 we cannot reasonably infer, that while of its normal healthy 
 proportions, its special function is to facilitate the egress of the 
 urine, for the female bladder, though wholly devoid of the pros¬ 
 tate, performs its own function perfectly. It appears to me, 
 therefore, that the real question should be, not what is the use 
 
 133 
 
134 
 
 COMMENTARY ON PLATES 61 & 02. 
 
 Eig. 1, Plate 61. — The prostate, a b, is here repre¬ 
 sented thinned in its walls above and below. The 
 lower wall is dilated into a pouch caused by the points 
 of misdirected instruments in catheterism having been 
 rashly forced against it. 
 
 Fig. 2, Plate 61.—The prostate, a b, is here seen to 
 be somewhat more enlarged than is natural. A tuber¬ 
 cle, b, surmounts the lower part, c, of the prostate, 
 and blocks up the vesical orifice. Catheters intro¬ 
 duced by the urethra for retention of urine which 
 existed in this case, have had their points arrested at 
 the bulb, and on being pushed forwards in this direc¬ 
 tion, have dilated the bulb into the form of a pouch, 
 seen at cl. The sinus of the bulb, being the lowest 
 part of the urethral canal, is very liable to be distorted 
 or perforated by the points of instruments descending 
 upon it from above and before.* 
 
 Fig. 3, Plate 61. — A cyst, c, is seen to grow from 
 the left side of the base of the prostate, a b, and to 
 form an obstruction at the vesical orifice. 
 
 Fig. 4, Plate 61. — A globular excrescence, a, ap¬ 
 pears blocking up the vesical orifice, and giving to 
 this the appearance of a crescentic slit, corresponding 
 to the shape of the obstructing body. The prostate, 
 
 bb, is enlarged in both its lateral lobes. A small 
 bougie, c, is placed in the prostatic canal and vesical 
 opening. 
 
 Fig. 5, Plate 61. — The prostate, d, is considerably 
 enlarged, and the vesical orifice is girt by a prominent 
 ring, b b, from the right border of which the nipple¬ 
 shaped body, a, projects and occupies the outlet. 
 Owing to the retention of urine caused by this state 
 of the prostate, the ureters, cc, have become very 
 much dilated. 
 
 Fig. 6, Plate 61.—The lateral lobes of the prostate, 
 cc, are seen enlarged, and from the inner side and 
 base of each, irregularly shaped masses, a, b, d, project, 
 and bend the prostatic urethra first to the right side, 
 then to the left. The part, a , resting upon the part, b, 
 acts like a valve against the vesical outlet, which 
 would become closed the tighter according to the de¬ 
 gree of superincumbent pressure. A flexible catheter 
 would, in such a case as this, be more likely, perhaps, 
 to follow the sinuous course of the prostatic jmssage 
 than a rigid instrument of metal. 
 
 Fig. 7, Plate 61.—A globular mass, a, of large size, 
 occupies the neck of the bladder, and gives the vesical 
 orifice, c, a crescentic shape, convex towards the right 
 
 of the prostate? but has it any proper function? If the former 
 question puzzled even the philosophy of Hunter, it was because 
 the latter question must be answered in the negative. The 
 prostate has no function proper to itself per se. It is a thing 
 distinct from the urinary apparatus, and distinct likewise from 
 the generative organs. It may be hypertrophied or atrophied, 
 or changed in texture, or wholly destroyed by abscess, and yet 
 neither of the functions of these two systems of organs will be 
 impaired, if the part while diseased act not as an obstruction 
 to them. In texture the prostate is similar to an unimpregnated 
 uterus. In form it is, like the uterus, symmetrical. In position 
 it corresponds to the uterus. The prostate has no ducts proper 
 to itself. Those ducts which are said to belong to it (prostatic 
 ducts) are merely mucous cells, similar to those in other parts 
 of the urethral lining membrane. The seminal ducts evidently 
 do not belong to it. The texture of the prostate is not such as 
 appears in glandular bodies generally. In short, the facts which 
 prove what it is not, prove what it actually is—namely, a uterus 
 arrested in its development, and as a sign of that all-encom¬ 
 
 passing law in nature, which science expresses by the term 
 “ unity in variety.” This interpretation of the prostate, which 
 I believe to be true to nature, will last perhaps till such time as 
 the microscopists shall discover in its “ secretion" some species 
 of mannikins, such as may pair with those which they term 
 spermatozoa. 
 
 * When a stricture exists immediately behind the bulb, this 
 circumstance will, of course, favour the occurrence of the 
 accident. “False passages (observes Mr. Benjamin Phillips) 
 are less frequent here (in the membranous part of the urethra) 
 than in the bulbous portion of the canal. The reason of this 
 must be immediately evident: false passages are ordinarily 
 made in consequence of the difficulty experienced in the en¬ 
 deavour to pass an instrument through the strictured portion 
 of the tube. Stricture is most frequently seated at the point 
 of junction between the bulbous and membranous portions of 
 the canal; consequently, the false passage will be usually an¬ 
 terior to this latter point.”—(On the Urethra, its Diseases, &c., 
 p. 15.) 
 
COMMENTARY ON PLATES 61 & 62. 
 
 135 
 
 side. The two lobes of the prostate, b, are much en¬ 
 larged. 
 
 Fig. 8, Plate 61.—The lateral lobes, bb, of the pros¬ 
 tate are irregularly enlarged, and the urinary passage 
 is bent towards the right side, c, from the membranous 
 portion, which is central. Surmounting the vesical 
 orifice, c, is seen the tuberculated mass, a, which being 
 moveable, can be forced against the vesical orifice and 
 thus produce complete retention of urine. In this 
 case, also, a flexible catheter would be more suitable 
 than a metallic one. 
 
 Fig. 9, Plate 61.—The lateral lobes, b b, of the pros¬ 
 tate are enlarged. The third lobe, a, projects at the 
 neck of the bladder, distorting the vesical outlet. A 
 small calculus occupies the prostatic urethra, and be¬ 
 ing closely impacted in this part of the canal, would 
 arrest the progress of a catheter, and probably lead to 
 the supposition that the instrument grated against a 
 stone in the interior of the bladder, in which case it 
 would he inferred that since the urine did not flow 
 through the catheter no retention existed. 
 
 Fig. 10, Plate 61. — Both lateral lobes, be, of the 
 prostate appear much increased in size. A large irre¬ 
 gular shaped mass, a, grows from the base of the right 
 lobe, and distorts the prostatic canal and vesical orifice. 
 When the lobes of the prostate increase in size in this 
 direction, the prostatic canal becomes much more 
 elongated than natural, and hence the instrument 
 which is to be passed for relieving the existing reten¬ 
 tion of urine should have a wide and long curve to 
 correspond with the form of this part of the urethra. :i: 
 
 Fig. 11, Plate 61. — Both lobes of the prostate are 
 enlarged, and from the base of each amass projects pro¬ 
 minently around the vesical orifice, a b. The prostatic 
 urethra has been moulded to the shape of the instru¬ 
 ment, which was retained in it for a considerable time. 
 
 Fig. 12, Plate 61. — The prostate, cb, is enlarged 
 and dilated, like a sac. Across the neck, a , of the 
 bladder the prostate projects in an arched form, and 
 is transfixed by the instrument, d. The prostate may 
 assume this appearance, as well from instruments 
 having been forced against it, as from an abscess cavity 
 formed in its substance having received, from time to 
 time, a certain amount of the urine, and retained this 
 fluid under the pressure of strong efforts, made to 
 void the bladder while the vesical orifice was closed 
 above. 
 
 Fig. 13, Plate 61. —The lateral lobes, de, of the 
 prostate are enlarged; and, occupying the position of 
 the third lobe, appear as three masses, abc, plicated 
 upon each other, and directed towards the vesical 
 orifice, which they close like valves. The prostatic 
 urethra branches upwards into three canals, formed 
 by the relative position of the parts, e, c, b, a, d, at the 
 neck of the bladder. The ureters are dilated, in con¬ 
 sequence of the regurgitation of the contents of the 
 bladder during the retention which existed. 
 
 Fig. 1, Plate 62, exhibits the lobes of the prostate 
 greatly increased in size. The part, a b, girds irregu¬ 
 larly, and obstructs the vesical outlet, while the lateral 
 lobes, c d, encroach upon the space of the prostatic 
 canal. The walls of the bladder are much thickened. 
 
 Fig. 2, Plate 62. — The three lobes, a,d, c, of the 
 prostate are enlarged and of equal size, moulded against 
 each other in such a way that the prostatic canal and 
 vesical orifice appear as mere clefts between them. 
 The three lobes are encrusted on their vesical surfaces 
 with a thick calcareous deposit. The surface of the 
 third lobe, a, which has been half denuded of the 
 calcareous crust, b, in order to show its real character, 
 appeared at first to be a stone impacted in the neck 
 of the bladder, and of such a nature it certainly would 
 
 * Both lobes of the prostate are equally liable to chronic 
 enlargement. Home believed the left lobe to be oftener in¬ 
 creased in size than the right. Wilson (on the Male Urinary 
 and Genital Organs) mentions several instances of the enlarge¬ 
 ment of the right lobe. No reason can be assigned why one 
 lobe should be more prone to hypertrophy than the other, even 
 
 supposing it to be matter of fact, which it is not. But the ob¬ 
 servations made by Cruveilhier (Anat. Pathol.), that the lobu- 
 lated projections of the prostate always take place internally 
 at its vesical aspect, is as true as the manner in which he accounts 
 for the fact is plausible. The dense fibrous envelope of the 
 prostate is sufficient to repress its irregular growth externally. 
 
136 
 
 COMMENTARY ON PLATES 61 & 62. 
 
 seem to the touch, on striking it with the point of a 
 sound or other instrument. 
 
 Fig. 3, Plate 62, represents the prostate with its 
 three lobes enlarged, and the prostatic canal and vesi¬ 
 cal orifice narrowed. The walls of the bladder are 
 thickened, fasciculated, and sacculated; the two former 
 appearances being caused by a hypertrophy of the 
 vesical fibres, while the latter is in general owing to a 
 protrusion of the mucous membrane between the 
 fasciculi. 
 
 Fig. 4, Plate 62.—The prostate presents four lobes, 
 a, b, c, d, each being of large size, and projecting far 
 into the interior of the bladder, from around the vesi¬ 
 cal orifice which they obstruct. The bladder is thick¬ 
 ened, and the prostatic canal is elongated. The urethra 
 and the lobes of the prostate have been perforated by 
 instruments, passed for the retention of urine which 
 existed. A stricturing band, e, is seen to cross the 
 membranous part of the canal. 
 
 Fig. 5, Plate 62. — The prostate, a a, is greatly en¬ 
 larged, and projects high in the bladder, the walls of 
 the latter, b b, being very much thickened. The ure¬ 
 ters, c, are dilated, and perforations made by instru¬ 
 ments are seen in the prostate. The prostatic canal 
 being directed almost vertically, and the neck of the 
 bladder being raised nearly as high as the upper border 
 of the pubic symphysis, it must appear that if a stone 
 rest in the bas fond of the bladder, a sound or staff 
 cannot reach the stone, unless by perforating the pros¬ 
 tate ; and if, while the staff occupies this position, 
 lithotomy be performed, the incisions will not be re¬ 
 quired to be made of a greater depth than if the pros¬ 
 tate were of its ordinary proportions. On the contrary, 
 if the staff happen to have surmounted the prostate, 
 the incision, in order to divide the whole vertical 
 thickness of this body, will require to be made very 
 deeply from the perinseal surface, and this circumstance 
 occasions what is termed a “ deep perinaeum.” 
 
 Fig. 6, Plate 62.—The lower half, c, b,f, of the pros¬ 
 tate, having become the seat of abscess, appears hol¬ 
 lowed out in the form of a sac. This sac is separated 
 from the bladder by a horizontal septum, e e, the pro¬ 
 per base of the bladder, gg. The prostatic urethra, 
 
 between ae, has become vertical in respect to the 
 membranous part of the canal, in consequence of the 
 upward pressure of the abscess. The sac opens into 
 the urethra, near the apex of the prostate, at the 
 point c; and a catheter passed along the urethra has 
 entered the orifice of the sac, the interior of which 
 the instrument traverses, and the posterior wall of 
 which it perforates. The bladder contains a large 
 calculus, i. The bladder and sac do not communicate, 
 but the urethra is a canal common to both. In a case 
 of this sort it becomes evident that, although symptoms 
 may strongly indicate either a retention of urine, or 
 the presence of a stone in the bladder, any instrument 
 taking the position and direction of dd, cannot relieve 
 the one or detect the other; and such is the direction 
 in which the instrument must of necessity pass, while 
 the sac presents its orifice more in a line with the 
 membranous part of the urethra than the neck of the 
 bladder is. The sac will intervene between the rec¬ 
 tum and the bladder; and on examination of the parts 
 through the bowel, an instrument in the sac will 
 readily be mistaken for being in the bladder, while 
 neither a calculus in the bladder, nor this organ in a 
 state of even extreme distention, can be detected by 
 the touch any more than by the sound or catheter. 
 If, while performing lithotomy in such a state of the 
 parts, the staff occupy the situation of ddd, then the 
 knife, following the staff, will open, not the bladder 
 which contains the stone, but the sac, which, more¬ 
 over, if it happen to be filled with urine regurgigated 
 from the urethra, will render the deception more com¬ 
 plete. 
 
 Fig. 7, Plate 62. — The walls, a a, of the bladder, 
 appear greatly thickened, and the ureters, b, dilated. 
 The sides, ccc, of the prostate are thinned; and in 
 the prostatic canal are two calculi, dd, closely impact¬ 
 ed. In such a state of the parts it would be impossible 
 to pass a catheter into the bladder for the relief of a 
 retention of urine, or to introduce a staff as a guide 
 to the knife in lithotomy. If, however, the staff can be 
 passed as far as the situation of the stone, the parts may 
 be held with a sufficient degree of steadiness to enable 
 the operator to incise the prostate upon the stone. 
 
COMMENTARY ON PLATES 63 & 64. 
 
 DEFORMITIES OF THE URINARY BLADDER.—THE OPERATIONS OF SOUNDING FOR STONE, 
 OF CATHETERISM AND OF PUNCTURING THE BLADDER ABOVE THE PUBES. 
 
 The urinary bladder presents two kinds of de¬ 
 formity—viz., congenital and pathological. As exam¬ 
 ples of the former may be mentioned that in which 
 the organ is deficient in front, and has become everted 
 and protruded like a fungous mass through an opening 
 at the median line of the hypogastrium; that in which 
 the rectum terminates in the bladder posteriorly; and 
 that in which the foetal urachus remains pervious as 
 a uniform canal, or assumes a sacculated shape be¬ 
 tween the summit of the bladder and the umbilicus. 
 The pathological deformities are, those in which vesi¬ 
 cal fistula*, opening either above the pubes, at the 
 perinteum, or into the rectum, have followed abscesses 
 or the operation of puncturing the bladder in these 
 situations, and those in which the walls of the organ 
 appear thickened and contracted, or thinned and ex¬ 
 panded, or sacculated externally, or ridged internally, 
 in consequence of its having been subjected to abdo¬ 
 minal pressure while overdistended with its contents, 
 
 and while incapable of voiding these from some per¬ 
 manent obstruction in the urethral canal* The bladder 
 is liable to become sacculated from two causes—from 
 a hernial protrusion of its mucous membrane through 
 the separated fasciculi of its fibrous coat, or from the 
 cyst of an abscess which has formed a communication 
 with the bladder, and received the contents of this 
 organ. Sacs, when produced in the former way, may 
 be of any number, or size, or in any situation; when 
 caused by an abscess, the sac is single, is generally 
 formed in the prostate, or corresponds to the base of 
 the bladder, and may attain to a size equalling, or 
 even exceeding, that of the bladder itself. The sac, 
 however formed, will be found lined by mucous mem¬ 
 brane. The cyst of an abscess, when become a reci¬ 
 pient for the urine, assumes after a time a lining 
 membrane similar to that of the bladder. If the sac 
 be situated at the summit or back of the bladder, it 
 will be found invested by peritonseum; but, whatever 
 
 * On considering these cases of physical impediments to the 
 passage of urine from the vesical reservoir through the urethral 
 conduit, it seems to me as if these were sufficient to account for 
 the formation of stone in the bladder, or any other part of the 
 urinary apparatus, without the necessity of ascribing it to a con¬ 
 stitutional disease, such as that named the lithic diathesis by the 
 humoral pathologists. 
 
 The urinary apparatus (consisting of the kidneys, ureters, 
 bladder, and urethra) is known to be the principal emunctory for 
 eliminating and voiding the detritus formed by the continual de¬ 
 cay of the parts comprising the animal economy. The urine is 
 this detritus in a state of solution. The components of urine are 
 chemically similar to those of calculi, and as the components of 
 the one vary according to the disintegration occurring at the time 
 in the vital alembic, so do those of the other. While, therefore, 
 a calculus is only as urine precipitated and solidified, and this 
 fluid only as calculous matter suspended in a menstruum, it must 
 appear that the lithic diathesis is as natural and universal as struc¬ 
 tural disintegration is constant and general in operation. As 
 every individual, therefore, may be said to void day by day a 
 dissolved calculus, it must follow that its form of precipitation 
 within some part of the urinary apparatus alone constitutes the 
 18 
 
 disease, since in this form it cannot be passed. On viewing the 
 subject in this light, the question that springs directly is, (while 
 the lithic diathesis is common to individuals of all ages and both 
 sexes,) why the lithic sediment should present in the form of 
 concrement in some and not in others ? The principal, if not the 
 sole, cause of this seems to me to be obstruction to the free egress 
 of the urine along the natural passage. Aged individuals of the 
 male sex, in whom the prostate is prone to enlargement, and the 
 urethra to organic stricture, are hence more subject to the forma¬ 
 tion of stone in the bladder, than youths, in whom these causes 
 of obstruction are less frequent, or than females of any age, in 
 whom the prostate is absent, and the urethra simple, short, readily 
 dilatable, and seldom or never strictured. When an obstruction 
 exists, lithic concretions take place in the urinary apparatus in the 
 same manner as sedimentary particles cohere or crystallize else¬ 
 where. The urine becoming pent up and stagnant while charged 
 with saline matter, either deposits this around a nucleus intro¬ 
 duced into it, or as a surplus when the menstruum is insufficient 
 to suspend it. The most depending part of the bladder is that 
 where lithic concretions take place ; and if a sacculus exist here, 
 ‘this, becoming a recipient for the matter, will favour the forma¬ 
 tion of stone. 
 
 ( 137 ) 
 
138 
 
 COMMENTARY ON PLATES 63 & 64. 
 
 be its size, structure, or position, it may be always 
 distinguished from the bladder by being devoid of the 
 fibrous tunic, and by having but an indirect relation 
 to the vesical orifice. 
 
 Fig. 1, Plate 63.—The lateral lobes of the prostate, 
 
 3, 4, are enlarged, and contract the prostatic canal. 
 Behind them the third lobe of smaller size occupies 
 the vesical orifice, and completes the obstruction. The 
 walls of the bladder have hence become fasciculated 
 and sacculated. One sac, 1, projects from the summit 
 of the bladder; another, 2, containing a stone, projects 
 laterally. When a stone occupies a sac, it does not 
 give rise to the usual symptoms as indicating its pre¬ 
 sence, nor can it be always detected by the sound. 
 
 Fig. 2, Plate 63. — The prostate, 2, 3, is enlarged, 
 and the middle lobe, 2, appears bending the prostatic 
 canal to an almost vertical position, and obstructing 
 the vesical orifice. The bladder, 1,1,1, is thickened; 
 the ureters, 7, are dilated; and a large sac, 6, 6, pro¬ 
 jects from the base of the bladder backwards, and 
 occupies the recto-vesical fossa. The sac, equal in size 
 to the bladder, communicates with this organ by a 
 small circular opening, 8, situated between the orifices 
 of the ureters. The peritonmuin is reflected from the 
 summit of the bladder to that of the sac. A catheter, 
 
 4, appears perforating the third lobe of the prostate, 2, 
 and entering the sac, 5, through the base of the blad¬ 
 der, below the opening, 8. In a case of this kind, a 
 catheter occupying the position 4, 5, would, while 
 voiding the bladder through the sac, make it seem as if 
 it really traversed the vesical orifice. If a stone occu¬ 
 pied the bladder, the point of the instrument in the 
 sac could not detect it, whereas, if a stone lay within 
 the sac, the instrument, on striking it here, would 
 give the impression as if it lay within the bladder. 
 
 Fig. 3, Plate 63.—The urethra being strictured, the 
 bladder has become sacculated. In the has fond of 
 the bladder appears a circular opening, 2, leading to a 
 sac of large dimensions, which rested against the rec¬ 
 tum. In such a case as this, the sac, occupying a 
 lower position than the base of the bladder, must first 
 become the recipient of the urine, and retain this fluid 
 even after the bladder has been evacuated, either vo- \ 
 
 luntarily or by means of instruments. If, in such a 
 state of the parts, retention of urine called for punc- 
 turation, it is evident that this operation would be 
 performed with greater effect by opening the depend¬ 
 ing sac through the bowel, than by entering the sum¬ 
 mit of the bladder above the pubes. 
 
 Fig. 4, Plate 63.—The vesical orifice is obstructed 
 by two portions, 3, 4, of the prostate, projecting up¬ 
 wards, one from each of its lateral lobes, 6, 6. The 
 bladder is thickened and fasciculated, and from its 
 summit projects a double sac, 1, 2, which is invested 
 by the peritonceum. 
 
 Fig. 5, Plate 63.—The prostatic canal is constricted 
 aud bent upwards by the third lobe. The bladder is 
 thickened, and its base is dilated in the form of a sac, 
 which is dependent, and upon which rests a calculus. 
 An instrument enters the bladder by perforating the 
 third lobe, but does not come into contact with the 
 calculus, owing to the low position occupied by this 
 body. 
 
 Fig. 6, Plate 63.—Two sacs appear projecting on 
 cither side of the base of the bladder. The right one, 
 5, contains a calculus, 6 ; the left one, of larger dimen¬ 
 sions, is empty. The rectum lay in contact with the 
 base of the bladder between the two sacs. 
 
 Fig. 7, Plate 63.—Four calculi are contained in the 
 bladder. This organ is divided by two septa, 2, 4, into 
 three compartments, each of which, 1, 3, 5, gives lodg¬ 
 ment to a calculus; and another, 6, of these bodies lies 
 impacted in the prostatic canal, and becomes a complete 
 bar to the passage of a catheter. Supposing lithotomy 
 to be performed in an instance of this kind, it is pro¬ 
 bable that, after the extraction of the calculi, 6, 5, the 
 two upper ones, 3, 1, would, owing to their being em¬ 
 bedded in the walls of the bladder, escape the forceps. 
 
 Fig. 8, Plate 63. — Two large polypi, and many 
 smaller ones, appear growing from the mucous mem¬ 
 brane of the prostatic urethra and vesical orifice, and 
 obstructing these parts. In examining this case during 
 life by the sound, the two larger growths, 1, 2, were 
 mistaken by the surgeon for calculi. Such a mistake 
 might well be excused if they happened to be encrust¬ 
 ed with litliic matter. 
 
COMMENTARY ON PLATES 63 & 64. 
 
 139 
 
 Fig. 9, Plate 63. — The base of the bladder, 8, 8, 
 appears dilated into a large uniform sac, and separated 
 from the upper part of the organ by a circular hori¬ 
 zontal fold, 2, 2. The ureters are also dilated. The 
 left ureter, 3, 4, opens into the sac below this fold, 
 while the right ureter opens above it into the bladder. 
 In all cases of retention of urine from permanent ob¬ 
 struction of the urethra, the ureters are generally 
 found more or less dilated. Two circumstances com¬ 
 bine to this effect—while the renal secretion continues 
 to pass into the ureters from above, the contents of the 
 bladder under abdominal pressure are forced regurgi¬ 
 tating into them from below, through their orifices. 
 
 Fig. 1, Plate 64. — The bladder, 6, appears sym¬ 
 metrically sacculated. One sac, 1, is formed at its 
 summit, others, 3, 2, project laterally, and two more, 
 5, 4, from its base. The ureters, 7, 7, are dilated, and 
 enter the bladder between the lateral and inferior 
 sacs. 
 
 Fig. 2, Plate 64.—The prostate is greatly enlarged, 
 and forms a narrow ring around the vesical orifice. 
 Through this an instrument, 12, enters the bladder. 
 The walls of the bladder are thickened and sacculated. 
 On its left side appear numerous sacs, 2, 3, 4, 5, 6, 7, 8, 
 and on the inner surface of its right side appear the 
 orifices of as many more. On its summit another sac 
 is formed. The ureters, 9, are dilated. 
 
 Fig. 3, Plate 64.—The prostate is enlarged, its canal 
 is narrowed, and the bladder is thickened and con¬ 
 tracted. A calculus, 1, 2, appears occupying nearly 
 the whole vesical interior. The incision in the neck 
 of the bladder in lithotomy must necessarily be ex¬ 
 tensive, to admit of the extraction of a stone of this 
 size. 
 
 Fig. 4, Plate 64.—The prostatic canal is contracted 
 by the lateral lobes, 4, 5; resting upon these, appear 
 three calculi, 1, 2, 3, which nearly fill the bladder. 
 This organ is thickened and fasciculated. In cases of 
 
 this kind, and that last mentioned, the presence of 
 stone is readily ascertainable by the sound. 
 
 Fig. 5, Plate 64. — The three prostatic lobes are 
 enlarged, and appear contracting the vesical orifice. 
 In the walls of the bladder are embedded several 
 small calculi, 2, 2, 2, 2, which, on being struck with 
 the convex side of a sound, might give the impression 
 as though a single stone of large size existed. In per¬ 
 forming lithotomy, these calculi would not be within 
 reach of the forceps. 
 
 Fig. 6, Plate 64.—Two sacculi, 4, 5, appear project¬ 
 ing at the middle line of the base of the bladder, be¬ 
 tween the vasa deferentia, 7, 7, and behind the pros¬ 
 tate, in the situation where the operation of puncturing 
 the bladder per anum is recommended to be performed 
 in retention of urine. 
 
 Fig. 7, Plate 64. — A sac, 4, is situated on the left 
 side of the bladder, 3, 3, immediately above the orifice 
 of the ureter. In the sac was contained a mass of 
 phosphatic calculus. This substance is said to be se¬ 
 creted by the mucous lining of the bladder, while in a 
 state of chronic inflammation, but there seems never¬ 
 theless very good reason for us to believe that it is, 
 like all other calculous matter, a deposit from the 
 urine. 
 
 Fig. 8, Plate 64, represents, in section, the relative 
 position of the parts concerned in catheterism.* In 
 performing this operation, the patient is to be laid 
 supine; his loins are to be supported on a pillow; and 
 his thighs are to be flexed and drawn apart from each 
 other. By this means the perina3um is brought fully 
 into view, and its structures are made to assume a 
 fixed relative position. The operator, standing on the 
 patient’s left side, is now to raise the penis so as to 
 render the urethra, 8, 8, 8, as straight as possible be¬ 
 tween the meatus, a, and the bulb, 7. The instru¬ 
 ment (the concavity of its curve being turned to the 
 left groin) is now to be inserted into the meatus, and 
 
 * It may be necessary for me to state that, with the exception | the prostate, and the bladder, have been made by myself from 
 of this figure (which is obviously a plan, but sufficiently accurate ' natural specimens in the museums and hospitals of London and 
 for the purposes it is intended to serve) all the others representing | Paris, 
 pathological conditions and congenital deformities of the urethra, , 
 
140 
 
 COMMENTARY ON PLATES 63 & 6 4. 
 
 while being gently impelled through the canal, the 
 urethra is to be drawn forwards, by the left hand, over 
 the instrument. By stretching the urethra, we render 
 its sides sufficiently tense for facilitating the passage 
 of the instrument, and the orifices of the lacunas be¬ 
 come closed. While the instrument is being passed 
 along this part of the canal, its point should be direct¬ 
 ed fairly towards the urethral opening, 6*, of the 
 triangular ligament, which is situated an inch or so 
 below the pubic symphysis, 11. With this object in 
 view, we should avoid depressing its handle as yet, 
 lest its point be prematurely tilted up, and rupture 
 the upper side of the urethra anterior to the ligament. 
 As soon os the instrument has arrived at the bulb, its 
 further progress is liable to be arrested, from these 
 causes : — 1st, This portion of the canal is the lowest 
 part of its perinatal curve, 3, 6, 8, and is closely em¬ 
 braced by the middle fibres of the accelerator urina? 
 muscle. 2nd, It is immediately succeeded by the 
 commencement of the membranous urethra, which, 
 while being naturally narrower than other parts, is 
 also the more usual seat of organic stricture, and is 
 subject to spasmodic constriction by the fibres of the 
 compressor urethra?. 3d, The triangular ligament is 
 behind it, and if the urethral opening of the ligament 
 be not directly entered by the instrument, this will 
 bend the urethra against the front of that dense struc¬ 
 ture. On ascertaining these to be the causes of resist¬ 
 ance, the instrument is to be withdrawn a little in the 
 canal, so as to admit of its being readjusted for en¬ 
 gaging precisely the opening in the triangular liga¬ 
 ment. As this structure, 6, is attached to the mem¬ 
 branous urethra, 6*, which perforates it, both these 
 parts may be rendered tense, by drawing the penis 
 forwards, and thereby the instrument may be guided 
 towards and through the aperture. The instrument 
 having passed the ligament, regard is now to be paid 
 tu the direction of the pelvic portion of the canal, 
 which is upwards and backwards to the vesical orifice, 
 3, d, 3. In order that the point of the instrument 
 may freely traverse the urethra in this direction, its 
 
 handle, a, requires to be depressed, b c, slowly towards 
 the perinseum, and at the same time to be impelled 
 steadily back in the line d, d, through the pubic arch, 
 11. If the third lobe of the prostate happen to be 
 enlarged, the vesical orifice will accordingly be more 
 elevated than usual. In this case, it becomes neces¬ 
 sary to depress the instrument to a greater extent 
 than is otherwise required, so that its point may sur¬ 
 mount the obstacle. But since the suspensory liga¬ 
 ment of the penis, 10, and the perinmal structures 
 prevent the handle being depressed beyond a certain 
 degree, which is insufficient for the object to be attain¬ 
 ed, the instrument should possess the prostatic curve , 
 c c, compared with c b. 
 
 In the event of its being impossible to pass a ca¬ 
 theter by the urethra, in cases of retention of urine 
 threatening rupture, the base or the summit of the 
 bladder, according as either part may be reached with 
 the greater safety to the peritonmal sac, will require 
 to be punctured. If the prostate'be greatly and irre¬ 
 gularly enlarged, it will be safer to puncture the blad¬ 
 der above the pubes, and here the position of the 
 organ in regard to the peritonmum, 1, becomes the 
 chief consideration. The shape of the bladder varies 
 very considerably from its state of collapse, 3, 3, 5, to 
 those of mediate, 3, 3, 2, 1, and extreme distention, 
 3, 3, 4. This change of form is chiefly effected by 
 the expansive elevation of its upper half, which is in¬ 
 vested by the peritonaeum. As the summit of the 
 bladder falls below, and rises above the level of the 
 upper margin of the pubic symphysis, it carries the 
 peritonaeum with it in either direction. While the 
 bladder is fully expanded, 4, there occurs an interval 
 between the margin of the symphysis pubis and the 
 point of reflexion of the peritonaeum, from the recti 
 muscles, to the summit of the viscus. At this inter¬ 
 val, close to the pubes, and in the median line, the 
 trocar may be safely passed through the front wall of 
 the bladder. The instrument should, in all cases, be 
 directed downwards and backwards, A, 7^, in a line 
 pointing to the hollow of the sacrum. 
 
tyir* 
 
COMMENTARY ON PLATES 65 & 66. 
 
 THE SURGICAL DISSECTION OF THE POPLITEAL SPACE AND THE POSTERIOR 
 
 CRURAL REGION. 
 
 On comparing the bend of the knee with the bend 
 of the elbow, as evident a correspondence can be dis¬ 
 cerned between these two regions, as exists between 
 the groin and the axilla. 
 
 Behind the knee-joint, the muscles which connect 
 the leg with the thigh enclose the space named popli¬ 
 teal. When the integuments and subcutaneous sub¬ 
 stance are removed from this place, the dense fascia 
 lata may be seen binding these muscles so closely 
 together as to leave but a very narrow interval be¬ 
 tween them at the mesial line. On removing this 
 fascia, bbmm, Plate 65, the muscles part asunder, 
 and the popliteal space as usually described is thereby 
 formed. This region now presents of a lozenge-shaped 
 form, b j d k, of which the widest diameter, d j, is 
 opposite the knee-joint. The flexor muscles, cdj, in 
 diverging from each other as they pass down from the 
 sides of the thigh to those of the upper part of the 
 leg, form the upper angle of this space; whilst its 
 lower angle is described by the two heads of the gas¬ 
 trocnemius muscle, e e, arising inside the flexors, from 
 the condyles of the femur. The popliteal space is 
 filled with adipose substance, in which are embedded 
 several lymphatic bodies and through which pass the 
 principal vessels and nerves to the leg. 
 
 In the dissection of the popliteal space, the more 
 important parts first met with are the branches of the 
 great sciatic nerve. In the upper angle of the space, 
 this nerve will be found dividing into the peronseal, i, 
 and posterior tibial branches, h k. The peronseal 
 nerve descends close to the inner margin of the tendon, 
 J, of the biceps muscle; and, having reached the outer 
 side of the knee, I*, Plate 66, below the insertion of 
 the tendon into the head of the fibula, winds round 
 the neck of this bone under cover of the peronceus 
 longus muscle, s, to join the anterior tibial artery. The 
 posterior tibial nerve, h k, Plate 65, descends the 
 
 popliteal space midway to the cleft between the heads 
 of the gastrocnemius; and, after passing beneath this 
 muscle, to gain the inner side of the vessels, h*, Plate 
 66, it then accompanies the posterior tibial artery. On 
 the same plane with and close to the posterior tibial 
 nerve in the popliteal space, will be seen the terminal 
 branch of the lesser sciatic nerve, together with a 
 small artery and vein destined for distribution to the 
 skin and other superficial parts on the back of the 
 knee. Opposite the heads of the gastrocnemius, the 
 peronmal and posterior tibial nerves give off each a 
 branch, both of which descend along the mesial line 
 of the calf, and joining near the upper end of the 
 tendo Achillis, the single nerve here, n, Plate 65, 
 becomes superficial to the fascia, and thence descends 
 behind the outer ankle to gain the external border of 
 the foot, where it divides into cutaneous branches and 
 others to be distributed to the three or four outer toes. 
 In company with this nerve will be seen the posterior 
 saphena vein, l, which, commencing behind the outer 
 ankle, ascends the mesial line of the calf to join the 
 popliteal vein, g, in the cleft between the heads of the 
 gastrocnemius. 
 
 On removing next the adipose substance and 
 lymphatic glands, we expose the popliteal vein and 
 artery. The relative position of these vessels and the 
 posterior tibial nerve, may now be seen. Between the 
 heads of the gastrocnemius, the nerve, h, giving off 
 large branches to this muscle, lies upon the popliteal 
 vein, G, where this is joined by the posterior saphena 
 vein. Beneath the veins lies the popliteal artery, f. 
 On tracing the vessels and nerve from this point up¬ 
 wards through the popliteal space, we find the nerve 
 occupying a comparatively superficial position at the' 
 mesial line, while the vessels are directed upwards, 
 forwards, and inwards, passing deeply, as they become 
 covered by the inner flexor muscles, c d, to the place 
 
 (141) 
 
142 
 
 COMMENTARY ON PLATES 65 & 66. 
 
 ■where they perforate the tendon of the adductor 
 magnus on the inner side of the lower third of the 
 femur. 
 
 The popliteal artery, f, Plate 66, being the continua¬ 
 tion of the femoral, extends from the opening in the 
 great adductor tendon at the junction of the middle 
 and lower third of the thigh, to the point where it 
 divides, in the upper, and back part of the leg, at the 
 lower border of the popliteus muscle, L, into the an¬ 
 terior and posterior tibial branches. In order to 
 expose the vessel through this extent, we have to 
 divide and reflect the heads of the gastrocnemius 
 muscle, e e, and to retract the inner flexors. The 
 popliteal artery will now be seen lying obliquely over 
 the middle of the back of the joint. It is deeply 
 placed in its whole course. Its upper and lower thirds 
 are covered by large muscles; whilst the fascia and a 
 quantity of adipose tisgue overlies its middle. The 
 upi r part of the artery rests upon the femur, its 
 middle part upon the posterior ligament of the joint, 
 and its lower part upon the popliteus muscle. The 
 popliteal vein, g. adheres to the artery in its whole 
 course, being situated on its outer side above, and pos¬ 
 terior to it below. The vein is not unfrequently found 
 to be double; one vein lying to either side of the 
 artery, and both having branches of communication 
 with each other, which cross behind the artery. In 
 some instances the posterior saphena vein, instead of 
 joining the popliteal vein, ascends superficially to 
 terminate in some of the large veins of the thigh. 
 Numerous lymphatic vessels accompany the superficial 
 and deep veins into the popliteal space, where they 
 join the lymphatic bodies, which here lie in the course 
 of the artery. 
 
 The branches derived from the popliteal artery are 
 the muscular and the articular. The former spring 
 from the vessel opposite those parts of the several 
 muscles which lie in contact with it; the latter are 
 generally five in number — two superior, two inferior, 
 and one median. The two superior articular branches 
 arise from either side of the artery, and pass, the one 
 beneath the outer, the other beneath the inner flexors, 
 above the knee-joint; and the two inferior pass off 
 
 from it, the one internally, the other externally, be¬ 
 neath the heads of the gastrocnemius below the joint; 
 while the middle articular enters the joint through the 
 posterior ligament. The two superior and inferior 
 articular branches anastomose freely around the knee 
 behind, laterally, and in front, where they are joined 
 by the terminal branches of the anastomotic, from the 
 femoral, and by those of the recurrent, from the an¬ 
 terior tibial. The main vessel, having arrived at the 
 lower border of the popliteus muscle, divides into two 
 branches, of which one passes through the interosseous 
 ligament to become the anterior tibial; while the other, 
 after descending a short way between the bones of the 
 leg, separates into the peronceal and posterior tibial 
 arteries. In some rare instances the popliteal artery 
 is found to divide above the popliteus muscle into the 
 anterior, or the posterior tibial, or the peronceal. 
 
 The two large muscles, (gastrocnemius and soleus,) 
 forming the calf of the leg, have to be removed to¬ 
 gether with the deep fascia in order to expose the 
 posterior tibial, and peronceal vessels and nerves. The 
 fascia forms a sheath for the vessels, and binds them 
 close to the deep layer of muscles in their whole 
 course down the back of the leg. The point at which 
 the main artery, f, Plate 66, gives off the anterior 
 tibial, is at the lower border of the popliteus muscle, 
 on a level with n, the neck of the fibula; that at 
 which the artery again subdivides into the peronceal, 
 p, and posterior tibial branches, o, is in the mesial line 
 of the leg, and generally on a level with the junction 
 of its upper and middle thirds. From this place the 
 two arteries diverge in their descent; the peronceal 
 being directed along the inner border of the fibula 
 towards the back of the outer ankle; while the pos¬ 
 terior tibial, approaching the inner side of the tibia, 
 courses towards the back of the inner ankle. The 
 gastrocnemius and soleus muscles overlie both arteries 
 in their upper two thirds; but as these muscles taper 
 towards the mesial line where they end in the tendo 
 Achillis, v v, Plate 65, they leave the posterior tibial 
 artery, o, with its accompanying nerve and vein, un¬ 
 covered in the lower part of the leg, except by the 
 skin and the superficial and deep layers of fasciae. 
 
143 
 
 COMMENTARY 01 
 
 The peronseal artery is deeply situated in its whole 
 course. Soon after its origin, it passes under cover of 
 the flexor longus pollicis, r, a muscle of large size 
 arising from the lower three fourths of the fibula, N, 
 and will be found overlapped by this muscle on the 
 outer border of the tendo Achillis, as low down as the 
 outer ankle. The two arteries are accompanied by 
 venae comites, which, with the short saphena vein, 
 form the popliteal vein. The posterior tibial artery is 
 closely followed by the posterior tibial nerve. In the 
 popliteal space, this nerve crosses to the inner side of 
 the posterior tibial artery, where both are about to 
 pass under the gastrocnemius muscle, to which they 
 give large branches. Near the middle of the leg, the 
 nerve recrosses the artery to its outer side and in this 
 relative position both descend to a point about midway 
 between the inner ankle and calcaneum, where they 
 appear having the tendons of the tibialis posticus and 
 flexor longus digitorum to their inner side and the 
 tendon of the flexor longus pollicis on their outer side. 
 Numerous branches are given off from the nerve and 
 artery to the neighbouring parts in their course. 
 
 The varieties of the posterior crural arteries are 
 these'—the tibial vessel, in some instances, is larger 
 than usual, while the peronteal is small, or absent; 
 and, in others, the peronseal supplies the place of the 
 posterior tibial, when the latter is diminished in size. 
 The peronaeal has been known to take the position of 
 the posterior tibial in the lower part of the leg, and 
 to supply the plantar arteries. In whatever condition 
 the two vessels may be found, there will always be 
 seen ramifying around the ankle-joint, articular 
 branches, which anastomose freely with each other 
 and with those of the anterior tibial. 
 
 The popliteal artery is unfavourably circumstanced 
 for the application of a ligature. It is very deeply 
 situated, and the vein adheres closely to its posterior 
 surface. Numerous branches (articular and muscular) 
 arise from it at short intervals; and these, besides 
 being a source of disturbance to a ligature, are liable 
 to be injured in the operation, in which case the col¬ 
 lateral circulation cannot be maintained after the main 
 vessel is tied. There is a danger, too, of injuring the 
 
 PLATES 65 & 66. 
 
 middle branch of the sciatic nerve, in the incisions 
 required to reach the artery; and, lastly, there is a 
 possibility of this vessel dividing higher up than usual. 
 Considering these facts in reference to those cases in 
 which it might be supposed necessary to tie the popli¬ 
 teal artery — such cases, for example, as aneurism of 
 either of the crural arteries, or secondary htemorrhages 
 occurring after amputations of the leg at a time when 
 the healing process was far advanced and the bleeding 
 vessels inaccessible,—it becomes a question whether it 
 would not be preferable to tie the femoral, rather than 
 the popliteal artery. But when the popliteal artery 
 itself becomes affected with aneurism, and when, in 
 addition to the anatomical circumstances which forbid 
 the application of a ligature to this vessel, we consider 
 those which are pathological, — such as the coats of 
 the artery being here diseased, the relative position 
 of the neighbouring parts being disturbed by the 
 tumour, and the large irregular wound which would 
 be required to isolate the disease, at the risk of danger 
 to the health from profuse suppuration, to the limb 
 from destruction of the collateral branches, or to the 
 joint from cicatrization, rendering it permanently 
 bent,—we must acknowledge at once the necessity for 
 tying the femoral part of the main vessel. 
 
 When the popliteal artery happens to be divided in 
 a wound, it will be required to expose its bleeding 
 orifices, and tie both these in the wound. For this 
 purpose, the following operation usually recommended 
 for reaching the vessel may be necessary. The skin 
 and fascia lata are to be incised in a direction corres¬ 
 ponding to that of the vessel. The extent of the in¬ 
 cision must be considerable, (about three inches,) so 
 as the more conveniently to expose the artery in its 
 deep situation. On laying bare the outer margin of 
 the semi-membranosus muscle, while the knee is 
 straight, it now becomes necessary to flex the joint, in 
 order that this muscle may admit of being pressed 
 inwards from over the vessel. The external margin 
 of the wound, including the middle branch of the 
 sciatic nerve, should be retracted outwards, so as to 
 ensuie the safety of that nerve, while room is gained 
 for making the deeper incisions. The adipose sub- 
 
144 
 
 COMMENTARY ON PLATES 65 & 66. 
 
 stance, which is here generally abundant, should now 
 be divided, between the mesial line and the semimem¬ 
 branosus, till the sheath of the vessels be exposed. 
 The sheath should be incised at its inner side, to avoid 
 wounding the popliteal vein. The pulsation of the 
 artery will now indicate its exact position. As the 
 vein adheres firmly to the coats of the artery, some 
 care is required to separate the two vessels, so as to 
 pass the ligature around each end of the artery from 
 without inwards, while excluding the vein. While 
 this operation is being performed in a case of wound 
 of the popliteal artery, the ha}morrhage may be ar¬ 
 rested by compressing the femoral vessel, either against 
 the femur or the os pubis. 
 
 In the operation for tying the posterior tibial artery 
 
 near its middle, an incision of three or four inches in 
 extent is to be made through the skiu and fascia, in a 
 line corresponding with the inner posterior margin of 
 the tibia and the great muscles of the calf. The long 
 saphena vein should be here avoided. The origins of 
 the gastrocnemius and soleus muscles require to be 
 detached from the tibia, and then the knee is to be 
 flexed and the foot extended, so as to allow these 
 muscles to be retracted from the plane of the vessels. 
 This being done, the deep fascia which covers the ar¬ 
 tery and its accompanying nerve is next to be divided. 
 The artery will now appear pulsating at a situation an 
 inch from the edge of the tibia. While the ligature is 
 being passed around the artery, due care should be 
 taken to exclude the vente comites and the nerve. 
 
 DESCRIPTION OF PLATES 65 & 66. 
 
 Plate 65. 
 
 A. Tendon of the gracilis muscle. 
 
 B B. The fascia lata. 
 
 C C. Tendon of the semimembranosus muscle. 
 
 D. Tendon of the semitendinosus muscle. 
 
 E E. The two heads of the gastrocnemius muscle. 
 
 F. The popliteal artery. 
 
 G. The popliteal vein joined by the short saphena vein. 
 
 H. The middle branch of the sciatic nerve. 
 
 I. The outer (peronteal) branch of the sciatic nerve. 
 
 K. The posterior tibial nerve continued from the 
 
 middle branch of the sciatic, and extending to 
 K, behind the inner ankle. 
 
 L. The posterior (short) saphena vein. 
 
 M M. The fascia covering the gastrocnemius muscle. 
 
 N. The short (posterior) saphena nerve, formed by 
 
 the union of branches from the perona)al and 
 posterior tibial nerves. 
 
 O. The posterior tibial artery appearing from beneath 
 
 the soleus muscle in the lower part of the leg. 
 
 P. The soleus muscle joining the tendo Acliillis. 
 
 Q. The tendon of the flexor longus communis digito- 
 
 rum muscle. 
 
 R. The tendon of the flexor longus pollicis muscle. 
 
 S. The tendon of the peronceus longus muscle. 
 
 T. The peronseus brevis muscle. 
 
 U U. The internal annular ligament binding down the 
 vessels, nerves, and tendons in the hollow be¬ 
 hind the inner ankle. 
 
 Y V. The tendo Achillis. 
 
 W. The tendon of the tibialis posticus muscle. 
 
 X. The vence comites of the posterior tibial artery. 
 
 Plate 66. 
 
 ACDEFGHI indicate the same parts as in 
 Plate 65. 
 
 B. The inner condyle of the femur. 
 
 K. The plantaris muscle lying upon the popliteal artery. 
 
 L. The popliteus muscle. 
 
 M M M. The tibia. 
 
 N N. The fibula. 
 
 0 0. The posterior tibial artery. 
 
 P. The perongeal artery. 
 
 Q R S T U Y W. The parts shown in Plate 65. 
 
 X. The astragalus. 
 
. 
 
COMMENTARY ON PLATES 67 & 68. 
 
 THE SUEGICAL DISSECTION OF THE ANTERIOR CRURAL REGION, THE ANKLES, AND 
 
 THE FOOT. 
 
 Beneath the integuments and subcutaneous adipose 
 tissue on the fore part of the leg and foot, the fascia 
 h n, Plate 67, Figure 2, is to be seen stretched over 
 the muscles and sending processes between them, thus 
 encasing each of these in a special sheath. 
 
 The fascia is here of considerable density. It is 
 attached on the inner side of the leg to the spine of 
 the tibia, d, Plate 67, Figure 2, and on the outer side 
 it passes over the peronseal muscles to those forming 
 the calf. Between the extensor communis digitorum, 
 b b, and the peronmus longus, f, it sends in a strong 
 process to be attached to the fibula, e. In front of the 
 ankle joint, the fascia is increased in density, consti¬ 
 tuting a band (anterior annular ligament) which 
 extends between the malleoli, forms sheaths for the 
 several extensor tendons, and binds these down in 
 front of the joint. From the lower border of the 
 annular ligament, the fascia is continued over the 
 dorsum of the foot, forming sheaths for the tendons 
 and muscles of this part. Behind the inner malleolus, 
 (1, Plate 67, Figure 1, the fascia attached to this pro¬ 
 cess and to the inner side of the os calcis appears as 
 the internal annular ligament, which being broad and 
 strong, forms a kind of arch, beneath which in special 
 sheaths the flexor tendons, and the posterior tibial 
 vessel and nerve, pass to the sole of the foot. On 
 tracing the fascia from the front to the back of the 
 leg, it will be seen to divide into two layers — superfi¬ 
 cial and deep; the former passes over the muscles of 
 the calf and their common tendon (tendo Achillis) to 
 which it adheres, while the latter passes between these 
 muscles and the deep flexors. The deep layer is that 
 which immediately overlies the posterior tibial and 
 peronoeal vessels and nerves. While exposing the 
 fascia on the forepart of the leg and dorsum of the 
 foot, we meet with the musculo-cutaneous branch of 
 the peronmal nerve, which pierces the fascia at about 
 19 
 
 the middle of the limb, and descends superficially in 
 a direction between the fibula, and the extensor longus 
 digitorum muscle, and after dividing into branches a 
 little above the outer ankle, these traverse in two 
 groups the dorsum of the foot, to be distributed to the 
 integuments of the five toes. On the inner side of the 
 tibia, d, Plate 67, Figure 1, will be seen the internal 
 or long saphena vein, b b, which commencing by nu¬ 
 merous branches on the dorsal surface of the foot 
 ascends in front of the inner ankle, d, to gain the 
 inner side of the leg, after which it ascends behind 
 the inner side of the knee and thigh, till it terminates 
 at the saphenous opening, where it joins the femoral 
 vein. In its course along the lower part of the thigh, 
 the leg and the foot, this vein is closely accompanied 
 by the long saphenous nerve, derived from the anterior 
 crural, and also by a group of lymphatics. 
 
 By removing the fascia from the front of the leg 
 and foot, we expose the several muscles and tendons 
 which are situated in these parts. In the upper part 
 of the leg the tibialis anticus, A, Plate 67, Figure 2, 
 and extensor-communis muscle, b, are adherent to the 
 fascia which covers them, and to the intermuscular 
 septum which divides them. In the lower part of the 
 leg where these muscles and the extensor pollicis, c, 
 terminate in tendons, ab c, they are readily separable 
 from one another. The tibialis anticus lies along the 
 outer side of the tibia, from which, and from the head 
 of the fibula and interosseous ligament, it arises tendi¬ 
 nous and fleshy. This muscle is superficial in its 
 whole length; its tendon commencing about the 
 middle of the leg, passes in a separate loose sheath of 
 the annular ligament in front of the inner ankle, to 
 be inserted into the inner side of the cuneiform bone 
 and base of the metatarsal bone of the great toe. The 
 extensor communis digitorum lies close to the outer 
 side of the anterior tibial muscle, and arises from the 
 
 ( 145 ) 
 
COMMENTARY ON PLATES 6 7 & 6 8. 
 
 146 
 
 upper three-fourths of the fibula, from the interosseous 
 ligament and intermuscular septum. At the lower 
 part of the leg, this muscle ends in three or four flat 
 tendons, which pass through a ring of the annular 
 ligament, and extending forwards, b b b b, over the 
 dorsum of the foot, become inserted into the four outer 
 toes. The peronmus tertius or anterior, is that part 
 of the common extensor muscle which is inserted into 
 the base of the fifth metatarsal bone. On separating 
 the anterior tibial and common extensor muscles, we 
 find the extensor pollicis, c c, which, concealed between 
 the two, arises from the middle of the fibula, and the 
 interosseous ligament; its tendon passes beneath the 
 annular ligament in front of the ankle joint, and after 
 traversing the inner part of the dorsum of the foot, 
 becomes inserted into the three phalanges of the great 
 toe. Beneath the tendons of the extensor communis 
 on the instep, will be seen the extensor digitorum 
 brevis, K K, lying in an oblique direction, between the 
 upper and outer part of the os calcis, from which it 
 arises, and the four inner toes, into each of which it is 
 inserted by a small flat tendon, which joins the corres¬ 
 ponding tendon of the long common extensor. 
 
 The anterior tibial artery, l, Plate 67, Figure 2, 
 extends from the upper part of the interosseous liga¬ 
 ment which it perforates, to the bend of the ankle, 
 whence it is continued over the dorsum of the foot. 
 In the upper third of the leg, the anterior tibial artery 
 lies deeply situated between the tibialis anticus, and 
 flexor communis muscles. Here it will be found, close 
 in front of the interosseous ligament, at about an inch 
 and-a-half in depth from the anterior surface, and re¬ 
 moved from the spine of the tibia at an interval equal 
 to the width of the tibialis anticus muscle. In its 
 course down the leg, the vessel passes obliquely from 
 a point close to the inner side of the neck of the 
 fibula, to midway between the ankles. In its descent, 
 it becomes gradually more superficial. In the middle 
 of the leg, the vessel passes between the extensor 
 longus pollicis, and the tibialis anticus muscles. 
 Above, beneath, and below the annular ligament, this 
 artery will be found to pass midway between the ex¬ 
 tensor pollicis tendon, and those of the extensor com¬ 
 
 munis, and to Hold the same relation to these parts 
 in traversing the dorsum of the foot, till it gains the 
 interval between the two inner metatarsal bones, 
 where it divides into two branches, one of which 
 passes forwards in the first iuterdigital space, while 
 the other sinks between the bones, to inosculate with 
 the plantar arteries. The innermost tendon of the 
 short common extensor crosses in front of the dorsal 
 artery of the foot near its termination. Between the 
 ankle and the first interosseous space the artery lies 
 comparatively superficial, being here covered only by 
 the skin and fascia and cellular membrane. Two 
 veins accompany the anterior tibial artery and its 
 continuation on the dorsum of the foot. The anterior 
 tibial nerve, a branch of the peronmal, joins the outer 
 side of the artery, about the middle of the leg, and 
 accompanies it closely in this position, till both have 
 passed beneath the annular ligament. On the dorsum 
 of the foot the nerve will be found to the inner side 
 of the artery. 
 
 The branches of the anterior tibial artery are ar¬ 
 ticular and muscular. From its upper end arises the 
 recurrent branch which anastomoses in front of the 
 knee with the articular branches of the popliteal ar¬ 
 tery. Near the ankle, arise on either side of the 
 vessel two malleolar branches, internal and external, 
 the former communicating with branches of the pos¬ 
 terior tibial, the latter with those of the peronmal. 
 Numerous muscular branches arise, at short intervals, 
 from the vessel in its passage down the leg. Tarsal, 
 metatarsal, and small digital branches spring from the 
 dorsal artery of the foot. The anterior tibial artery 
 is rarely found to deviate from its usual course; in 
 some cases it appears of less or of greater size than 
 usual. When this vessel appears deficient, its place 
 is usually supplied by some branch of the peronmal 
 or posterior tibial, which pierces the interosseous liga¬ 
 ment from behind. 
 
 The anterior tibial artery when requiring a ligature 
 to be applied to it in any part of its course, may be 
 exposed by an incision, extending for three or four 
 inches, (more or less, according to the depth of the 
 vessel) along the outer border of the tibialis anticus 
 
147 
 
 COMMENTARY 01 
 
 muscle. The fibrous septum between this muscle and 
 the extensor communis, will serve as a guide to the 
 vessel in the upper third of the leg, where it lies 
 deeply on the interosseous ligament. In the middle 
 of the leg, the vessel is to be sought for between the 
 anterior tibial and extensor longus pollieis muscles. 
 In the lower part of the leg, and on the dorsum of the 
 foot, it will be found between the extensor longus 
 pollieis, and extensor communis tendons, the former 
 being taken as a guide for the incision. In passing 
 the ligature around this vessel at either of these situa¬ 
 tions, care is required to avoid including the venm 
 comites and the accompanying nerve. 
 
 The sole of the foot is covered by a hard and thick 
 integument, beneath which will be seen a large quan¬ 
 tity of granulated adipose tissue so intersected by 
 bands of fibrous structure as to form a firm, but elastic 
 cushion, in the situations particularly of the heel and 
 joints of the toes. On removing this structure, we 
 expose the plantar fascia, b, Plate 68, Figure 1, ex¬ 
 tending from the os calcis, A, to the toes. This fascia 
 is remarkably strong, especially its middle and outer 
 parts, which serve to retain the arched form of the 
 foot, and thereby to protect the plantar structures from 
 superincumbent pressure during the erect posture. 
 The superficial plantar muscles become exposed on re¬ 
 moving the plantar fascia, to which they adhere. In 
 the centre will be seen the thick fleshy flexor digitorum 
 brevis muscle, B, arising from the inferior part of the 
 os calcis, and passing forwards to divide into four small 
 tendons, bbbb, for tile four outer toes. On the inner 
 side of the foot appears the abductor pollieis, d, arising 
 from the inner side of the os calcis and internal an¬ 
 nular ligament, and passing to be inserted with the 
 flexor pollieis brevis, H, into the sesamoid bones and 
 base of the first phalanx of the great toe. On the 
 external border of the foot is situated the abductor 
 minimi digiti, c, arising from the outer side of the os 
 calcis, and passing to be inserted with the flexor brevis 
 minimi digiti into the base of the first phalanx of the 
 little toe. When the flexor brevis digitorum muscle 
 is removed, the plantar arteries, L M, and nerves, are 
 brought partially into view; and by further dividing 
 
 PLATES 67 & 68. 
 
 the abductor pollieis, D, their continuity with the pos¬ 
 terior tibial artery and nerves, K L, Plate 67, Figure 
 1, behind the inner ankle may be seen. 
 
 The plantar branches of the posterior tibial artery 
 are the internal and external, both of which are deeply 
 placed between the superficial and deep plantar 
 muscles. The internal plantar artery is much the 
 smaller of the two. The external plantar artery, l, 
 Plate 68, Figure 1, is large, and seems to be the proper 
 continuation of the posterior tibial. It corresponds, 
 in the foot, to the deep palmar arch in the hand. 
 Placed at first between the origin of the abductor 
 pollieis and the calcaneum, the external plantar artery 
 passes outwards between the short common flexor, B, 
 and the flexor accessorius, e, to gain the inner borders 
 of the muscles of the little toe ; from this place it 
 curves deeply inwards between the tendons of the 
 long common flexor of the toes, f ff and the tarso¬ 
 metatarsal joints, to gain the outer side of the first 
 metatarsal bone, n, Plate 68, Figure 2. In this course 
 it is covered in its posterior half by the flexor brevis 
 digitorum, and in its anterior half by this muscle, to¬ 
 gether with the tendons of the long flexor, f, Plate 
 68, Figure 1, of the toes and the lumbricales muscles, 
 i i i i. From the external plantar artery are derived 
 the principal branches for supplying the structures in 
 the sole of the foot. The internal plantar nerve 
 divides into four branches, for the supply of the four 
 inner toes, to which they pass between the superficial 
 and deep flexors. The external plantar nerve, passing 
 along the inner side of the corresponding artery, sends 
 branches to supply the outer toe and adjacent side of 
 the next, and then passes, with the artery, between 
 the deep common flexor tendon and the metatarsus, 
 to be distributed to the deep plantar muscles. 
 
 The posterior tibial artery may be tied behind the 
 
 inner ankle, on being laid bare in the following way :_ 
 
 A curved incision (the concavity forwards) of two 
 inches in length, is to be made midway between the 
 tendo Achillis and the ankle. The skin and superfi¬ 
 cial fascia having been divided, we expose the inner 
 annular ligament, which will be found enclosing the 
 vessels and nerve in a canal distinct from that of the 
 
148 
 
 COMMENTARY ON 
 
 PLATES 67 & 68. 
 
 tendons. Their fibrous sheath having been slit open, 
 the artery will be seen between the venrn comites, and 
 with the nerve, in general, behind it. 
 
 When any of the arteries of the leg or the foot are 
 wounded, and the haemorrhage cannot be commanded 
 by compression, it will be necessary to search for the 
 divided ends of the vessel in the wound, and to apply 
 
 a ligature to both. The expediency of this measure 
 must become fully apparent when we consider the 
 frequent anastomoses existing between the collateral 
 branches of the crural arteries, and that a ligature 
 applied to any one of these above the seat of injury 
 will not arrest the recurrent circulation through the 
 vessels of the foot. 
 
 DESCRIPTION OE 
 
 PLATE 67. 
 
 Figure 1. 
 
 A. The tendon of the tibialis anticus muscle. 
 
 B B. The long saphena vein. 
 
 C C. The tendon of the tibialis posticus muscle. 
 
 D. The tibia; d, the inner malleolus. 
 
 E E. The tendon of the flexor longus digitorum 
 muscle. 
 
 F. The gastrocnemius muscle; /, the tendo Acliillis. 
 
 G. The soleus muscle. 
 
 II. The tendon of the plantaris muscle. 
 
 11. The venm comites. 
 
 K K. The posterior tibial artery. 
 
 L L. The posterior tibial nerve. 
 
 Figure 2. 
 
 A. The tibialis anticus muscle; a , its tendon. 
 
 B. The extensor longus digitorum muscle; b b b b, its 
 
 four tendons. 
 
 C C. The extensor longus pollicis muscle. 
 
 D D. The tibia. 
 
 E. The fibula; e, the outer malleolus. 
 
 F F. The tendon of the peronmus longus muscle. 
 
 G G. The peronreus brevis muscle; i, the peronmus 
 tertius. 
 
 H H. The fascia. 
 
 K. The extensor brevis digitorum muscle; 7c 7c, its 
 tendons. 
 
 L L. The anterior tibial artery and nerve descending 
 to the dorsum of the foot. 
 
 PLATES 67 & 68. 
 
 PLATE 68. 
 
 Figure 1. 
 
 A. The calcaneum. 
 
 B. The plantar fascia and flexor brevis digitorum 
 
 muscle cut; b b b, its tendons. 
 
 C. The abductor minimi digiti muscle. 
 
 D. The abductor pollicis muscle. 
 
 E. The flexor accessorius muscle. 
 
 F. The tendon of the flexor longus digitorum muscle, 
 
 subdividing into / / / /, tendons for the four 
 outer toes. 
 
 G. The tendon of the flexor pollicis longus muscle. 
 
 II. The flexor pollicis brevis muscle. 
 
 i Hi. The four lumbricales muscles. 
 
 K. The external plantar nerve. 
 
 L. The external plantar artery. 
 
 M. The internal plantar nerve and artery. 
 
 Figure 2. 
 
 A. The heel covered by the integument. 
 
 B. The plantar fascia and flexor brevis digitorum 
 
 muscle cut; b b b, the tendons of the muscle. 
 
 C. The abductor minimi digiti. 
 
 D. The abductor pollicis. 
 
 E. The flexor accessorius cut. 
 
 F. The tendon of the flexor digitorum longus cut; 
 
 fff, its digital ends. 
 
 G. The tendon of the flexor pollicis. 
 
 H. The head of the first metatarsal bone. 
 
 I. The tendon of the tibialis posticus. 
 
 K. The external plantar nerve. 
 
 L L. The arch of the external plantar artery. 
 
 M M M M. The four interosseous muscles. 
 
 N. The external plantar nerve and artery cut. 
 


 
 
 
 
 
 
 
CONCLUDING COMMENTARY. 
 
 ON THE FORM AND DISTRIBUTION OF THE VASCULAR SYSTEM AS A WHOLE 
 ANOMALIES. — RAMIFICATION. — ANASTOMOSIS 
 
 I-—TnE heart, in all stages of its development, is to 
 the vascular system what the point of a circle is to the 
 circumference — namely, at once the beginning and the 
 end. The heart, occupying, it may be said, the centre of 
 the thorax, circulates the blood in the same way, by 
 similar channels, to an equal extent, in equal pace, and 
 at the same period of time, through both sides of the 
 body. In its adult normal condition, the heart pre¬ 
 sents itself as a double or symmetrical organ. The 
 two hearts, though united and appearing single, are 
 nevertheless, as to their respective cavities, absolutely 
 distinct. Each heart consists again of two compart¬ 
 ments — an auricle and a ventricle. The two auricles 
 are similar in structure and form. The two'ventricles 
 are similar in the same respects. A septum divides 
 the two auricles, and another — the two ventricles. 
 Between the right auricle and ventricle, forming the 
 right heart, there exists a valvular apparatus (tricus¬ 
 pid), by which these two compartments communicate; 
 and a similar valve (bicuspid) admits of communication 
 between the left auricle and ventricle. The two hearts 
 being distinct, and the main vessels arising from each 
 respectively being distinct likewise, it follows that the 
 capillary peripheries of these vessels form the only 
 channels through which the blood issuing from one 
 heart can enter the other. 
 
 II. —As the aorta of the left heart ramifies through¬ 
 out all parts of the body, and as the countless ramifi¬ 
 cations of this vessel terminate in an equal number 
 of ramifications of the principal veins of the right 
 heart, it wi 11 appear that between the systemic vessels 
 of the two hearts respectively, the capillary anasto¬ 
 motic circulation reigns universal. 
 
 III. —The body generally is marked by the median 
 line, from the vertex to the perimeum, into corres¬ 
 ponding halves. All parts excepting the main blood¬ 
 vessels in the neighbourhood of the heart are naturally 
 divisible by this line into equals. The vessels of each 
 
 heart, in being distributed to both sides of the body 
 alike, cross each other at the median line, and hence 
 they are inseparable according to this line, unless by 
 section. If the vessels proper to each heart, right 
 and left, ramified alone within the limits of their 
 respective sides of the body, then their capillary 
 anastomosis could only take place along the median 
 line, and here in such case they might be separated 
 by median section into two distinct systems. But as 
 each system is itself double in branching into both 
 sides of the body, the two would be at the same time 
 equally divided by vertical section. From this it will 
 appear that the vessels belonging to each heart form a 
 symmetrical system, corresponding to the sides of the 
 body, and that the capillary anastomosis of these 
 systemic veins and arteries is divisible into two great 
 fields, one situated on either side of the median line, 
 and touching at this line. 
 
 ^ ^ ■ The vessels of the right heart do not commu¬ 
 nicate at their capillary peripheries, for its veins are 
 systemic, and its arteries are pulmonary. The vessels 
 of the left heart do not anastomose, for its veins are 
 pulmonary, and its arteries are systemic. The arteries 
 of the right and left hearts cannot anastomose, for the 
 former are pulmonary, and the latter are systemic; 
 and neither can the veins of the right and left hearts, 
 for a similar reason. Hence, therefore, there can be, 
 between the vessels of both hearts, but two provinces 
 of anastomosis — viz., that of tile lungs, and that of 
 the system. In the lungs, the arteries of the right 
 heart and the veins of the left anastomose. In the 
 body generally (not excepting the lungs), the arteries 
 of the left heart, and the veins of the right, anasto¬ 
 mose ; and thus in the pulmonary and the systemic 
 circulation, each heart plays an equal part through 
 the medium of its proper vessels. The pulmonary 
 bear to the systemic vessels the same relation as a 
 lesser circle contained within a greater; and the 
 
 ( 149 ) 
 
 | 
 
150 
 
 -CONCLUDING COMMENTARY. 
 
 vessels of each heart form the half of each circle, the 
 arteries of the one being opposite the veins of the 
 other. 
 
 Y.—The two hearts being, by the union of their 
 similar forms, as one organ in regard to place, act, by 
 an agreement of their corresponding functions, as one 
 organ in respect to time. The action of the auricles 
 is synchronous; that of the ventricles is the same; 
 that of the auricles and ventricles is consentaneous; 
 and that of the whole heart is rhythmical, or harmo¬ 
 nious — the diastole of the auricles occurring in 
 harmonical time with the systole of the ventricles, 
 and vice versa. By this correlative action of both 
 hearts, the pulmonary and systemic circulations take 
 place synchronously; and the phenomena resulting in 
 both reciprocate and balance each other. In the 
 pulmonary circulation, the blood is aerated, decar¬ 
 bonized, and otherwise depurated; whilst in the 
 systemic circulation, it is carbonized and otherwise 
 deteriorated. 
 
 VI.—The circulation through the lungs and the 
 system is carried on through vessels having the fol¬ 
 lowing form and relative position, which, as being 
 most usual, is accounted normal. The two brachio¬ 
 cephalic veins joining at the root of the neck, and the 
 two common iliac veins joining in front of the lumbar 
 vertebrae, form the superior and inferior venae cavae, 
 by which the blood is returned from the upper and 
 lower parts of the body to the right auricle, and thence 
 it enters the right ventricle, by which it is impelled 
 through the pulmonary artery into the two lungs; and 
 from these it is returned (aerated) by the pulmonary 
 veins to the left auricle, which passes it into the left 
 ventricle, and by this it is impelled through the sys¬ 
 temic aorta, which branches throughout the body in a 
 similar way to the systemic veins, with which the 
 aortic branches anastomose generally. On viewing 
 together the system of vessels proper to each heart, 
 they will be seen to exhibit in respect to the body a 
 figure in doubly symmetrical arrangement, of which 
 the united hearts form a duplex centre. At this 
 centre, which is the theatre of metamorphosis, the 
 principal abnormal conditions of the bloodvessels ap¬ 
 
 pear; and in order to find the signification of these, 
 we must retrace the stages of development. 
 
 VII.—From the first appearance of an individualized 
 centre in the vascular area of the human embryo, that 
 centre (punctum saliens) and the vessels immediately 
 connected with it, undergo a phaseal metamorphosis, 
 till such time after birth as they assume their perma¬ 
 nent character. In each stage of metamorphosis, the 
 embryo heart and vessels typify the normal condition 
 of the organ in one of the lower classes of animals. 
 The several species of the organ in these classes are 
 parallel to the various stages of change in the human 
 organ. In its earliest condition, the human heart 
 presents the form of a simple canal, similar to that of 
 the lower Invertebrata, the veins being connected with 
 its posterior end, while from its anterior end a single 
 artery emanates. The canal next assumes a bent 
 shape, and the vessels of both its ends become thereby 
 approximated. The canal now being folded upon 
 itself in heart-shape, next becomes constricted in 
 situations, marking out the future auricle and ven¬ 
 tricle and arterial bulb, which still communicate with 
 each other. From the artery are given off on either 
 side symmetrically five branches (branchial arches), 
 which arch laterally from before, outwards and back¬ 
 wards, and unite in front of the vertebrae, forming the 
 future descending aorta. In this condition, the human 
 heart and vessels resemble the Piscean pipe. The 
 next changes which take place consist in the gradual 
 subdivision, by means of septa, of the auricle and 
 ventricle respectively into two cavities. On the 
 separation of the single auricle into two, while the 
 ventricle as yet remains single, the heart presents 
 that condition which is proper to the Reptilian class. 
 The interauricular and interventricular septa, by gra¬ 
 dual development from without inwards, at length 
 meet and coalesce, thereby dividing the two cavities 
 into four — two auricles and two ventricles — a condi¬ 
 tion proper to the Avian and Mammalian classes 
 generally. In the centre of the interauricular septum 
 of the human heart, an aperture {foramen ovale ) is 
 left as being necessary to the foetal circulation. While 
 the septa are being completed, the arterial bulb also 
 
CONCLUDING COMMENTARY. 
 
 151 
 
 ■becomes divided by a partition formed in its interior 
 in such a manner as to adjust the two resulting 
 arteries, the one in connexion with the right, the other 
 with the left ventricle. The right ventricular artery 
 (pulmonary aorta) so formed, has assigned to it the 
 fifth (posterior) opposite pair of arches, and of these 
 the right one remaining pervious to the point where 
 it gives off the right pulmonary branch, becomes 
 obliterated beyond this point to that where it joins 
 the descending aorta, while the left arch remains 
 pervious during foetal life, as the ductus arteriosus still 
 communicating with the descending aorta, and giving 
 off at its middle the left pulmonary branch. The left 
 ventricular artery (systemic aorta) is formed of the 
 fourth arch of the left side, while the opposite arch 
 (fourth right) is altogether obliterated. The third 
 and second arches remain pervious on both sides, 
 afterwards to become the right and left brachio¬ 
 cephalic arteries. The first pair of arches, if not 
 converted into the vertebral arteries, or the thyroid 
 axes, are altogether metamorphosed. By these changes 
 the heart and primary arteries assume the character 
 in which they usually present themselves at birth, 
 and in all probability the primary veins corresponded 
 in form, number, and distribution with the arterial 
 vessels, and underwent, at the same time, a similar 
 mode of metamorphosis. One point in respect to the 
 original symmetrical character of the primary veins 
 is demonstrable — namely, that in front of the aortic 
 branches the right and left brachio-cephalic veins, after 
 joining by a cross branch, descend separately on either 
 side of the heart, and enter (as two superior venm 
 cavce) the right auricle by distinct orifices. In some 
 of the lower animals, this double condition of the 
 superior veins is constant, but in the human species 
 the left vein below the cross branch (left brachio¬ 
 cephalic) becomes obliterated, whilst the right vein 
 (vena cava superior) receives the two brachio-cephalic ; 
 veins, and in this condition remains throughout life. 
 After birth, on the commencement of respiration, the ^ 
 foramen ovale of the interauricular septum closes, and 
 the ductus arteriosus becomes impervious. This com¬ 
 pletes the stages of metamorphosis, and changes the J 
 
 course of the simple foetal circulation to one of a more 
 complex order — viz., the systemic-pulmonary charac¬ 
 teristic of the normal state in the adult body. 
 
 VIII.— Such being the phases of metamorphosis of 
 the primary (branchial) arches which yield the vessels 
 in their normal adult condition, we obtain in this 
 history an explanation of the signification not only 
 of such of their anomalies as are on record, but of 
 such also as are potential in the law of development; 
 a few of them will suffice to illustrate the meaning of 
 the whole number:—1$£. The interventricular as well 
 as the interauricular septum may be arrested in growth, 
 leaving an aperture in the centre of each; the former 
 condition is natural to the human foetus , the latter to 
 the reptilian class, while both would be abnormal in the 
 human adult. 2nd. The heart may be cleft at its apex 
 in the situation of the interventricular septum — a 
 condition natural to the Dugong. A similar cleavage 
 may divide the base of the heart in the situation of the 
 interauricular septum. 3rd. The partitioning of the 
 bulbus arteriosus may occur in such a manner as to 
 assign to the two aortas a relative position, the reverse 
 of that which they normally occupy — the pulmonary 
 aorta springing from the left ventricle and the systemic 
 aorta arising from the right, and giving off from its 
 arch the primary branches in the usual order.* 4 th. 
 As the two aortce result from a division of the common 
 primary vessel (bulbus arteriosus), an arrest in the 
 growth of the partition would leave them still as one 
 vessel, which (supposing the ventricular septum re¬ 
 mained also incomplete) would then arise from a single 
 ventricle. 5 th. The ductus arteriosus may remain per¬ 
 vious, and while co-existing with the proper aortic arch, 
 two arches would then appear on the left side. 6 th. 
 The systemic normal aortic arch may be obliterated as 
 far up as the innominate branch, and while the ductus 
 arteriosus remains pervious, and leading from the pul¬ 
 monary artery to the descending part of the aortic 
 
 * This physiological truth has, I find, been applied by Dr. 
 R. Quain to the explanation of a numerous class of malforma¬ 
 tions connected with the origins of the great vessels from the 
 heart, and of their primary branches. See The Lancet, vol. I. 
 1842 . 
 
152 
 
 CONCLUDING COMMENTARY. 
 
 arch, this vessel would then present the appearance 
 of a branch ascending from the left side and giving 
 off the brachio-cephalic arteries. The right ventricular 
 artery would then, through the medium of the ductus 
 arteriosus, supply both the lungs and the system. 
 Such a state of the vessels would require (in order 
 that the circulation of a mixed blood might be carried 
 on) that the two ventricles freely communicate. 7th. 
 If the fourth arch of the right side remained pervious 
 opposite the proper aortic arch, there would exist two 
 aortic arches placed symmetrically, one on either side 
 of the vertebral column, and, joining below, would 
 include in their circle the trachea and oesophagus. 8 th. 
 If the fifth arch of the right side remained pervious 
 opposite the open ductus arteriosus, both vessels would 
 present a similar arrangement, as two symmetrical ducti 
 arteriosi co-existing with symmetrical aortic arches. 
 9 th. If the vessels appeared co-existing in the two con¬ 
 ditions last mentioned, they would represent four aortic 
 arches, two on either side of the vertebral column. 10 th. 
 If the fourth right arch, instead of the fourth left (aorta), 
 remained pervious, the systemic aortic arch would then 
 be turned to the right side of the vertebral column, 
 and have the trachea and oesophagus on its left. 
 11th. When the bulbus arteriosus divides itself into 
 three parts, the two lateral parts, in becoming connected 
 with the left ventricle, will represent a double ascending 
 system ic aorta, and having the pulmonary artery passing 
 between them to the lungs. 12 th. When of the two 
 original superior venae cavce the right one instead of the 
 left suffers metamorphosis, the vena cava superior will 
 then appear on the left side of the normal aortic arch* 
 Of these malformations, some are rather frequently 
 met with, others very seldom, and others cannot exist 
 compatible with life after birth. Those which involve 
 a more or less imperfect discharge of the blood-aerating 
 functions of the lungs, are in those degrees more or 
 less fatal, and thus nature aborting as to the fitness 
 of her creation, cancels it. 
 
 * For an analysis of the occasional peculiarities of these 
 primary veins in the human subject, see an able and original 
 monograph in the Philosophical Transactions, Part I., 1850, en¬ 
 titled, “On the Development of the Great Anterior Veins in 
 Man and Mammalia.’’ By John Marshall, F.R.C.S., &c. 
 
 IX.—The portal system of veins passing to the liver, 
 and the hepatic veins passing from this organ to join 
 the inferior vena cava, exhibit in respect to the median 
 line of the body an example of a-symmetry, since ap¬ 
 pearing on the right side, they have no counterparts 
 on the left. As the law of symmetry seems to prevail 
 universally in the development of organized beings, 
 forasmuch as every lateral organ or part has its coun¬ 
 terpart, while every central organ is double or com¬ 
 plete, in having two similar sides, then the portal 
 system, as being an exception to this law, is as a 
 natural note of interrogation questioning the signifi¬ 
 cation of that fact, and in the following observations, 
 it appears to me, the answer may be found. Every 
 artery in the body has its companion vein or veins. 
 The inferior vena cava passes sidelong w T ith the aorta 
 in the abdomen. Every branch of the aorta which 
 ramifies upon the abdominal parietes has its accom¬ 
 panying vein returning either to the vena cava or the 
 vena azygos, and entering either of these vessels at a 
 point on the same level as that at which itself arises. 
 The renal vessels also have this arrangement. But 
 all the other veins of the abdominal viscera, instead 
 of entering the vena cava opposite their corresponding 
 arteries, unite into a single trunk (vena porta?), which 
 enters the liver. The special purpose of this destina¬ 
 tion of the .portal system is obvious, but the function 
 of a part gives no explanation of its form or relative 
 position, whether singular or otherwise. On viewing 
 the vessels in presence of the general law of symmetri¬ 
 cal development, it occurs to me that the portal and 
 hepatic veins form one continuous system, which taken 
 in the totality, represents the companion veins of the 
 arteries of the abdominal viscera. The liver under this 
 interpretation appears as a gland developed midway 
 upon these veins, and dismembering them into a mesh 
 of countless capillary vessels, (a condition necessary 
 for all processes of secretion,) for the special purpose 
 of decarbonizing the blood. In this great function 
 the liver is an organ correlative or compensative to 
 the lungs, whose office is similar. The secretion of 
 the liver (bile) is fluidform; that of the lungs is 
 aeriform. The bile being necessary to the digestive 
 process, the liver has a duct to convey that product 
 
CONCLUDING COMMENTARY. 
 
 153 
 
 of its secretion to tlie intestines. The trachea is as it 
 were the duct of the lungs. In the liver, then, the 
 portal and hepatic veins being continuous as veins , the 
 two systems, notwithstanding their apparent distinct¬ 
 ness, caused by the intervention of the hepatic lobules, 
 may be regarded as the veins corresponding with the 
 arteries of the cceliac axis, and the two mesenteric. The 
 hepatic artery and the hepatic veins evidently do not 
 
 pair in the sense of afferent and efferent, with respect 
 to the liver, both these vessels having destinations as 
 different as those of the bronchial artery and the pul¬ 
 monary veins in the lungs. The bronchial artery is 
 attended by its vein proper, while the vein which 
 corresponds to the hepatic artery joins either the 
 hepatic or portal veins traversing the liver, and in 
 this position escapes notice.* 
 
 * In instancing these facts, as serving under comparison to 
 explain how the hepatic vessels constitute no radical exception to 
 the law of symmetry which presides over the development and 
 distribution of the vascular system as a whole, I am led to inquire 
 in what respect (if in any) the liver as an organ forms an exception 
 to this general law either in shape, in function, or in relative po¬ 
 sition. While seeing that every central organ is single and sym¬ 
 metrical by the union of two absolutely similar sides, and that 
 each lateral pair of organs is double by the disunion of sides so 
 similar to each other in all respects that the description of either 
 side serves for the other opposite, it has long since seemed to me 
 a reasonable inference that, since the liver on the right has no 
 counterpart as a liver on the left, and that, since the spleen on 
 the left has no counterpart as a spleen on the right, so these two 
 organs (the liver and spleen) must themselves correspond to each 
 other, and as such, express their respective significations. Under 
 the belief that every exception (even though it be normal) to a 
 general law or rule, is, like the anomaly itself, alone explicable 
 according to such law, and expressing a fact not more singular 
 or isolated from other parallel facts than is one form from another, 
 or from all others constituting the graduated scale of being, I 
 would, according to the light of this evidence alone, have no 
 hesitation in stating that the liver and spleen, as opposites, repre¬ 
 sent corresponding organs, even though they appeared at first 
 view more dissimilar than they really are. In support of this 
 analogy of both organs, which is here, so far as I am aware, 
 originally enunciated for anatomical science, I record the follow¬ 
 ing observations: — lsi. Between the opposite parts of the same 
 organic entity (between the opposite leaves of the same plant, for 
 example), nature manifests no such absolute difference in any 
 case as exists between the leaf of a plant and of a book. 2ndly. 
 When between two opposite parts of the same organic form there 
 appears any differential character, this is simply the result of a 
 modification or metamorphosis of one of the two perfectly similar 
 originals or archetypes, but never carried out to such an extreme 
 degree as to annihilate all trace of their analogy. 3 rdly. The 
 liver and the spleen are opposite parts; and as such, they are 
 associated by arteries which arise by a single trunk (cceliac axis) 
 from the aorta, and branch right and left, like indices pointing to 
 the relationship between both these organs, in the same manner 
 as the two emulgent arteries point to the opposite renal organs. 
 
 4 thly. The liver is divided into two lobes, right and left; the ! 
 
 20 
 
 1 left is less than the right; that quantity which is wanting to the 
 | left lobe is equal to the quantity of a spleen; and if in idea we 
 j add the spleen to the left lobe of the liver, both lobes of this 
 organ become quantitatively equal, and the whole liver symmetri¬ 
 cal ; hence, as the liver plus the spleen represents the whole 
 structural quantity, so the liver minus the spleen signifies that the 
 two organs now dissevered still relate to each other as parts of 
 the same whole. 5 thly. The liver, as being three-fourths of the 
 whole, possesses the duct which emanates at the centre of all 
 glandular bodies. The spleen, as being one-fourth of the whole, 
 is devoid of the duct. The liver having the duct, is functional as 
 a gland, while the spleen having no duct, cannot serve any such 
 function. If, in thus indicating the function which the spleen 
 does not possess, there appears no proof positive of the function 
 which it does , perhaps the truth is, that as being the ductless por¬ 
 tion of the whole original hepatic quantity, it exists as a thing 
 degenerate and functionless, for it seems that the animal economy 
 suffers no loss of function when deprived of it. Gthly. In early 
 fcetal life, the left lobe of the liver touches the spleen on the left 
 side; but in the process of abdominal development, the two 
 organs become separated from each other right and left. 7thly. 
 In animals devoid of the spleen, the liver appears of a symmetrical 
 shape, both its lobes being equal; for that quantity which in other 
 animals has become splenic, is in the former still hepatic. 8 thly. 
 In cases of transposition of both organs, it is the right lobe of 
 the liver — that nearest the spleen , now on the right side — which 
 is the smaller of the two lobes, proving that whichever lobe be in 
 this condition, the spleen , as being opposite to it, represents the 
 minus hepatic quantity. From these, among other facts, I infer 
 that the spleen is the representative of the liver on the left side, 
 and that as such, its signification being manifest, there exists no 
 exception to the law of animal symmetry. “ Tam miram uni- 
 formitatem in planetarum systemate, necessario fatendum est in- 
 telligentia et concilio fuisse effectam. Idemque dici possit de 
 uniforraitate ilia qum est in corporibus animalium. Habent vide¬ 
 licet animalia pleraque omnia, bina latera, dextrum et sinistrum, 
 forma consimili: et in lateribus illis, a posteriore quidem corporis 
 sui parte, pedes binos; ab anteriori autem parte, binos armos, vel 
 pedes,vel alas, humeris affixos: interquehumeros collum, in spinam 
 excurrens, cui affixum est caput; in eoque capite binas aures, bi¬ 
 nos oculos, nasum, os et linguam ; similiter posita omnia, in omni¬ 
 bus fere animalibus.”— J\ r ewton, Optices, sive de reflex,fyc. p. 411. 
 
154 
 
 CONCLUDING COMMENTARY. 
 
 X.— The heart , though being itself the recipient, the 
 prime mover, and the dispenser of the blood, does not 
 depend either for its growth, vitality, or stimulus to 
 action, upon the blood under these uses, but upon the 
 blood circulating through vessels which are derived 
 from its main systemic artery, and disposed in capil¬ 
 lary ramifications through its substance, in the manner 
 of the nutrient vessels of all other organs. The two 
 coronary arteries of the heart arise from the systemic 
 aorta immediately outside the semilunar valves, 
 situated in the root of this vessel, and in passing 
 right and left along the auriculo-ventricular furrows, 
 they send off some branches for the supply of the 
 organ itself, and others by which both vessels anasto¬ 
 mose freely around its base and apex. The vasa cordis 
 form an anastomotic circulation altogether isolated 
 from the vessels of the other thoracic organs, and 
 also from those distributed to the thoracic parietes. 
 The coronary arteries are accompanied by veins which 
 open by distinct orifices ( foramina Thebesii ) into the 
 right auricle. Like the heart itself, its main vessels 
 do not depend for their support tipon the blood con¬ 
 veyed by them, but upon that circulated by the small 
 arteries (vasa vasorum) derived either from the vessel 
 upon which they are distributed, or from some others 
 in the neighbourhood. These little arteries are at¬ 
 tended by veins of a corresponding size (venules) 
 which enter the venm comites, thus carrying out the 
 general order of vascular distribution to the minutest 
 particular. Besides the larger nerves which accompany 
 the main vessels, there are delicate filaments of the 
 cerebro-spinal and sympathetic system distributed to 
 their coats, for the purpose, as it is supposed, of govern¬ 
 ing their “ contractile movements.” The vasa vasorum 
 form an anastomosis as well upon the inner surface of 
 the sheath as upon the artery contained in this part; 
 and hence in the operation for tying the vessel, the 
 rule should be to disturb its connexions as little as 
 possible, otherwise its vitality, which depends upon 
 these minute branches, will, by their rupture, he de¬ 
 stroyed in the situation of the ligature, where it is most 
 needed. 
 
 XI.— The branches of the systemic aorta form fre¬ 
 quent anastomoses with each other in all parts of the 
 
 body. This anastomosis occurs chiefly amongst the 
 branches of the main arteries proper to either side. 
 Those branches of the opposite vessels which join at 
 the median line are generally of very small size. 
 There are but few instances in which a large blood¬ 
 vessel crosses the central line from its own side to the 
 other. Anastomosis at the median line between oppo¬ 
 site vessels happens either by a fusion of their sides 
 lying parallel, as for example (and the only one) that 
 of the two vertebral arteries on the basilar process of 
 the occipital bone; or else by a direct end-to-end union, 
 of which the lateral pair of cerebral arteries, forming 
 the circle of Willis, and the two labial arteries, forming 
 the coronary, are examples. The branches of the 
 main arteries of one side form numerous anastomoses 
 in the muscles and in the cellular and adipose tissue 
 generally. Other special branches derived from the 
 parent vessel above and below the several joints ramify 
 and anastomose so very freely over the surfaces of 
 these parts, and seem to pass in reference to them out 
 of their direct course, that to effect this mode of dis¬ 
 tribution appears to be no less immediate a design 
 than to support the structures of which the joints are 
 composed. 
 
 XII.— The innominate artery. When this vessel is 
 tied, the free direct circulation through the principal 
 arteries of the right arm, and the right side of the 
 neck, head, and brain, becomes arrested; and the 
 degree of strength of the recurrent circulation depends 
 solely upon the amount of anastomosing points between 
 the following arteries of the opposite sides. The small 
 terminal branches of the two occipital, the two auricu¬ 
 lar, the two superficial temporal, and the two frontal, 
 inosculate with each other upon the sides, and over 
 the vertex of the head; the two vertebral, and the 
 branches of the internal carotid, at the base and over 
 the surface of the brain; the two facial with each 
 other, and with the frontal above and mental below, 
 at the median line of the face; the two internal 
 maxillary by their palatine, pharyngeal, meningeal, 
 and various other branches upon the surface of the 
 parts to which they are distributed; and lastly, the 
 two superior thyroid arteries inosculate around the 
 larynx and in the thyroid body. By these anasto- 
 
155 
 
 CONCLUDING 
 
 moses, it will be seen that the circulation is restored 
 to the branches of the common carotid almost solely. 
 In regard to the subclavian artery, the circulation would 
 be carried on through the anastomosing branches of 
 the two inferior thyroid in the thyroid body; of the 
 two vertebral, in the cranium and upon the cervical 
 vertebrae; of the two internal mammary, with each 
 other behind the sternum, and with the thoracic 
 branches of the axillary and the superior intercostal 
 laterally; lastly, through the anastomosis of the as¬ 
 cending cervical with the descending branch of the 
 occipital, and with the small lateral offsets of the 
 vertebral. 
 
 XIII-— The common carotid arteries. Of these two 
 vessels, the left one arising, in general, from the arch 
 of the aorta, is longer than the right one by the mea¬ 
 sure of the innominate artery from which the riglV 
 arises. When either of the common carotids is tied, 
 the circulation will be maintained through the anasto¬ 
 mosing branches of the opposite vessels as above 
 specified. When the vertebral or the inferior thyroid 
 branch arises from the middle of the common carotid, 
 this vessel will have an additional source of supply if 
 the ligature be applied to it below the origin of such 
 branch. In the absence of the innominate artery, the 
 right as well as the left carotid will be found to spring 
 directly from the aortic arch. 
 
 XIV. —The subclavian arteries. When a ligature 
 is applied to the inner third of this vessel within its 
 primary branches, the collateral circulation is carried 
 on by the anastomoses of the arteries above mentioned; 
 but if the vertebral or the inferior thyroid arises either 
 from the aorta or the common carotid, the sources of 
 arterial supply in respect to the arm will, of course, 
 be less numerous. When the outer portion of the 
 subclavian is tied between the scalenus and the 
 clavicle, while the branches arise from its inner part 
 in their usual position and number, the collateral cir¬ 
 culation in reference to the arm is maintained by the 
 following anastomosing branches : —viz., those of the 
 superficialis colli, and the supra and posterior scapular, 
 with those of the acromial thoracic; the subscapular, 
 and the anterior and posterior circumflex around the 
 shoulder-joint, and over the dorsal surface-of the 
 
 COMMENTARY. 
 
 scapula; and those of the internal mammary and 
 superior intercostal, with those of the thoracic arteries 
 arising from the axillary. Whatever be the variety 
 as to their mode or place of origin, the branches ema¬ 
 nating from the subclavian artery are constant as to 
 their destination. The length of the inner portion of 
 the right subclavian will vary according to the place 
 at which it arises, whether from the innominate ar¬ 
 tery, from the ascending, or from the descending part 
 of the aortic arch. 
 
 The axillary artery. As this vessel gives oil 
 throughout its whole length, numerous branches which 
 inosculate principally with the scapular, mammary, 
 and superior intercostal branches of the subclavian, 
 it will be evident that, in tying it above its own 
 branches, the anastomotic circulation will with much 
 greater freedom bo maintained in respect to the arm, 
 than if the ligature be applied below those branches. 
 Hence, therefore, when the axillary artery is affected 
 with aneurism, thereby rendering it unsafe to apply a 
 ligature to this vessel, it becomes not only pathologi¬ 
 cally, but anatomically, the more prudent measure to 
 tie the subclavian immediately above the clavicle. 
 
 XVI. The brachial artery. When this artery is 
 tied immediately below the axilla, the collateral circu¬ 
 lation will be weakly maintained, in consequence of 
 the small number of anastomosing branches arising 
 from it above and below the seat of the ligature. The 
 two circumflex humeri alone send down branches to 
 inosculate with the small muscular offsets from the 
 middle of the brachial artery. When tied in the 
 middle of the arm between the origins of the superior 
 and inferior profunda arteries, the collateral circulation 
 will depend chiefly upon the anastomosis of the former 
 vessel with the recurrent branch of the radial, and of 
 muscular branches with each other. When the liga¬ 
 ture is applied to the lower third of the vessel, the 
 collateral circulation will be comparatively free through 
 the anastomoses of the two profundi and anastomotic 
 branches with the radial, interosseous, and ulnar re¬ 
 current branches. If the artery happen to divide in 
 the upper part of the arm into either of the branches 
 of the forearm, or into all three, a ligature applied to 
 any one of them- will, of course, be insufficient to 
 
156 
 
 CONCLUDING COMMENTARY. 
 
 arrest the direct circulation through the forearm, if 
 this be the object in view. 
 
 XVII.— The radial artery. If this vessel be tied in 
 any part of its course, the collateral circulation will 
 depend principally upon the free communications be¬ 
 tween it and the ulnar, through the medium of the 
 superficial and deep palmar arches and those of the 
 branches derived from both vessels, and from the two 
 interossei distributed to the* fingers and back of the 
 hand. 
 
 XVIII.— The ulnar artery. When this vessel is 
 tied, the collateral circulation will depend upon the 
 anastomosis of the palmar arches, as in the case last 
 mentioned. While the radial, ulnar, and interosseous 
 arteries spring from the same main vessel, and are 
 continuous with each other in the hand, they represent 
 the condition of a circle of which, when either side is 
 tied, the blood will pass in a current of almost equal 
 strength towards the seat of the ligature from above 
 and below—a circumstance which renders it necessary 
 to tie both ends of the vessel in cases of wounds. 
 
 XIX. — The common iliac artery. When a ligature 
 is applied to the middle of this artery, the direct cir¬ 
 culation becomes arrested in the lower limb and side 
 of the pelvis corresponding to the vessel operated on. 
 The collateral circulation will then be carried on by 
 the anastomosis of the following branches—viz., those 
 of the lumbar, the internal mammary, and the epigas¬ 
 tric arteries of that side with each other, and with 
 their fellows in the anterior abdominal parietes; those 
 of the middle and lateral sacral; those of the superior 
 with the middle and inferior hmmorrhoidal; those of 
 the aortic and internal iliac uterine branches in the 
 female ; and of the aortic and external iliac spermatic 
 branches in the male. The anastomoses of these ar¬ 
 teries with their opposite fellows along the median 
 line, are much less frequent than those of the arteries 
 of the neck and head. 
 
 XX. — The external iliac artery. This vessel, when 
 tied at its middle, will have its collateral circulation 
 carried on by the .anastomoses of the internal mam¬ 
 mary with the epigastric; by those of the ilio-lumbar 
 with the circumflex ilii; those of the internal circum¬ 
 flex femoris, and superior perforating arteries of the 
 profunda femoris, with the obturator, when this branch 
 arises from the internal iliac; those of the gluteal 
 with the external circumflex; those of the latter with 
 
 the sciatic; and those of both obturators, with each 
 other, when arising — the one from the internal, the 
 other from the external iliac. Not unfrequently either 
 the epigastric, obturator, ilio-lumbar, or circumflex 
 ilii, arises from the middle of the external iliac, in 
 which case the ligature should be placed above such 
 branch. 
 
 XXI. — The common femoral artery. On considering 
 the circles of inosculation formed around the innomi¬ 
 nate bone between the branches derived from the iliac 
 arteries near the sacro-iliac junction, and those ema¬ 
 nating from the common femoral, above and below 
 Poupart’s ligament, it will at once appear that, in 
 respect to the lower limb, the collateral circulation 
 will occur more freely if the ligature be applied to the 
 main vessel (external iliac) than if to the common 
 femoral below its branches. 
 
 XXII. — The superficial femoral artery. When a 
 ligature is applied to this vessel at the situation where 
 it is overlapped by the sartorius muscle, the collateral 
 circulation will be maintained by the following ar¬ 
 teries :—the long descending branches of the external 
 circumflex beneath the rectus muscle, inosculate with 
 the muscular branches of the anastomotica magna 
 springing from the lower third of the main vessel; 
 the three perforating branches of the profunda inoscu¬ 
 late with the latter vessel, with the sciatic, and with 
 the articular and muscular branches around the knee- 
 joint. 
 
 XXIII.— The popliteal artery. When any circum¬ 
 stance renders it necessary to tie this vessel in prefer¬ 
 ence to the femoral, the ligature should be placed 
 above its upper pair of articular branches; for by so 
 doing a freer collateral circulation will take place in 
 reference to the leg. The ligature in this situation 
 will lie between the anastomotic and articular arteries, 
 which freely communicate with each other. 
 
 XXIV.— The anterior and posterior tibial and pero- 
 nceal arteries. As these vessels correspond to the ar¬ 
 teries of the forearm, the observations which apply to 
 the one set apply also to the other.* 
 
 * For a complete history of the general vascular system, see 
 The Anatomy of the Arteries of the Human Body , by Richard 
 Quain, F.R.S., &.C., in which work, besides the results of the 
 author’s own great experience and original observations, will be 
 found those of Haller’s, Scarpa’s, Tiedemann’s, &c., systemati¬ 
 cally arranged with a view to operative surgery. 
 
 THE END.