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A TREATISE 
 
 ON 
 
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 PART THE FIRST, 
 
 BY ABRAHAM COLLES, 
 
 ONE OF THE PROFESSORS OF ANATOMY AND SURGERY IN 
 THE ROYAL COLLEGE OF SURGEONS IN IRELAND, 
 
 &c. &c. &c. 
 
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 riLADELPHTA: 
 J. MAXWELL, FOURTH AND WALNUT STREETS. 
 
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TO THE 
 
 PRESIDENT, 
 
 MEMBERS, AND LICENTIATES 
 
 OF THE 
 
 ROYAL COLLEGE OF SURGEONS 
 
 IN IRELAND, 
 
 THIS TREATISE IS RESPECTFULLY DEDICATED, 
 
 BY THEIR OBEDIENT 
 
 HUMBLE SERVANT, 
 
 A. COLJUES. 
 
PREFACE. 
 
 The author of the following work had observed with 
 regret, the slow progress, which, even the most assi- 
 duous of the Pupils of the College of Surgeons, gene- 
 rally made in the acquirement of anatomical know- 
 ledge. A close consideration of the matter led him to 
 apprehend, that this originated from some material 
 defects in the established mode of teaching this science. 
 What these defects are, he has endeavoured to explain 
 in the Address prefixed to this work. Further reflec- 
 tion convinced him, that most of the obstacles which 
 retarded the progress of the Student might be removed, 
 by devising a plan of instruction, which should point 
 out at each step, the practical application of anatomi- 
 cal researches to surgical uses. And the rapid advances 
 in useful knowledge, made by the Pupils, since the 
 adoption of such a plan, have served to confirm his 
 opinion of its utility. 
 
 The following work was undertaken with the view 
 of giving additional efficacy to an experiment, in the 
 success of which, the Author feels himself so deeply 
 interested. It was hoped, that such a publication would 
 
VI PREFACE. 
 
 enable the Student to examine, for himself, the anato- 
 mical structure of the parts, by pointing out to him, 
 the best plan of proceeding in the Dissection; and that 
 it would also serve to imprint on his memory, when he 
 retires to his closet, what he had seen and learned in 
 the Dissecting-room. 
 
 It is by no means intended to offer here, a full sys- 
 tem of what the Author has termed Surgical Anatomy. 
 The Anatomy of some parts is altogether omitted — in 
 treating of others, he has pointed out only some few 
 of their many practical applications. In fact the pre- 
 sent Essay is nothing more than a rough and imperfect 
 sketch; but should the plan be approved of, it will not 
 be a difficult matter to extend it hereafter into a com- 
 plete system. 
 
 The plans for making the Dissections have been 
 laid down in such a manner, as will enable the Student 
 to enjoy, from the dissection of each part on a single 
 subject, a connected and comprehensive view of the 
 structure: so that he may have it in his power to form 
 an accurate idea of the various relations which the 
 structure of this part bears to the phenomena of its 
 diseases, and the modes of operation recommended for 
 their removal. 
 
 Stephen's-green, ) 
 April 9,d, 1811. 5 
 
AN ADDRESS TO THE PUPILS OF THE ROYAL COL- 
 LEGE OF SURGEONS IN IRELAND, 
 
 On the preparatory Education necessary for the Surgi- 
 cal Student. 
 
 It requires but little argument to prove, that to form 
 a good Surgeon, a good education is the first and most 
 essential requisite. For nothing contributes more effec- 
 tually either to expand the understanding, or to mature 
 the judgment, than an early exercise of the intellectual 
 faculties. It enables the Student to take more clear 
 and comprehensive views of the facts which occur to 
 his observation; it teaches him to deduce from those 
 facts, none bat logical inferences, and secures his rea- 
 son from the danger of being hurried away by the spe- 
 ciousness of false analogies. But so extended is the 
 circle of human sciences, and so short the time alotted 
 to preparatory studies, that (even with the most strenu- 
 ous and best directed exertions,) the sum of general 
 information which can be acquired in the earliest years 
 of life, must necessarily be very limited; it is therefore 
 of importance, that the earlier studies of those who 
 may be intended for any profession, be directed to such 
 subjects as will be most subservient to their future 
 pursuits. And it is incumbent on the Student, in whose 
 case this early attention has been omitted, to remedy 
 the defect with all the diligence he can exercise. Kow, 
 as some Sciences are very closely connected with that 
 of Surgery, while others bear no manner of relation to 
 it whatever, I think it my duty to prevent as far as in 
 
Viii AN ADDBESS, &C. 
 
 me lies, any waste of time, or misapplication of talent 
 in the outset of your professional career, by pointing 
 out to you the several sciences which appear to me 
 materially connected with the study of Surgery, by ex- 
 plaining their respective importance, by showing how 
 far each may be useful, and marking the line where it 
 ceases to be so. 
 
 On the necessity of Classical information, it is need- 
 less to dwell, because, in fact, no person can be ad- 
 mitted a registered Pupil of the College of Surgeons, 
 until he has undergone a public examination in Greek 
 and Latin, before the Court of Examiners; hut as the 
 course appointed to be read for entrance, comprises 
 little more than Virgil, Sallust, and Horace, in one 
 language; and Lucian, Xenophon, and Homer, in the 
 other, I would recommend it to you occasionally, to 
 refresh and extend your knowledge of the classics at 
 your leisure hours. A knowledge of French is scarce- 
 ly less necessary than that of Greek and Latin, for 
 many of the most eminent works on Surgical subjects, 
 have been published originally in that language, and 
 have not yet been translated into our own; and fortu- 
 nately for us, the study of French is one which requires 
 neither much time nor much labour. A slight appli- 
 cation for a few months, will enable you to read any 
 Surgical author in this language, with sufficient facility. 
 But, besides a knowledge of the Classics, an ac- 
 quaintance with the Sciences also, is necessary to com- 
 plete the preparatory education of the Surgeon. And 
 as the College has not yet fixed upon a scientific, as it 
 has on a classical course, I shall take the liberty of 
 
AN ADDRESS, &X. 9 
 
 discussing in order, the several sciences which most 
 particularly demand your serious attention. 
 
 No science tends so effectually to strengthen the 
 understanding, and to improve the reasoning faculties, 
 as that of mathematics; for it requires that complete 
 retirement of the mind within itself, that straight-for- 
 ward, unbroken progress of thought, which can alone 
 enable us to follow up a long chain of arguments, and 
 arrive at a remote conclusion. But besides the im- 
 portant benefits which are thus derived from the culti- 
 vation of this science, it is also in a great degree, the 
 key to most of the other sciences. I would, therefore, 
 recommend it you in the first place, to acquire a com- 
 petent knowledge of geometry, both for the purpose of 
 improving your intellectual powers, and of assisting 
 your studies in the various branches of natural philo- 
 sophy. But, allow me to warn you, that the direct 
 application of mathematics to the science of medicine, 
 is altogether impracticable. Our predecessors indeed, 
 dazzled by the success with which the immortal New- 
 ton had applied the principles of mathematics to un- 
 fold the laws of nature, conceived the preposterous 
 design of making the science of medicine a subject of 
 mathematical demonstration; and so confident were 
 they, that the cure of medical diseases could be made 
 as certain as the solution of mathematical problems, 
 that one of them triumphantly exclaims, " Jam solvi 
 nobile problema, dato aliquo morbo invenire reme- 
 diiun." An appeal to experiment, however, soon taught 
 them that the fixed and immutable laws of mathematics 
 were little applicable to the science of medicine: a 
 
10 AN ADDRESS, &C. 
 
 science heretofore so unfortunately characterized by the 
 instability of its principles. 
 
 Natural philosophy will be found of great use, to 
 explain some of the functions of the animal body, and 
 the laws to which they are subject. Thus it is impos- 
 sible that any person unacquainted with the general 
 principles of optics, can form an accurate idea of the 
 manner in which vision is performed in the natural 
 state of the eye; and he consequently cannot clearly 
 comprehend why distinct vision is in some persons, 
 confined to objects close to the organ, while in others, 
 those objects only which are placed at a distance can 
 be seen distinctly. Without a knowledge of acousticks, 
 it is equally impossible for him to comprehend the 
 manner in which the pulses of the air, strike upon the 
 tympanum of the ear, so as to produce the sensation of 
 hearing. It would be tedious to enumerate all the 
 particular instances in which you may apply the prin- 
 ciples of natural philosophy to the study of surgery. 
 You should, however, be careful to apply them with 
 the utmost caution. You should recollect that in the 
 animal system, physical laws are often counteracted 
 by the superior powers of the living principle. From 
 an inattention to this fact, originated most of those 
 errors in physiology and pathology, into which the 
 great Boerhaave was betrayed. It was owing to this, 
 that he conceived, the circulation of the blood through 
 the arterial and venous systems to be subject to the 
 same laws, which regulate the motion of fluids through 
 inanimate tubes. A theory w r hich, though perfectly 
 consonant to the laws of hydraulics, is yet totally in- 
 compatible with the laws of the living system. On 
 
AN ADDRESS, &C. 11 
 
 these misapplied principles did he also account for the 
 derangements which take place in the circulation from 
 disease, and on this fundamental error is built his cele- 
 brated Theory of Inflammation. 
 
 Chemistry, Gentlemen, affords such a luminous ex- 
 planation of the great phenomena of nature, and leads 
 to such important improvements in the various arts 
 subservient to human life, that mankind at large, must 
 regard it most as a science at once most highly pleas- 
 ing, and most eminently useful. To the surgical stu- 
 dent in particular, it is of indispensible importance. 
 For without a knowledge of the chemical properties 
 of those substances which he uses in the composition 
 of external applications, or of internal remedies, how 
 is it possible for him to avoid combining together 
 medicines, which though innocent or useful in them- 
 selves, may yet by their combination be rendered either 
 dangerously active, or totally inert? Thus, if the prac- 
 titioner were to administer flowers of zinc to a child* 
 and were at the same time to advise a mixture con- 
 taining dilute sulphuric acid, he would induce highly 
 distressing symptoms, by thus combining together two 
 medicines — each of which separately taken, would have 
 been perfectly mild. On the contrary, if he were to 
 combine together vinegar of squills, and volatile 
 alkali, which are each of them useful expectorants, for 
 the purpose of increasing their expectorating powers, 
 he would produce a compound much inferior in utility 
 to either of the medicines used singly. Nor is chem^ 
 istry of less use to the surgeon in administering, than 
 in compounding medicines. For unless he knows the 
 chemical combinations which a medicine is likely to 
 
12 AN ADDRESS, &C. 
 
 form with the various substances which it may meet in 
 the human body, how is it possible for him to know in 
 any instance, that the effect produced, shall not be the 
 very contrary to that intended? For example, mag- 
 nesia is in itself an inert substance with respect to the 
 human frame, but should it meet with any acid when 
 taken into the stomach, it then becomes an active pur- 
 gative. Now, if a practitioner, from an ignorance of 
 this property, were to administer the simple substance 
 to a patient, in whose stomach no previous acidity ex- 
 isted, he would in all probability, not only fail in the 
 object of evacuating the bowels, but might even cause 
 a state of more obstinate constipation, than had before 
 prevailed. 
 
 But the advantages which the surgeon derives from 
 the knowledge of chemistry, are not confined to the 
 composition and administration of medicines. This 
 science is of still more material use to him, in eluci- 
 dating several important phenomena of the animal 
 economy; for by Chemical analysis, we acquire a more 
 accurate knowledge of the component parts of many 
 substances, which are secreted from the general mass 
 of the blood, and lodged in various cavities of the body. 
 Thus, we learn more clearly the composition of urine 
 and of bile; and thus we gain a more distinct idea of 
 certain morbid changes which take place in these fluids, 
 as in the formation of biliary and urinary calculi. Nor 
 perhaps will it be deemed too sanguine a hope, to ex- 
 pect that chemistry may one day furnish us with 
 remedies which shall possess the power of dissolving 
 those concretions, and thus free mankind from the suf- 
 ferings of a most painful disease, and the necessity of 
 
AN ADDRESS, &C. 13 
 
 a most dangerous operation. In a word, chemistry 
 applied to the investigation of any phenomena in the 
 animal system, which do not strictly depend on the 
 vital principle, or employed to discover the composition 
 of substances, which, though deposited in certain ap- 
 propriated receptacles of the living body, are yet to be 
 considered as not under the immediate influence of the 
 living power: chemistry, I say, applied thus far, will 
 not only assist our researches into the animal economy, 
 but may also ultimately guide our practice to a more 
 judicious treatment. But this is the utmost extent of 
 its utility to the healing art. Thus far, and no farther, 
 are the principles of the one science applicable to the 
 phenomena of the other. Here, nature seems to have 
 fixed so immoveably, the common boundaries of both, 
 that beyond those limits, it appears scarcely possible 
 for chemistry ever to extend her empire over the pro- 
 vince of medicine. I know how contrary this is to the 
 prevailing opinion — I well know how fashionable it is 
 to lavish on chemistry the most unqualified praise, and 
 to attribute to it the most unbounded utility to the study 
 and practice of medicine; but however popular the 
 study of this fascinating science may be, however ar- 
 dent the hopes, and enthusiastic the expectations of its 
 admirers, I trust that I shall be able to satisfy your in- 
 genuous and unprejudiced minds, that the vital proper- 
 ties of the human system, depend not on its chemical 
 principles, and that the great and complicated opera- 
 tions of the animal economy are not subject to the 
 same laws that govern the minute and detached par- 
 ticles of inanimate matter. And if I shall thereby 
 prove the means of preventing that total disgust, which 
 
14 AN ADDRESS, &C. 
 
 you would naturally conceive to this science, on finding 
 that your time and industry had been thus thrown 
 away, upon an attempt no less laborious than imprac- 
 ticable: I am confident you will do me the justice to 
 believe, that so far from being inimical to this beautiful 
 and useful study, I am on the contrary, strongly actuat- 
 ed by a sincere solicitude, for the advancement of its 
 real interests. 
 
 To show how little the science of mutual affinities is 
 calculated to elucidate the phenomena of animal life, 
 we shall begin with an examination of the most simple 
 facts, and from thence proceed to an investigation of 
 the more complex. 
 
 For this purpose, we shall in the first place consider 
 chemistry, as applied merely to explain the composi- 
 tion and properties of the fluids, and the texture and 
 uses of the solids. By chemical analysis then we dis- 
 cover, that all our fluids and solids (with the single 
 exception of bone) are composed of nearly the same 
 chemical principles, and that they differ from each 
 other, chiefly by having those principles combined in 
 different proportions — but how is it possible to suppose, 
 that such slight differences in the proportions of the 
 same elementary principles, can be the cause of such 
 astonishing differences in the living properties? or in- 
 deed how is it possible, that any conceivable combina- 
 tion of chemical elements can impart any living pro- 
 perty whatever? Can any chemical analysis teach us, 
 for instance, why the elementary particles of animal 
 matter combined in muscle, possess the astonishing 
 properties of motion; or how those combined in nerves 
 communicate the still more surprising properties of 
 
AN ADDRESS, &C 15 
 
 sensation. Or can it explain to us, why it is, that both 
 these extraordinary agents retain their respective powers 
 during life, and yet lose them immediately after death, 
 although no alteration in their component principles 
 have taken place? If the science of chemistry then 
 be insufficient to explain the more simple properties of 
 any individual part, how can we expect it to elucidate 
 the complicated process of any particular function? 
 For example, can chemistry elucidate the wonderful 
 process of digestion, by which, dead vegetable matter 
 is converted into living animal matter, and the food 
 taken into the stomach, is made to participate in the 
 sensations of the animal whose body it nourishes? If 
 then chemistry can neither explain the properties of 
 individual parts, nor the process of particular functions 
 — is it from this science we are to expect an explana- 
 tion of the vital principle itself — that mysterious prin- 
 ciple which pervading every part of the sentient system, 
 at once directs, sustains, and harmonizes, all those 
 wonderful and complicated movements of the animal 
 machine? 
 
 Such are the considerations which induce me to 
 think, that the value of chemistry to the surgeon is 
 extravagantly overrated by modern authors. 
 
 Had these wild ideas of the perfectibility of medi- 
 cine, by the aid of chemistry, remained confined to 
 the speculations of the theorist, I should have passed 
 them over in silence; but when I see the crude and 
 imperfect principles of animal chemistry, extensively 
 applied to the practice of medicine, to detect the proxi- 
 mate causes of disease, to discover the appropriate 
 remedies, and to explain the specific mode in which 
 
16 AN ADDRESS, &C. 
 
 those remedies chemically operate, I feel it my bound- 
 en duty, to warn you, as strongly as I can, against so 
 dangerous a delusion. And perhaps I cannot do this 
 more effectually, than by stating to you some few of 
 the many cases in which this attempt has been already 
 made. The chemico-medical philosophers of the 
 French school, a few years since, laid it down as the 
 theory of intermittent fever, that the disease consists 
 in a general debility of the muscular fibre, arising from 
 the defect of gelatin in the constitution, and from the 
 imperfect fixation of oxygen or pure air in the gelatin. 
 From this theory it immediately followed, that the pro- 
 per remedy was to make gelatin the food of the patient, 
 and to let him enjoy the benefit of fresh air. They 
 therefore resolved to substitute this new medicine with 
 the modus operandi of which, they conceived them- 
 selves to be perfectly acquainted, for the established 
 specific which cured the disease, it is true, but cured 
 it in a manner to them inexplicable. They according- 
 ly did actually administer jelly for the cure of the ague, 
 instead of peruvian bark. And what was the success 
 of the remedy? Exactly such as any man of common 
 sense must naturally have anticipated. Thus, by the 
 misapplication of an useful science, have these men 
 been induced to abandon the established and success- 
 ful treatment of intermittent fever, and to adopt a prac- 
 tice perfectly inert, founded on a theory perfectly puer- 
 ile. In the same manner, and with nearly the same 
 success, have factitious airs been applied to the cure 
 of pulmonary consumption, and oxygenated potash to 
 the cure of lues venerea. 
 
AN ADDRESS, &C. 17 
 
 I have now pointed out to you, the course of prepa- 
 ratory study best suited to the surgical pupil, and have 
 taken a general survey of the several sciences best cal- 
 culated to assist either in the improvement of your 
 understandings, or the advancement of your professional 
 pursuits. And if there be any of you so unfortunate 
 as not to have enjoyed all the advantages of a well- 
 directed early education, I would earnestly recommend 
 it to you to endeavour to supply that defect with all 
 practicable expedition, by devoting to those studies, the 
 leisure of your Summer months, and bestowing on those 
 various sciences, an application proportioned to their 
 respective importance. 
 
 You may perhaps think, that if the time required for 
 those general studies, were devoted solely to the pur- 
 suits of your own particular profession, it would be 
 more wisely and profitably employed. But this opinion 
 is equally narrow and unfounded: for be assured, that 
 no man can know his own profession perfectly, who 
 knows nothing else; and that he who aspires to emi- 
 nence in any particular science, must first acquire the 
 habit of philosophizing on matters of science in general 
 
PLAN OF STUDY TO BE PURSUED BY THE SURGICAL 
 PUPIL. 
 
 Having thus taken a view of the sciences necessary 
 to be acquired before you enter on the study of sur- 
 gery, I shall now proceed to the consideration of those, 
 immediately subordinate to surgery itself, namely, 
 medicine, physiology and anatomy. 
 
 So inseparably connected are the two sciences of 
 medicine and surgery, that he who hopes to practice 
 either profession with benefit to his patient, or confi- 
 dence in himself, must take care to combine the study 
 of both. It is only from the mutual lights which these 
 kindred sciences reflect on each other, that the prac- 
 titioner can reasonably hope to attain either superior 
 sagacity in the discrimination, or superior skill in the 
 treatment of disease. 
 
 The talent of discriminating diseases, of distinguish- 
 ing that which is before us, from every other to which 
 it may bear any possible resemblance, is of all others, 
 the most useful to possess, and the most difficult to 
 attain. But it not unfrequently happens, that surgical 
 and medical diseases mutually assume such a strong 
 resemblance to each other, in their symptoms and 
 characters, that it becomes a matter of serious diffi- 
 culty to discriminate between them. In such cases 
 then, the practitioner cannot possibly ascertain under 
 which of them his patient labours, unless he be per- 
 fectly acquainted with the characters of both. For 
 instance, if a surgeon unacquainted with medical dis- 
 
PLAN OF STUDY, &C. 19 
 
 ease, were called to visit a patient affected with a re- 
 cent inflammation of the testicle, he would in all pro- 
 bability, at once apply those topical and general reme- 
 dies which the rules of surgery direct, instead of first 
 ascertaining whether the disease had been preceded by 
 a degree of fever and a swelling of the parotid gland. 
 And thus, by mistaking a mere consequence of cy- 
 nanche parotidasa for an original disease of the part 
 affected, he might seriously endanger both his own 
 character, and the life of his patient. 
 
 But medical knowledge is no less useful to the sur- 
 geon in the treatment than in the discrimination of 
 diseases. For it often happens, that a patient labour- 
 ing under a surgical complaint, is attacked with a 
 medical disease, which though not originally connected 
 with the local injury, may yet act on it in such a man- 
 ner, as to produce very material changes in its symp- 
 toms. Under those new and alarming appearances, 
 the surgeon, if ignorant of the origin and nature of 
 the constitutional complaint, would be led to adopt a 
 plan of treatment for the surgical disease, unnecessa- 
 rily severe, or absolutely dangerous. Thus a patient 
 labouring under a wound of the scalp, may be seized 
 with idiopathic fever; and this disease may produce 
 alterations in the wound, resembling those which take 
 place when the parts within the skull are engaged in 
 the injury. Were the surgeon, under those circum- 
 stances, ignorant of the causes of ordinary fever, he 
 might rashly proceed to the operation of the trepan, 
 an operation in this case absolutely unnecessary, at all 
 times attended with considerable danger, and that 
 danger highly aggravated by the existing state of fever. 
 
20 PLAN OP STUDY, &C. 
 
 It may, however, be urged, that the surgeon will 
 find it more prudent in all medical diseases, to call in 
 the aid of a physi ian; but to this plan there exists an 
 insuperable objection, namely, that in all dubious and 
 difficult cases of mixed disease, an ignorance of sur- 
 gical diseases must incapacitate the mere physician, 
 just as much as an ignorance of medical diseases can 
 incapacitate the mere surgeon. For instance, if a 
 physician be called to treat the fever which often at- 
 tends strictures of the urethra, he might conclude from 
 the similarity of the symptoms, that his patient was 
 attacked by intermittent fever, and would accordingly 
 pour in bark and other remedies, calculated for the 
 cure of that disease, by which the symptoms of the 
 fever would be rather exasperated than relieved. 
 
 Since then it is absolutely necessary for the benefit 
 and security of the patient, that the physician and 
 surgeon should each be acquainted with both medical 
 and surgical diseases; that surgeon must be inexcu- 
 sable, who is found to want this combined knowledge. 
 The additional labour necessary to acquire it is not 
 great, and the student will be amply recompensed, by 
 an exemption from mistakes prejudicial to his profes- 
 sional character, and dangerous to the life of his pa- 
 tient Let it not be supposed, that I would inculcate 
 the idea of unnecessarily uniting the practice of both 
 physic and surgery in the same person; on the con- 
 trary, i am decidedly of opinion, that in great cities the 
 surgeon should never undertake the cure of a case 
 purely medical, nor the physician of a case purely 
 surgical. All I mean to assert is, that the study of 
 both professions should be combined by the man who 
 
PLAN OP STUDY, &C. 21 
 
 wishes to practice either to the greatest advantage. 
 But this knowledge once acquired, the practitioner 
 should direct his attention to one branch exclusively. ' 
 
 To such of you as intend to devote your profession- 
 al services to the army or navy, I cannot too earnestly 
 recommend an early application to the study of medi- 
 cine; for you will find on entering into the service, that 
 the principal part of the cases committed to your care, 
 belong to the class of medical diseases, and as in that 
 situation there is no possibility of calling in the aid of 
 a physician, the lives of numbers must depend solely 
 and entirely on your medical skill. Study therefore, 
 all medical diseases in general, but study those with 
 peculiar attention, which are most incident to the mili- 
 tary or naval life. Study them not in books but in na- 
 ture — and instead of artfully and unconscientiously 
 making yourselves up to pass your examination, let it 
 be your care seriously and efficiently, to prepare your- 
 selves for the awful responsibility that is to devolve 
 upon you. 
 
 Phvsiology, which comprises a knowledge of the 
 living actions of individual parts, and of the various 
 functions of the animal system in a state of health, 
 must obviously strike you, as being of essential import- 
 ance to the surgeon. For without a knowledge of the 
 healthy actions and functions, how can he know which 
 of them are disturbed by disease? How can he under- 
 take to regulate them when out of order? How is he 
 to check them when excessive — or to rouse them when 
 languid? It is impossible for a man ignorant of the 
 operations and resources of the system, to say, that any 
 disease is such as cannot be relieved or remedied by 
 
22 PLAN OF STUDY, &C. 
 
 the operations of the system itself; but that the destruc- 
 tion or removal of the diseased part, is the only means 
 left to rescue the patient from the ravages of this 
 irremediable malady. In order to acquire a knowledge 
 of this science, you must make yourselves acquainted 
 with the structure of the various parts. For we shall 
 find that the nature of some of the functions will be 
 best elucidated, by an investigation of the organs con- 
 cerned in that function. Thus the structure of the 
 heart, the valves or floodgates which are situated in the 
 cavities of that organ, and in the mouths of the large 
 vessels connected with it, and the direction in which 
 these valves open, show most clearly the course in 
 which the blood must necessarily flow. From not at- 
 tending to the structure of this organ, physiologists 
 long remained in the dark on this subject, and framed 
 the most fanciful and wild hypothesis, until the immortal 
 Harvey proved the real course of the blood, from the 
 anatomical structure of these parts. However neces- 
 sary it may be to investigate the structure of our seve- 
 ral organs, it must yet be confessed, that the anatomy 
 of any one animal cannot explain all the functions of 
 that animal's body; and this is more especially the case 
 in man, and in the higher orders of animals, which' 
 have their organs composed of a structure more deli- 
 cate and complex, fitting them to produce those numer- 
 ous and varied effects, so difficult of comprehension. 
 The ultimate texture of our organs is often so complex 
 and minute, as to elude the severest scrutiny of our 
 senses. Under these circumstances then, we should 
 despair of ever arriving at a knowledge of many func- 
 tions of our own body, if we did not reflect, that in the 
 
PLAN OF STUDY, &1C. 23 
 
 inferior orders of animals, as each function becomes 
 less perfect, the organization on which it depends be- 
 comes more simple. By comparing them together, me 
 corresponding organs in various animals, we can ascer- 
 tain in what part of the organ resides the structure 
 essential to the performance of that function — and 
 which are those parts that may be considered as only 
 contributing to render the function more perfect. But 
 it is much to be lamented, that a considerable portion 
 of this branch of science is not established on such 
 secure foundations, but seeks for support from loose 
 analogies, or vague hypotheses. You should, therefore, 
 carefully weigh the degree of credit which is to be at- 
 tached to each theory in physiology, and allow your 
 practice to be guided only by those which are found to 
 be of sterling value. 
 
 Among all those sciences which are subservient to 
 the profession of surgery, anatomy justly challenges 
 the first and highest rank; it is not only of the greatest 
 importance, but of the most indispensable necessity 
 both to the study and practice of surgery. It is, in 
 fact, the very basis of all surgical education, the only 
 foundation on which a solid superstructure can be rais- 
 ed. But it is much to be lamented, that the very science 
 which, of all your professional studies, is the most im- 
 portant and indispensable, should be at the same time 
 beyond all comprehension, the most difficult and dis- 
 gusting. It is greatly to be regretted, that the student 
 should find it so hard to acquire a knowledge of anato- 
 my, and the practitioner should so soon lose that anato- 
 mical knowledge which had cost him so much time 
 and labour to acquire. It may be therefore not with- 
 
£4 PLAN OF STUDY, &C. 
 
 out its use to examine, whether a knowledge of this 
 science can be acquired with greater facility, or em- 
 ployed with greater effect than at present? Let us for 
 this purpose inquire, in what consists this difficulty of 
 which we so universally complain. Does it arise from 
 the abstruse and complicated nature of the subject it- 
 self? or is it not rather owing to some radical defect in 
 our method of investigating it? 
 
 That the study of anatomy is encompassed with 
 many natural and unavoidable difficulties; that the 
 science is of vast extent and infinite variety; and that 
 the multiplicity and diversity of the objects it presents, 
 must at the first view, oppress and bewilder the student 
 — all this I do not hesitate frankly to acknowledge. 
 These are, certainly, difficulties inherent in the subject, 
 and inseparable from it, these are obstacles which na- 
 ture herself has opposed to our progress, obstacles 
 which we cannot remove, and which we must therefore 
 only labour to surmount. 
 
 But admitting the existence of all those natural dif- 
 ficulties in the fullest extent, still I cannot help think- 
 ing, that some of the most formidable evils of which 
 we complain, are those we have ourselves created, and 
 that many of the most serious obstacles we have to 
 encounter, are actually those we have thrown in our 
 own way. It is, in fact, our deviation from that line of 
 study which the nature of the subject points out, that 
 renders a knowledge of anatomy so difficult to acquire, 
 and almost as difficult to retain; it is this that obstructs 
 the progress of the youthful student, and excites the 
 apprehensions of the experienced practitioner. 
 
PLAN OF STUDY, &C. 25 
 
 What the particular defects are in the present mode 
 of study, that chiefly contribute to retard the acquire- 
 ment of anatomical knowledge, I shall now endeavour 
 to explain. 
 
 In the first place, the authors of all elementary sys- 
 tems of anatomy, describe the various parts of the 
 human frame as if all of equal importance, instead of 
 giving to each part, just that degree of attention it de- 
 serves, and no more. Thus they are as full and cir- 
 cumstantial in their descriptions of the minute ramifi- 
 cations of an artery or nerve, as in that of the trunk or 
 principal branches; by these means the mind is over- 
 crowded with a collection of so much superfluous mat- 
 ter, and the memory over-burdened by the pressure of 
 so much dead weight. 
 
 The language too, in which these descriptions are 
 conveyed is no less tedious, than the descriptions them- 
 selves are trifling. By labouring after a minute and 
 unattainable accuracy, it serves only to impress an idea 
 of difficult), where no difficulty really exists. 
 
 Another essential mistake is, that of considering 
 anatomy in no other light than as a science in itself, 
 distinct and independent of any other, instead of con- 
 sidering it as a science altogether subservient to the 
 practice of medicine or surgery. Hence the inexpe- 
 rienced student, taught to regard anatomy, without 
 any reference to its uses, views it only as a collection 
 of detached and uninteresting facts, and a catalogue of 
 barbarous and unmeaning terms. Whereas, had he 
 in every step of his progress, been shown the connexion 
 between the anatomical structure of each part, and the 
 surgical diseases and operations to which it is subject, 
 
 D 
 
26 PLAN OF STUDY, &C. 
 
 he then would have had such a lively interest excited 
 in his mind, as must have impelled him to overcome 
 the natural difficulties of the study, and must have fixed 
 in his memory an indelible impression of the structure 
 of the parts. 
 
 But the principal and parent error arises from mis- 
 application of that which has been of so much utility 
 in the study of other sciences, and which, if not carried 
 to excess, would have been equally useful in this — 
 methodical arrangement. How far this principle has 
 proved injurious, and how far it has been productive 
 of real advantages, it may be of some importance to 
 distinguish. 
 
 The profound and comprehensive mind of the phi- 
 losophic Bacon, having discovered and demonstrated 
 the necessity of methodical arrangement in the culti- 
 vation of the sciences, Anatomists hastened to avail 
 themselves of its advantages; they accordingly divided 
 this science into several distinct branches, as Osteology, 
 Myology, Neurology, corresponding to the different 
 distinct parts of the animal frame. These divisions 
 they termed Systems. Each system they described 
 separately, without taking any notice .in this descrip- 
 tion of its connexions with the other systems, unless 
 where it happened that, that which was the immediate 
 subject of examination, should have remained abso- 
 lutely unintelligible, without such a reference. And 
 succeeding anatomists have ever since continued to 
 tread implicitly in the footsteps of their predecessors. 
 By these means we are certainly enabled to examine 
 the several parts with an accuracy, and to describe 
 them with a precision before unknown. But though 
 
I'LAN OF STUDY, &C. 21 
 
 the description of each particular part be now more 
 perfect, yet the plan is still so far defective, that the 
 description of any one part seldom reminds the student 
 of any other, the examination of any one system seldom 
 leads him to trace its connexions and relations with the 
 other systems, nor do so many detached views of the 
 several parts enable him to take any general and con- 
 nected view of the whole. Thus, the student who has 
 been shown the distribution of the venous, arterial, and 
 nervous systems of the arm, does not know how each 
 of them lies with respect to the other, at the bend of 
 the elbow, and therefore he knows not how he should 
 attempt, in cases of aneurism, to pass a ligature round 
 the artery, without at the same time including its ac- 
 companying nerve, which communicates sensation to 
 the principal part of the limb. Nor can lie. in the 
 common operation of bloodletting, account for that 
 sharp pain of which the patient particularly complains, 
 when the basilic vein is opened, because these detached 
 descriptions of the different systems did not lead him 
 to observe, that some considerable branches of the 
 nerves run down along the face of this vein. In short, 
 an attempt to explain the nature and structure of the 
 animal machine, by dividing the several parts of which 
 it is composed, into distinct classes, and then giving 
 only a detached and unconnected description of each 
 class, without ever considering them as the component 
 parts of one organized whole, is, in my mind, as pre- 
 posterous and unavailing, as would be an attempt to 
 explain the mechanism of a watch, by taking it to 
 pieces, and giving a separate description of every par- 
 ticular wheel and spring, without afterwards attempting 
 
28 PLAN OF STUDY, &C. 
 
 to show by what contrivance the one moves the other, 
 or how each wheel contributes by its particular motion, 
 to regulate the general movements of the whole ma- 
 chine. Is it then to be wondered at, that a plan so 
 little calculated to excite industry, or stimulate curiosi- 
 ty, a plan which so far from showing the subservience 
 of anatomy to surgery, does not even teach anatomy 
 itself as a distinct science; a plan which leaves the 
 whole weight to press on the memory, and that too, in 
 the most unfavourable manner, should have but few 
 attractions for the youthful student? Is it surprising 
 that he should consider the study of the science a 
 drudgery rather than a pleasure? That he should take 
 it up with disinclination, and turn from it with disgust? 
 In fact, the student who has been employed in acquir- 
 ing an anatomical knowledge of the different divisions 
 or systems of the human body, has but encountered all 
 the difficulties, without securing any of the benefits. 
 For such a plan of study can neither enable him to 
 form a perfect idea of the structure of any part of the 
 body; nor can these partial and detached views of the 
 anatomy, in any degree qualify him to perform a sur- 
 gical operation. The study of anatomy too generally 
 ends at that point where it begins to be useful. 
 
 While systems of anatomy are multiplied beyond 
 number, we have scarcely any elementary treatise, the 
 sole object of which is, to describe the relative position 
 of the parts, or point out the subserviency of anatomi- 
 cal knowledge to surgical practice. To supply that 
 defect for the pupils of this school, is the design of the 
 present work. 
 
PLAN OF STUDY, &C 29 
 
 If it shall enable you to trace for yourselves in the 
 dissecting-room, those parts which are most necessary 
 to be known; if, when you retire to your closet, it shall 
 assist to imprint on your memory, a knowledge of those 
 parts which you had previously dissected; if it shall 
 explain to you the different operations in surgery, and 
 demonstrate to you the anatomical principles, on which 
 each step of every surgical operation is founded, the 
 views of its author will be fully accomplished. 
 
 You may possibly think it a defect, that this work 
 is not accompanied by plates; and as it has of late be- 
 come so customary to embellish professional works 
 with splendid engravings, I feel it necessary to account 
 for the omission of them on the present occasion. — 
 Had they been added, the price must necessarily have 
 been too extravagant for an elementary treatise. !Nor 
 do 1 conceive them essential to you, as the surgical 
 pupils in this city, enjoy such unbounded opportunities 
 of seeing the parts displayed by dissection. 
 
THE ANATOMY 
 
 or 
 
 INGUINAL, CRURAL AND UMBILICAL HERNIA. 
 
 ANATOMY OF INGUINAL HERNIA. 
 
 The structure of the parts concerned in Inguinal 
 and Crural Hernia, has of late, much occupied the 
 attention of our most able and industrious anato- 
 mists. The very valuable discoveries which they 
 nave made, have led them into a most minute de- 
 tail of the situation, connexions, and origins (as 
 they term it) of the different fascia? which constitute 
 so material a part in the anatomy of those diseases; 
 but this very great minuteness, so necessary to the 
 description of newly discovered parts, appears to 
 be one cause of that embarrassment and difficulty 
 of which the pupil so generally complains, when 
 engaged in the study of those parts. Fortunately 
 for him, however, the description of this piece of 
 anatomy is much more complex, than the dissec- 
 tion is difficult. 
 
 I have attempted a description of those parts as 
 they present themselves on dissection, observing 
 such an order as may enable the student at the 
 same time, to comprehend the connexions, extent, 
 and uses of those parts. In some particulars, I 
 have ventured to differ from the received opinions; 
 
32 
 
 ANATOMY OF 
 
 but I trust, that the descriptions here given, will 
 be confirmed by dissection, will elucidate some of 
 the obscure parts of former descriptions, and may 
 lead to useful practical inferences Two plates 
 have been added, to illustrate the structure, of 
 which it was found impossible to convey a clear 
 idea, by any verbal description. 
 Mode of Make a transverse incision through the skin, 
 
 commenc- r , . „ . ... . ,. ° ,. ' 
 
 ing the dis- from the spine of the ilium to the hnea alba, and 
 section. a perpendicular one from that to the symphysis 
 pubis, begin to raise the integuments at the spine 
 of the ilium, where you know the fleshy part of 
 the external abdominal muscle lies; in doing this, 
 be careful not to raise along with them a fascia 
 which lies between them and the external abdominal 
 L a Sr U " mus cle, and which is termed the fascia superfici- 
 
 perhcialis. ' . . r . 
 
 alis; continue the dissection until you have raised 
 the skin which covers the upper third of the fore- 
 part of the thigh. In this stage of the dissection 
 you may observe, that this superficial fascia is not 
 confined to those parts which are ordinarily the 
 seat of rupture, you may by a little pains, trace it 
 up over all the forepart of the body and throat, and 
 Us extent, down upon the thigh. When we come to speak of 
 the anatomy of the limbs, I shall point out to you 
 what share it has in some of the morbid conditions 
 to which these parts are subject Your notice will 
 now be attracted by a long and pretty large vein 
 lying upon the surface of this fascia, this vein you 
 of the arte- see rising through the fascia of the thigh, turning 
 ria and ve- over tfo e e( jo- e f Pouparts ligament, at the distance 
 
 na pudenda _ • • i r r». i ' • 1 • r \ 
 
 of an inch and a quarter from the tuberosity ot the 
 pubis, directing its course towards the umbilicus, 
 and as it approaches this point, becoming gradually 
 smaller, in consequence of the numerous branches 
 which it has given off on each side; this vein is 
 accompanied by an artery which is sometimes of 
 pretty considerable size, and which is one of the 
 
INGUINAL HERNIA. 
 
 33 
 
 branches of the external pudendal artery. These {J'jjjjt 
 vessels then are liable to be wounded in the opera- ed in the 
 tion for inguinal, or crural hernia; and the divi- Jf^jjJJi 
 sion of this vein, and its accompanying artery, or ingui- 
 niight yield such an effusion of blood, as would " a 
 embarrass the surgeon in the commencement of his 
 operation, if he chanced to be unacquainted with 
 its source. Now raise the superficial fascia, by ^^g 
 making an incision from the spine of the ilium the fascia 
 to the Tinea alua, and continue its dissection down jf* 
 upon the forepart of the thigh, as low as you had 
 made the dissection of the skin; cut across the 
 fascia where it goes down to cover the penis, and 
 reserve the examination of this portion, until you 
 come to investigate particularly the anatomy ol the 
 genital organs. In raising the fascia you will connected 
 observe, that it is more closely connected with "j* j>" 
 Pouparts ligament, than with any other of the sub- ment. 
 jacent parts, and that it is also attached to the 
 pubis, in consequence of which attachment, it may 
 make a considerable degree of pressure on inguinal 
 hernia. — On raising this fascia from the groin, 
 you expose to view, the numerous inguinal lym- 
 phatic glands. These, lying under this fascia, Reiationof 
 will be materially affected by it, whenever they fall J2fc|3£ 
 into a state of inflammation; for in this condition to inguinal 
 of those glands, very considerable pain wall be in gau s * 
 duced in them, by any posture which will put this 
 fascia on the stretch, and hence it is, that patients 
 
 labouring under inflammation of those glands, will Effect . sof 
 • • r i • a- ■ ' . it on in- 
 
 experience an increase 01 their sunerings when gU mai 
 
 the body is erect, and a mitigation of them when |'j^ s tbey 
 the fascia is relaxed, either by the body being areinflanv 
 bended forward, or by the thigh being raised up- ed - 
 ward. 
 
 The external abdominal muscle being thus ex- 
 posed, you often observe near to Pouparts liga- 
 ment, two or three bands of tendinous fibres more of 
 thick, with intermediate portions more thin than external 
 
 E 
 
34 
 
 ANATOMY OF 
 
 mutiT al ordinary, so as to afford a remote resemblance to 
 the descriptions given of the abdominal ring; while 
 in the site of the ring itself, the structure of the 
 D . ffi parts is much more uniform and smooth; so that 
 discover.' an unexperienced person cannot readily discover 
 the real place of the ring in this stage of the dis- 
 Howto sect i° n - Catch with the forceps the spermatic 
 discover chord, as it passes over the face of the pubis; gently 
 its place. p U |] [^ anc j y 0U observe it com i n g out from under 
 a very thin fascia; pass the handle of your knife 
 between this fascia and the chord up towards the 
 spine of the ilium, and you will perceive the texture 
 of this fascia gradually to become thicker, as you 
 Fascia ascend towards the ilium. It is this small fascia 
 which which passing from one pillar of the ring to the 
 the nng. other, and connecting itself to each, which had 
 concealed these pillars from your view. This 
 membrane nearer to the ilium, is of a ligamentous 
 texture, but as it descends it loses of its ligamen- 
 its extent, tous nature, and degenerates into a cellular struc- 
 ture, but may in many subjects be traced for a 
 quarter of an inch along the spermacetic chord. If 
 you now recollect that by frequent distention and re- 
 Howaiter- peated slight attacks of inflammation, this cellular 
 disease, and tendinous structure becomes thicker; you will 
 understand, that in performing the operation for 
 Effects of inguinal hernia, you may not, after you have di- 
 operation. vided the skin and superficial fascia, be able to 
 discover the abdominal ring. You will therefore 
 not feel embarrassed, when, instead of this opening 
 with well defined borders, you find close to the 
 surface of the abdominal muscles, the tumour 
 covered at its neck, by this ligamentous membrane, 
 which now, in consequence of thickening and dis- 
 tention, is seen to descend perhaps for half an inch 
 proceed in along the tumour. Consider now, in what manner 
 th's^tep you can most readily introduce your knife between 
 operation, the hernia and abdominal ring; and from the pre- 
 sent view of the anatomy of the parts, it is plain 
 
INGUINAL HERNIA. B5 
 
 lhat this will be best effected by dividing this fascia 
 about a quarter of an inch below the abdominal 
 parietes with cautious touches of the knife. 
 
 From the course in which the spermatic chord 
 is seen to run down along the forepart of the pubis, 
 you may infer that, in the old manner of applying 
 the pad of the truss upon the external ring, there of ^p. 
 was some danger that the chord would be com- p'y in g the 
 pressed between the instrument and the bone. The 
 pain caused by this, you must suppose, would be 
 very great, and yet it has been submitted to, by 
 some patients, for a length of time, at least, suffi- 
 cient to produce serious diseases of the chord or 
 testicle. Observe now, that the spermatic chord 
 does not completely fill the external ring, and that a 
 quantity of loose cellular substance occupies the 
 remainder of the aperture. Next turn your atten- 
 tion to the situation of the ring relatively to the 
 pubis, as a familiar knowledge of this will assist 
 you in deciding on the nature of many obscure and 
 complicated diseases, which occur in the vicinity 
 of this part. Before you displace the external 
 abdominal muscle, make yourself familiar with the 
 course of the spermatic chord along Pouparts liga- S p e ™atic 
 ment, as it approaches the pubis. When you pull chold - 
 the chord, you can mark its course close to this 
 ligament, and can see that it is very loosely con- 
 nected to the parts on which it lies, by a lax cellular 
 substance. 
 
 Now raise the lower part of the external muscle, father 
 
 • . *, , dissection 
 
 by making an incision from the spine of the ilium of external 
 across to the linea alba; when you have separated ob, "i ue - 
 it from the subjacent internal oblique, so low down 
 as within one or two inches of Pouparts ligament, 
 you should divide the raised portion by a perpen- 
 dicular incision, which shall run midway between 
 the spine of the ilium and spinous process of the 
 pubis, and shall be continued down nearly to the 
 ligament. J3y this step you will be enabled to throw 
 
36 ANATOMY OF 
 
 down the external oblique upon the forepart of the 
 thigh, and thus gain a view of the parts it had 
 covered. The most important of these is the sper- 
 wh?ch e tb" mat * c chord; observe the groove in which part of 
 chord runs its course is run; this groove you see is formed 
 anteriorly, by that portion of the tendon which is 
 visible on the external view; the under part of the 
 How groove is formed by a folding in of Pouparts liga- 
 fomcd. ment, which passing backwards, is fixed to the 
 crest of the pubis or ileo-pectineal line; and this is 
 termed the third insertion of the external oblique. 
 This third insertion is not visible in the external 
 view of this muscle, and yet it acts a very important 
 part in femoral hernia, as shall be explained when 
 treating of the anatomy of this species of hernia. 
 The united tendons of the internal oblique and 
 transversalis muscles form the posterior part of 
 this groove, 
 internal The internal oblique is seen arising from the 
 muBcufar mner surface of Pouparts ligament, so far forwards 
 as two-thirds of its length from the spine of the 
 ilium; here the spermatic chord passes under the 
 edge of this muscle, and here those muscular fibres, 
 Cremaster which are termed the cremaster muscle, are seen 
 passing down on the face of the chord. These are 
 intimately blended with the fibres of the internal 
 oblique, so that no very marked division between 
 them is to be seen naturally, although with the 
 knife we can trace a distinction. In this stage of 
 the dissection you will observe, that in some points 
 i/SSXg °f view -> this bundle of muscular fibres appears to 
 from nans- come from under the edge of the internal oblique, 
 and to have arisen from the transversalis. In short, 
 this view of the parts will enable you to account 
 for the different descriptions of the origin of the 
 cremaster, as given by some of the most able anato- 
 mical authors. From this view of the parts also, 
 you will perceive that the older anatomists who 
 spoke of the ring in the internal oblique, were 
 
INGUINAL HERNIA. 57 
 
 misled by the intimate connection between that 
 muscle and the cremaster. You should now raise 
 the cellular substance from the anterior surface of 
 the chord, and thereby gain a distinct view of the 
 cremaster along its whole course. Remark now, Looseiy 
 the scattered older of its fibres, and what is of JJSSS1, 
 more consequence, remark how loosely those fibres and easily 
 are connected with the chord, and how easily a Dy P hernia, 
 hernia may either by gradual descent, or by sud- 
 den protrusion detach them from the chord and 
 tunica vaginalis of the testicle. 
 
 Now raise the internal oblique, that you may 
 obtain a distinct view of the lower portion of the 
 transversalis foiuscle, and its relation to inguinal 
 hernia. The most easy mode of effecting this, To raise 
 is to make an incision from the spine of the ilium ^ "Jf" 
 along its crista, cutting down through the muscular Hque. 
 fibres until you come upon the circumrlexa iliaca 
 vein and artery, which, being surrounded by much 
 cellular membrane, form at this place a veiy 
 marked division between these two muscles; having 
 thus ascertained the depth of the muscular fibres, 
 which belong to the internal oblique, you proceed 
 to raise this muscle, but when you have advanced 
 to its tendinous expansion, you will be at a loss to 
 ascertain how much of this belongs to each muscle 
 respectively. We may therefore say. that the com- conjoined 
 bined tendons of these two muscles, form a common tendons f 
 thin tendinous expansion, which passes anteriorly na iobiique 
 to the rectus muscle, until it reaches the linea alba, a,d ,rans - 
 while its lower edge, leaving Pouparts ligament is 
 stretched in an arched form over the spermatic 
 chord, and then inserts itself into the crest of the 
 pubis, this insertion being continued onwards even 
 to its symphysis. 
 
 It must, however, be admitted, that this tendon 
 is, in general, so closely connected with the fascia 
 transversals, that no regular, well defined line 
 can be observed, as marking the edge of the tendon, 
 
38 ANATOMY OF 
 
 on the inner side of the chord; nor can we say 
 
 positively, at what point, this tendon ceases to be 
 
 attached to the crest of the pubis. 
 
 opening" 1 It has not any opening for transmitting the sper- 
 
 for passage matic chord; but its lower edge stretches over this 
 
 ticXoiT process, immediately on its passing through the 
 
 internal abdominal ring. 
 
 The texture of this tendinous expansion, is not 
 Too weak uniform, close, nor strong, from which you will 
 P^oKion readily infer, that it is incapable of affording any 
 of bowels, great security, against the protrusion of the bowels, 
 through the parietes of the abdomen, immediately 
 behind the external ring; and therefore, that we 
 should, in all probability, be more subject to hernia 
 of this description, had not this part been strength- 
 ened by some other means; these we shall describe 
 when speaking of the fascia transversalis. 
 
 Before you displace the transversalis muscle, at- 
 tend to the course of the spermatic chord, as it 
 passes beneath it, and you will perceive, that this 
 takes place, at a point still more externally, or 
 nearer to the ilium, than the place where it had 
 passed under the internal oblique. 
 
 We have thus seen, that the spermatic chord 
 
 f rch h"i P asses under an arch, formed by the edges of the 
 
 the chord conjoined tendons of the internal oblique, and trans- 
 
 passes. versalis, and not through any aperture in those 
 
 muscles. 
 
 The size of this arch, is much more than suffi- 
 cient for transmitting the spermatic chord, and we 
 should be liable to frequent protrusions of the ab- 
 dominal viscera, at this point, had this arch been 
 the first opening, through which the spermatic chord 
 was to pass, in its descent to the scrotum. 
 How the We accordingly find interposed between these 
 Panted 6 tendons and the abdominal cavity, a fascia which 
 fromenter- lines this arch, and at the same time affords the first 
 thfs arch, aperture of that canal, by which the spermatic chord 
 is to pass through the parietes of tue abdomen. 
 
INGUINAL HERNIA. 
 
 39 
 
 For the discovery and description of this fascia 
 and its opening, the profession must ever feel the 
 most serious obligations to Mr. Astley Cooper, as Mr. A. 
 heretofore our knowledge of the anatomy of these uSerics 
 parts had been incomplete, and consequently our 
 operations for the cure of inguinal hernia, had 
 been founded on uncertain rules, and unnecessarily 
 exposed to dangerous accidents. 
 
 The exact description of this fascia, we must re- Fascia 
 serve, until we are examining the structure of the t JJJJ wi 
 parts engaged in femoral hernia; at present we shall 
 merely observe, that this is a fascia, which, attach- 
 ing itself to Pouparts ligament and the crest of the 
 pubis, is continued upwards on the anterior part of 
 the abdomen, lying between the peritoneum and 
 the transversalis muscle; in this fascia is an open- 
 ing, which Mr. Cooper calls the internal abdomi- internal 
 nal ring. This is situated about half an inch above r\ng° 
 Pouparts ligament, and its inner edge is midway 
 between the spine of the ilium, and the symphysis 
 pubis. To discover the fascia, cut cautiously 
 through the fibres of the transversalis muscle, and 
 as you raise the muscle, this fascia becomes expos- 
 ed. The opening in the fascia cannot yet be clear- tn ° jJJJJ? 
 ly seen, because a thin cellular substance, passes Da .' aM .°- 
 from the edges of the opening along the spermatic m ' 
 chord. Make an incision at half an inch anterior 
 to the fascia, round the chord, through this cellular 
 substance, and then strip it up towards the fascia. 
 By this proceeding, the ring will be plainly seen, 
 with its inner and its lower edges well defined and 
 pretty thick, while its outer and upper edges ap- 
 pear very indistinct and thin. 
 
 Thus you have seen, that the spermatic chord 
 passes through the various layers of parts, at points 
 not immediately opposite to each other, by which 
 structure, the strength of the parietes of the abdo- 
 men has been preserved, and the occurrence of 
 hernia rendered much less frequent 
 
40 
 
 ANATOMY OF 
 
 ?f b !'ugui- y The obliquity of this course is such, that the 
 naicunai. length of the canal, along which the chord runs 
 among the abdominal parietes, or the distance be- 
 tween the internal and external rings, is one inch 
 and a half, while the depth of the parietes is not 
 equal to a quarter of an inch. In this stage of the 
 dissection, you will study well the situation of this 
 opening, mark its position, with respect to the 
 spines of the ilium and pubis, to Pouparts ligament, 
 and to the external abdominal ring. Remember, 
 that as this is the first part of the parietes of the 
 abdomen, at which inguinal hernia ordinarily be- 
 gins to descend, so this is the spot, at which you 
 At this are particularly to look for suspe- ted hernia, either 
 sei for m tn °se who labour under symptoms indicative of 
 suspected the disease, or in those whom you inspect for the 
 service of the army or navy. Again, as the chance 
 Here pad of curing hernia by wearing a truss depends on 
 oftmss to our 5 e j n or aD i e to close up, or restore to its natural 
 
 be applied. n y ' 
 
 state, that opening at which tne bowel protrudes, it 
 is obvious, that the instrument should be made to 
 press on this point, or on tne internal abdominal 
 and why. ring; for pressure applied to any part below this, 
 leaves the mouth of the sac open, and ready to re- 
 ceive the viscera on any future exertion. 
 Relative Let us now take a view of the relations, which 
 position of the ordinary species of inguinal hernia has, to the 
 hernia to different parts in its vicinity. We first observe, 
 ™j° us that as the spermatic chord and this species of 
 hernia have the same course, so must they hold 
 Position of the same relative position, to the epigastric artery. 
 inguinal You see that the epigastric artery runs at the inner 
 epigastric ea *ge of the internal abdominal ring, that it lies 
 artery. posterior to the fascia transversalis, between it and 
 course of ^ e peritoneum, gradually coming up through this 
 this artery, fascia, until it has arrived about midway, between 
 the pubis and the umbilicus; that it here meets the 
 lower edge, of the sheath of the rectus, formed by 
 the conjoined tendons of the internal oblique and 
 
INGUINAL HERNIA. 
 
 41 
 
 transversalis muscles, and that insinuating itself 
 
 between the sheath and the rectus, it runs along 
 
 the posterior surface of this muscle. Now, as this 
 
 artery, in the natural state of the parts, lies along 
 
 the inner edge of the internal ring, and as this 
 
 species of hernia, descends in the same course 
 
 with the chord, it follows, that the artery must be 
 
 on the inner or pubic side of every such hernia, as 
 
 it is passing through the internal ring; so that, if 
 
 a division of the inner edge of this aperture be 
 
 , , , . .P . ,. ,., r . How en- 
 
 made, by carrying the knite in a direction towards dangered 
 
 the linea alba, this artery must inevitably be divid- jJ*J °P e " 
 ed. But when the hernia, having passed through 
 the internal ring, has descended to the edge of the 
 transversalis muscle, it must at this place, lie an- 
 terior to the artery; so that, if we had occasion to when free 
 divide the edge of this muscle, the artery could Jj™" r . 
 not be endangered, as it is removed out of the reach 
 of the knife, by the interposition of the hernia. 
 
 In short, the epigastric artery can only be wound- 
 ed in operations on this species of hernia, when the 
 knife is passed so deep, as to enter into the internal 
 abdominal ring, and then carried towards the linea 
 alba. To give you some idea of the importance 
 which should be attached to Mr. Cooper's dis- 
 covery of the fascia transversalis and internal ring, 
 I shall transcribe the sentiments of the celebrated 
 Peter Camper on this subject, — " In herniis, igitur, 
 inguinalibus, arteria et vena Epigastrica versus 
 pubem a prolapsis intestinis compelluntur, et radi- 
 cibus suis sub herniis sitae, nullo modo in bubono- 
 celes curatione, scalpello attingi possunt. Suspicor 
 Chirurgos deceptos fuisse magna et violenta pro- 
 fusione sanguinis, quae ex pudenda externa semper 
 provenit, simul ac scrotum secundum longitudinem 
 dividitur." 
 
 Next, with respect to the cremaster muscle; as Relation of 
 this comes off from the lower edge of the internal he,nia t0 
 oblique, it must be anterior to the hernia while 
 
 F 
 
4<2 ANATOMY OF 
 
 passing under the edge of the transversalis muscle, 
 and therefore the hernia must either force its way- 
 through the fibres of the cremaster muscle, or it 
 must insinuate itself between it, and the chord on 
 which it has lain. The former occurrence, I be- 
 lieve, has never been observed; the latter has so in- 
 variably been the case, that the situation of the 
 cremaster muscle is one of the means, by which 
 we judge of the nature of the hernia. We must 
 therefore expect, when operating on the ordinary 
 Cremaster form of inguinal hernia, to meet with the cremaster, 
 one of the as oae f those parts which cover the tumour on 
 
 smterioF 
 
 coverings its anterior surface, and this will invariably happen, 
 herl?a whatever may be the relative position of the hernia, 
 
 with the chord. 
 ^Itfonof From numerous instances, and from respectable 
 spermatic authorities, we learn, that the relative position of 
 toguinaT 1 tne cnor d and the hernia, varies materially in dif- 
 hemia. ferent instances. Thus, the entire chord has been 
 chord an- found to lie, on the anterior surface of the hernia, 
 tenor. instead of lying in its more usual, and more natural 
 situation, behind the hernia. The chord has been 
 chord spiitfbund^ as it were, split or divided by the hernia; 
 its blood vessels running anteriorly, while the vas 
 deferens ran behind the hernia. This you can sa- 
 How ac- tisfactorily account for, if you will recollect, how 
 counted the constituent parts of the chord diverge from 
 each other at the internal ring, by the vas deferens 
 passing down into the pelvis, while the artery and 
 vein run along the edge of the psoas muscle. Hence 
 you see the possibility of the chord being split by 
 the hernia, forcibly pushed down, and thus its vas- 
 cular part, may be found lying anterior to the her- 
 nial sac, while the vas deferens lies behind it; or 
 the vas deferens may be on the internal, while the 
 blood-vessels run on the external side of the hernia. 
 Other varieties in the position of the chord, have 
 . been described by authors. Hence we see what 
 
 Gaution in • 1 1 • 1 i 
 
 the opera- caution is required, when we are cutting through 
 
INGUINAL HERNIA. 
 
 43 
 
 the parts which cover inguinal hernia, lest we j,»° t n e( j ndl * 
 injure, irretrievably and unnecessarily, the struc- 
 ture and functions of the testicle. It must, how- 
 ever, be confessed, that the spermatic chord is, in 
 general, found to lie behind the hernia. 
 
 From the connexion which inguinal hernia hasp'""" 
 with the spermatic chord, you must expect that resemble 
 those diseases to which the chord is subject, will jgjJJ 1 
 bear a resemblance, more or less strong to this fo»m 
 of hernia. Thus, when water, collects, in a cyst 
 on that part of the spermatic chord, which lies in 
 the inguinal canal, forming encysted hydrocele ot 
 the chord, the appearance and feel of the parts, JjJ™^ 
 will not be such as to constitute a satisfactory dis- resembles 
 tinction between these diseases. We must .then '[JgJiJJ 1 
 depend, a good deal, upon the history of their origin 
 and growth, and also upon their attendant symp- 
 toms. 
 
 Sometimes the fluid of a hydrocele of the tuni- Hydrocele 
 ca vaginalis testis, distends this sac upwards, and jjv^fj 
 raises it even so high, that part of it shall pass testis. 
 within the external abdominal ring; here the form 
 of the diseased parts, and the impulse which each 
 receives from the abdominal muscles in coughing, 
 add to the difficulty of a Diagnosis. 
 
 V aricoceleor enlargement of the spermatic veins, Varicocele, 
 has been mistaken for hernia, as both are similarly Sp'igl 
 affected by posture and exertions. But a line of na, > eraia ' 
 distinction may thus be drawn. — Place the patient 
 in a recumbent posture, until the veins have nacl distin- 
 time to unload themselves, then, with the fingers g uished - 
 firmly catch the spermatic chord close to the ab- 
 dominal ring; let the patient now stand up, and if 
 the disease be a Varicocele, the tumour will soon 
 reappear and increase in size, as the veins cannot 
 now return their blood, being prevented by the 
 pressure: but if the disease be an hernia, the tumor 
 cannot appear as long as the pressure against the 
 ring is kept up. I have known the varicose state 
 
44 
 
 ANATOMY OF 
 
 of the chord, combined with hernia: this threw 
 great obscurity on the nature of the disease, and 
 caused great difficulty in remedying it, as the pres- 
 sure of the truss for retaining the hernia, increased 
 the obstruction in the spermatic veins. 
 Testicle There is no disease more difficult to be distin- 
 not'pasaed g u i sne d from hernia than an inflamed state of the 
 the exter- testicle, which having passed through the internal 
 ua nng ' abdominal ring, remains covered by the tendon of 
 the external abdominal muscle, not having descend- 
 ed so low as to escape through the second ring. 
 How closely this must resemble a variety of ingui- 
 nal hernia may be readily inferred; for the situation 
 of the tumor is precisely the same in both cases, 
 and the symptoms attending inflammation of the 
 testicle, thus situated, exactly correspond with those 
 of strangulated inguinal hernia. To these difficul- 
 ties we must add, that the surgeon is apt, at once, 
 to set down the case as incarcerated hernia, a 
 complaint with which he is familiar, and does not 
 suspect the existence of a disease which must be 
 extremely rare, 
 inflamed Inguinal hernia, may be confounded with in- 
 l3 tands atic fl amma tion of the lymphatic glands in the vicinity 
 mistaken of the spermatic canal. I do not suppose that any 
 for herma. slir g eon f competent anatomical knowledge could 
 mistake it for inflammation of those lymphatic 
 glands which lie in the fold of the groin; but an 
 enlargement, whether from a venereal, or any other 
 cause, of two lymphatic glands which lie on the 
 side of the abdomen, as high up, but rather more 
 internally than the internal abdominal ring; an en- 
 largement of these glands will produce appear- 
 ances, resembling those of inguinal hernia. 
 
 A knowledge of the parts concerned in this dis- 
 ease, constitutes the best foundation, upon which 
 we can establish useful and safe rules, for the sur- 
 gical treatment of hernia. When we attempt the 
 Taxis, cure by the taxis, as surgeons technically term it. 
 
INGUINAL HERNIA. 4$ 
 
 our efforts will be assisted by all tbose means, which 
 tend to increase the capacity of the abdomen, and 
 diminish the resistance of its walls. It is obvious 
 too, that the openings through which the viscera 
 have passed, should, as much as possible, be re- 
 laxed, and the intestine be pushed back along the 
 same route, by which it had descended. Most of 
 these benefits will be obtained by placing the pa- 
 tient in a proper posture. We should therefore lay p rin cipaiiy 
 the patient on his back, with his head and pelvis by posture. 
 raised by pillows, his thighs drawn up towards the 
 abdomen, and the knee of the affected side turned Effects of 
 inwards. Mark the effects of this posture on the ^J'JJ.J 
 walls of the abdomen, and on the apertures through of the 
 which the hernia had passed. 
 
 The lumbar vertebrae, instead of forming an 
 arch with its convexity projecting into the cavity of 
 the abdomen, now present a concave surface to- 
 wards that cavity. All the abdominal muscles are 
 relaxed, by their points of origin and insertion, viz. 
 the thorax and pelvis being made to approach each 
 other. 
 
 While this posture removes every resistance 
 which might be offered by the parietes of the ab- 
 domen to the return of the viscera, it affords the 
 most effectual means of relaxing the borders of 
 those apertures through which the bowels had 
 escaped, and to a certain degree, relieves them from JJJJjj 
 pressure and stricture. For the pressure of thecanai. 
 fascia superficialis is removed: by this fascia being 
 relaxed, particularly at the groin. The external 
 ring will, in some measure, partake of the relaxed 
 state of the external abdominal muscle in which 
 it is formed. The state of the external abdominal 
 muscle, and the relaxed condition of the fascia 
 lata of the thigh, produce a most complete relaxa- 
 tion of Pouparts ligament, which is now made 
 quite slack. From this state of the ligament, most 
 material benefits arise. For thus the arched edge 
 
m 
 
 ANATOMY OF 
 
 of the conjoined tendons of the internal oblique 
 and transversalis muscles, the fascia transversalis 
 and its aperture, the internal ring, are all relaxed: 
 because these muscles and this fascia are so inti- 
 mately connected with Pouparts ligament, that the 
 former must partake of that state of tension in 
 which the latter is placed. 
 performing Having secured all these advantages by the po- 
 the taxis, sition of the patient, you may new proceed to re- 
 turn the vise, ra. For this purpose, you w r ill grasp 
 the tumour with one hand and raise it up towards, 
 but not press it against the abdominal ring, while 
 with the two first fingers and thumb of the other 
 S'Thlch h an d> y ou compress the neck of the hernia, and 
 it is to be then endeavour to push it up in the direction of 
 returned. fa e i n gui na l canal, viz. towards the spine of the 
 Except for ilium and slightly upwards. From this line of 
 erma. direction you will deviate in old hernia, because 
 in these, the long continuance of the disease tends 
 to draw the two rings more and more opposite to 
 each other. 
 Hernia ap- A small portion of the tumour being returned, 
 tar*r w heT affords reasonable grounds for expecting that the 
 it is only rest will follow. But take care that you be not 
 S"e k e part deceived by the contents of the hernia passing 
 of scrotum backwards into the upper portion of the scrotum, 
 instead of being returned into the cavity of the ab- 
 domen. You may flatter yourself, on feeling the 
 contents of the hernia recede under the pressure, 
 cause of ^ iat they are returning into the cavity of the abdo- 
 this decep- men. The elastic state of the tumor: the facility 
 with which the lax texture of the scrotum can re- 
 ceive it: the difficulty with which it is made to re- 
 pass the external ring: and the situation of that 
 ring so near to the edge of the pubis, all conspire 
 to render this deception more frequent. By such 
 of s^ich 08 a mistake, not only will the object of the operation 
 mistake. De f or tne tuxie frustrated, but the safety of the 
 patient will be materially endangered; for the in- 
 
INGUINAL HERNIA. 
 
 47 
 
 testines must be here forcibly pressed against the 
 bone of the pubis, and thus subjected to a degree 
 of violence equally dangerous and useless; but all 
 this mischief may be avoided by directing the 
 pressure upwards and outwards in the line of the 
 inguinal canal. 
 
 As the best directed efforts must often fail, from 
 causes which it is unnecessary here to enumerate, 
 let us consider what rules of practice the operator 
 can derive from his knowledge of the anatomy of 
 the parts engageu in inguinal hernia. 
 
 Before the surgeon proceeds to this operation, cimim- 
 he should recollect the occasional deviation of the st 'f} c * s 
 
 r . . . which 
 
 spermatic chord from its ordinary position; he point out 
 should also recollect that the fascia superficialis^ 1 ^^. 
 is naturally oi different degrees of thickness, in Hon in this 
 different individuals: that the cellular substauce operation ' 
 surrounding the spermatic chord, may be much 
 thickened by this disease, or it may constitute but 
 a very thin layer. A recollection of all these cir- 
 cumstances will impress his mind strongly, with 
 the propriety and even necessity of slow, and cau- 
 tious proceedings. " Festina lente," is a rule more 
 applicable to this than to any other operation in 
 surgery. 
 
 The surgeon, when about to perform this opera- Mode of 
 tion, will grasp the tumour behind with his left fhe °opS 
 hand, that he may at the same time, make steady tion - 
 the parts on which he is to operate, and make tense 
 the integuments, so that they shall immediately 
 recede on being divided by the knife, Bis first 
 incision through the skin will begin a little above External 
 the upper, and be continued down to the lower end incision - 
 of the tumour; he will next divide to the same ex- 
 tent the fascia superficialis, but not with the same 
 boldness and freedom that he had used with the 
 skin; he will pinch up with his fingers or forceps, D j v j s j onof 
 a small portion of it, and make a small hole in this fa*™ su- 
 raised portion, by cutting it horizontally: he will per cialiS * 
 
48 
 
 ANATOMY OF 
 
 then introduce a director into the opening, on 
 
 which he divides the fascia, first to the upper end 
 
 of the external incision, and then changing the 
 
 direction of the instrument down to the lower end 
 
 of the tumor. Should any considerable haemorrage 
 
 Hamor- occur > ^ rom tne division of any branch of the ex- 
 
 hage from ternal pudendal artery, it should now be stopped 
 
 KTtto - ky pressure with the fingers of an assistant, or 
 
 ped. secured by a ligature. 
 
 Division of I n the same manner as he had divided the super- 
 cremaster. ficial fascia, will he divide the ere master muscle, 
 and then that cellular membrane in which the 
 hernial sac had formerly lain loose, but which now 
 serves to connect it closely to the surrounding 
 parts, and apparently to constitute a part of the 
 protruded peritoneum, adding in some instances 
 considerably to its thickness, and in others but 
 very slightly. All those parts which remain to be 
 How to cut cut after the division of the cremaster, should be 
 Shicffe fi rst opened at the inferior part of the tumor, as 
 under the this is the most safe spot for opening the sac, and 
 as the operator cannot be positive what depth, or 
 how many layers of parts he will have to divide be- 
 fore he penetrates the sac. 
 To open Having come to what he conceives to be the sac, 
 
 the sac. 1 -n i • n • • i i • 
 
 he will now cautiously pinch a portion ol it in his 
 fingers, and rub them on each other, to be certain 
 that none of the intestine intervene. Having cut 
 horizontally the raised portion, so as to make an 
 opening into the sac, large enough to admit the 
 director, he will pass this into the sac and up to- 
 eaution in war d s the ring, taking care always to keep every 
 
 introduciD 01 ' r % • * • 
 
 the direc- 3 part oi the groove applied as closely as possible to 
 tOT - the inner surface of the sac, lest any portion of 
 intestine should unfortunately insinuate itself be- 
 tween them and be wounded by the knife. With 
 the probe-pointed knife introduced on the director, 
 he will enlarge the opening in the sac, so that he 
 can iutroduce his fore finger, and using this as a 
 
INGUINAL HERNIA. 49 
 
 director he will divide the sac up towards the ring. 
 He now searches for the external ring, which will 
 be obscured by that small thin tendon, which is 
 stretched between its two pillars, and spread down Externa i 
 on the chord to a short distance, this being cau- ring con- 
 tiously divided, the pillars of the ring become ap- ce 
 parent: Mr. Cooper, whose authority should have 
 the greatest weight, advises ' that the sac should 
 not be divided, higher than to an inch below the Sac not t0 
 abdominal ring, as its division near the abdomen be divided 
 makes the wound more difficult to be closed, and "f ng ° 
 exposes the patient to greater danger of peritoneal 
 inflammation / 
 
 If the stricture be owing to the pressure of the 
 tendinous columns which form the external abdo- 
 minal ring, it is then to be divided in the following How to 
 manner; the surgeon passes his finger into the sac snr ™ c ture e 
 as far as the stricture, and then conveys a probe when in the 
 pointed bistoury on the forepart of the sac, and ring™* 
 insinuating it within the ring, cuts through it, in a 
 direction upwards, opposite to the middle of the 
 sac, and to an extent proportioned to the size of 
 the tumor. 
 
 i The dilatation of the ring should not be larger Extent of 
 than sufficient to return the protruded parts, but it eSnai^ 
 should allow them to pass without committing any ring. 
 violence by the pressure exerted in effecting their 
 return. In general, if the finger can be readily ad- 
 mitted into the abdomen by the side of the protru- 
 ded parts, the dilatation is sufficiently free.' 
 
 ' It is best to divide the stricture by passing the 
 knife between the ring and the sac, as a larger 
 portion of the peritoneum is thus left uncut, and 
 the cavity of the abdomen is afterwards more easily 
 closed/ 
 
 Sometimes however the stricture is not made by stricture 
 the borders of the external abdominal ring, but is at ihe in - 
 seated at the internal ring, where the pressure is er " nDS " 
 made on the protruded viscera by the border of the 
 
 6 
 
50 
 
 ANATOMY OF 
 
 tendon of the transversalis muscle above, and by 
 the edge of the opening in the fascia transversalis 
 below. In this case Mr. Cooper directs us to act 
 thus: 'The surgeon passes his finger up the sac, 
 divided. e towards the abdominal ring, until he meets with 
 the stricture, he then introduces the probe pointed 
 bistoury with its flat side towards the finger, but 
 anterior to the sac and between it and the abdomi- 
 nal ring, his finger being still a director to the 
 knife. Thus he carries the knife along the fore- 
 part of the sac, until he insinuates it under the 
 stricture formed by the lower edge of the trans- 
 versalis, and internal oblique muscles, and then 
 turning the edge of the knife forwards by a gentle 
 motion of its handle, he divides the stricture suffi- 
 ciently to allow the finger to slip into the abdomen, 
 the knife is then to be withdrawn with its flat side 
 towards the finger as it was introduced, to prevent 
 any unnecessary injury of the parts. 5 
 Advantage The direction in which this orifice is divided 
 of incision! i s straight upwards opposite the middle of the 
 mouth of the sac, as in this way the epigastric 
 artery can scarcely be cut, whatever be its relative 
 situation with respect to the sac. 
 
 ' An advantage is derived from dilating the stric- 
 ture without cutting the sac itself, for there is no 
 danger of injuring the intestine with the naked 
 edge of the knife.' 
 
 It has been objected to this proposal of Mr. 
 Cooper's, that to effect it the operator should pos- 
 sess a more than common share of dexterity com- 
 bined with a familiar knowledge of the anatomy 
 of the parts, engaged in this disease; that the inti- 
 mate connexion which is formed between the sac 
 and the surrounding parts, must render the attempt 
 not only very difficult, but extremely dangerous 
 when made by men less conversant with anatomy 
 and less practiced in the operation. 
 
INGUINAL HERNIA. 51 
 
 Sometimes the stricture is seated in the neck of stricture 
 the hernial sac: this will be known by the dilata- ma f e ^ 
 
 r, , i- i • • «» • .., neck ol sac 
 
 tion ol the transversalis being insufficient to libe- How dis- 
 rate the intestine, and when this is found to be the covered < 
 case, the same direction must be given to the inci- 
 sion; this operation differing from the foregoing operation 
 only in this circumstance, that now the knife must IDthlscase 
 be carried along the finger, within the sac, and be- 
 ing passed into the stricture must be turned, so as 
 to present its cutting edge to the anterior part of 
 the stricture, which can now be readily divided by 
 gently moving the handle of the knife forwards and 
 upwards opposite to the middle of the anterior part 
 of the sac. 
 
 It has been already mentioned that the division 
 of the parts which form the stricture, should not 
 be to a greater extent than is necessary for the 
 easy return of the protruded bowels: and that, in 
 general, when the finger can be readily passed into 
 the abdomen by the side of the protruded parts, 
 the dilatation is sufficiently free. Yet something Difficulty 
 more than the free division of the stricture is ne-? fretum " 
 cessary to obtain the easy and safe return of the boweislnto 
 viscera, when a large fold of the intestine is down: the abdo ~ 
 for I have, on more occasions than one, seen the m 
 operator embarrassed, by the unexpected difficulty 
 and delay, which he has experienced in this step of 
 the operation. I have seen him use a degree of 
 pressure unnecessarily severe, and decidedly in- 
 jurious. Nay, I have seen him enlarge the inci- 
 sions which were already sufficiently free: conceiv- 
 ing that the difficulties he encountered could only 
 have arisen from a stricture of the surrounding 
 parts. I have seen him, 1 say, after all this delay, 
 embarrassment and unnecessary violence, resign 
 the task to one of his assistants, whose suggestions, 
 but a few minutes before, he had disdained to re- 
 ceive. Now all these difficulties are occasioned 
 by the readiness, with which the portion of intes- 
 
32 ANATOMY OF 
 
 tine just pushed up, is forced out again from the 
 cavity of the abdomen. You can see the operator, 
 obviously push up a portion of the gut: this he 
 effects with readiness, but the moment he with- 
 draws his fingers from the cavity, you see a por- 
 tion of the bowel again to descend; whether forced 
 out by the muscular exertion of the walls of the 
 cavity, or by the elasticity of the air confined in the 
 intestinal tube — again he pushes up the same, or 
 Rule for an °ther portion, and again the same disappoint- 
 guarding ment occurs. Now all this is to be obviated by 
 dffficuny h ' s attention to this single and simple rule: push up the 
 gut nearest to the ring, assuring yourself that it has 
 entered the cavity of the abdomen, by passing in 
 your finger along with it, retain this portion by 
 holding your finger on it, until, with those of the 
 other hand, you have pushed up a second portion: 
 and in this way, support each part as you return it, 
 until the whole be replaced. 
 
 We sometimes, though rarely meet with a variety 
 of Inguinal of this kind of inguinal hernia, differing from that 
 hemia. already described, chiefly in this circumstance: that 
 it has not passed through the external ring, but 
 lies immediately under the tendon of the external 
 oblique muscle. 
 Appearan- The appearance of this variety of hernia, is as a 
 ces of it. fulness, stretching from the site of the internal ring 
 along the inguinal canal, down to the vicinity of 
 the external ring: this will be increased by cough- 
 ing, sneezing or any violent action of the abdominal 
 Relative muscles. The relative position of this to the neigh- 
 position of bouring parts is precisely the same as that of the 
 the parts. more ordinary form of the disease, with this single 
 exception, that it has not passed through the ring, 
 but remains under the tendon of the external ab- 
 dominal muscle. 
 
 The anatomy of this variety of the disease in- 
 theo S f ° r - ^icates tne same rules for the taxis, and for the 
 ti o e n ° pera operation as apply to the ordinary form of inguinal 
 
INGUINAL HERNIA. 
 
 53 
 
 hernia, only, that here you must divide the tendon 
 which covers the tumor, making a small opening 
 into it by pinching it up and cutting it horizontally: 
 into this opening introduce a director, by which 
 you will be enabled to divide so much of the tendon 
 as is necessary to bring the tumor fully into view. 
 The manner of opening the sac is the same as that 
 already described. The arched edges of the in- 
 ternal oblique and transversalis muscles are then 
 to be divided directly upwards. 
 
 While the more common species of inguinal 
 hernia escapes from the abdomen by the same 
 aperture at which the spermatic chord begins to 
 pass through the walls of this cavity, another, and 
 less frequent species, forces through those parts Another 
 which constitute the thickness of the walls, imme-Eiia! 
 diately behind the external abdominal ring; this 
 may be termed the direct descent. This form of The direct 
 hernia, however, is very rare, owing to the position descent 
 of the external abdominal ring, and to the parts 
 placed directly behind it. We observe that this 
 opening is not only bounded below, but is partly wb y so 
 occupied, by the portion of the pubis between the ra 
 spine and angle of this bone; towards the linea 
 alba, it is bounded by the edge of the rectus muscle. 
 The wall of the abdomen immediately behind this 
 ring, consists of the conjoined tendons of the trans- 
 versalis, and internal oblique muscles, and of the 
 transversalis fascia, the natural strength of which, 
 at this spot, is increased by their attachment to the 
 crest of the pubis, and by the connection which 
 the outer edge of the rectus has with the fascia 
 transversalis. An additional security is derived 
 from two small but strong fasciae, between which 
 the chord passes; one of these is the fascia, so often 
 mentioned, which stretching from one pillar of the 
 ring to the other, fills up all that part of it which 
 is above the spermatic chord. The other, is a 
 
54 
 
 AiNATOMY OF 
 
 strong triangular fascia, arising by a pretty broad 
 base from the crest of the pubis, anteriorly to the 
 insertion of the internal oblique and transversalis 
 tendons, passing immediately behind the external 
 abdominal muscle, until it reaches the linea alba, 
 in which it terminates by a narrow point about one 
 inch and a half above the pubis. The edge of this 
 fascia which looks towards the spermatic chord, is 
 slightly grooved or hollowed out. When the ab- 
 dominal muscles, and linea alba are stretched, that 
 edge of this ligament is seen to rise up from the 
 pubis, and consequently to shut up a greater por- 
 tion of the external ring Another advantage de- 
 rived from this ligament is, that it strengthens the 
 insertion of the tendons of the internal oblique and 
 transversalis into the pubis. This fascia is delineat- 
 ed, but not marked in plate first of Mr. Astley 
 Cooper's Treatise on Inguinal Hernia, nor is it 
 noticed in his description. 
 Appearan- \ n appearance, this species differs from common 
 specks. 1S inguinal hernia, by being situated nearer to the 
 Relative penis; its relative position to the neighbouring 
 parts, also differs from what takes place in the 
 common form of bubonocele. For as the epigas- 
 ofepigas- trie artery lies to the outer or iliac side of the ex- 
 tnc artery. t erna i ring, and as this hernia pushes down directly 
 through this aperture, the artery must lie on the 
 outer or iliac side of such hernia. Again, the sper- 
 matic chord, at the external ring, is seen covered 
 ofcremas-by the cremaster muscle, and lying close to the 
 ter - outer side of the hernia, but from the place of this 
 aperture, these parts are receding from each other, 
 the chord passing outwards and upwards, while the 
 hernia passes directly upwards into the cavity of 
 m . . the abdomen. In this species of hernia, the at- 
 
 Taxis in • 
 
 tws specie, tempt at reduction should be made by directing the 
 pressure upwards and a little inwards. The opera- 
 tion by the knife, when necessary, is to be perform- 
 
INGUINAL HERNIA. 55 
 
 ed, as for the ordinary form of bubonocele, with Extraordi- 
 this additional motive of proceeding with caution, JJ?,, ^" 
 that here the hernial sac is not covered by the ere- ration re- 
 master muscle, and therefore the operator will have quired 
 so much the less depth of parts to cut through be- 
 fore he reaches the hernial sac. 
 
56 ANATOMY OF 
 
 HERNIA CONGENITA, 
 
 This species differs from common inguinal her- 
 nia, in this circumstance, that it occurs while the 
 onferuh? commun i ca t' on yet remains open between the peri- 
 congenita. toneum lining the abdomen, and the production of 
 this membrane which descends into the scrotum, 
 to constitute the tunica vaginalis. Hence we find 
 that the bowels do not push down before them a 
 hernial sac, but fall into this open process of pe- 
 ritoneum which surrounds the testicle in the scro- 
 tum, and consequently the protruded bowels are 
 found in contact with the testicle. 
 Anatomy The anatomy of congenital is nearly the same 
 of hemi^ with that of the ordinary species of inguinal hernia. 
 ,ongenita. rjr^ Q S p erma tj c chord, always lies behind the her- 
 nial sac. The testicle, involved in the contents 
 of the hernia, cannot be clearly distinguished. 
 This species of hernia is particularly liable to be 
 Liable to mistaken for hydrocele; being sometimes combined 
 kenTr 8- wmi a quantity of water, which, falling from the 
 hydrocele, abdomen, into the lower part of the tumour, ren- 
 ders it transparent, and gives the idea of the whole 
 being an hydrocele. 
 
 This complication of disease, may be known by 
 disTn- e returning the whole contents into the cavity of the 
 guisued. abdomen, when the patient is in a horizontal pos- 
 ture; then putting the finger against the abdominal 
 ring, the water will slip by it, and fall down into 
 the scrotum, producing a transparent tumor, or 
 true hydrocele; after which, if the pressure of the 
 finger be a little lessened at the ring, and the pa- 
 tient desired to cough, the intestine, and omen- 
 tum, will be felt falling down into their former 
 situation. 
 
HERNIA CONGENITA. 57 
 
 This mode of discriminating, however, cannot JJf" ,5^ 
 be employed when an adhesion exists between the applicable, 
 testicle and the contents of the hernia. The mode 
 of effecting the taxis, and of performing the opera- 
 tion, is the same as that for ordinary inguinal her- Pe ^ ,ia "? 
 
 . • i i • • i i JP , . in the ope- 
 
 nia: with this exception, that so much ol the tunica ration, 
 vaginalis should be left unopened, as will be suffi- 
 cient to cover the testicle completely. 
 
 Having treated of the anatomy of inguinal her- 
 nia, the kind of rupture most frequent in males, 
 I shall now proceed to the anatomy of crural her- 
 nia, to which females principally are liable. 
 
 H 
 
58 
 ANATOMY OF FEMORAL HERNIA, 
 
 I have too frequently had occasion to remark 
 how much surgical students complain of the diffi- 
 X'thesub- Cl ^ty which they encounter, in acquiring a know- 
 ject. ledge of the anatomy of the parts concerned in 
 this disease. These complaints it must be admitted, 
 arise in some degree from the complicated struc- 
 ture Of the parts; in some degree also from the 
 prolixity and minuteness of detail into which those 
 who describe newly discovered parts, almost ne- 
 Causes of cessarily descend. The principal and most fruit- 
 cutty^ ^ source > however, of these difficulties, appears 
 to be the want of a systematic plan of examining 
 these pauts, so as to obtain from a single dissec- 
 tion, a Connected view of their several relations to 
 this disease. 
 
 The following mode of making the dissection, 
 appears to me best calculated to attain this desira- 
 ble end, 
 
 Cut through the abdominal muscles and peri- 
 toneum, by an incision extending from the spine of 
 one ilium to that of the other. Divide the muscles 
 of the opposite sides by an incision through the 
 linea alba, down to the pubis. Turn down the 
 abdominal muscles of each side, upon the top of the 
 thigh; pass your finger along the inner side of the 
 iliac vein, towards the limb, and when it has reach- 
 ed to the abdominal muscles, you will feel it, en- 
 tering into an opening which leads from the abdo- 
 men to the top of the thigh. The finger cannot 
 enter farther than half an inch, through this open- 
 ing in that direction. This is the opening through 
 which crural hernias pass from the cavity of the 
 abdomen, and at this opening only can the bowels 
 escape to constitute B this species of the disease: 
 
FEMORAL HERNIA. 59 
 
 contrary to what happens in inguinal hernia, where 
 the bowels may escape from the abdomen, at two 
 points, viz. either by entering the internal abdomi- 
 nal ring, along with the spermatic chord, or by 
 forcing their way through those parts which lie 
 immediately behind the external abdominal ring. 
 This aperture then, the only one through which cmraj 
 crural hernia can protrude, is called the crural ring. nn °- 
 To prevent any confusion arising from the simili- 
 tude of names, observe that Pouparts ligament has 
 occasionally been termed the crural arch. Before Cr f al 
 you disturb any part, study well the situation of 
 this opening, its relation to the vessels and other 
 important parts in its vicinity. Remark then, that 
 the femoral vein forms the boundary of this open- 
 ing, on the iliac side, observe through the perito- How boun- 
 neum, the epigastric artery and vein running at 
 the outer or iliac side of this opening, and distant 
 from it about half an inch. The spermatic chord 
 in the male, or round ligament of the uterus in the 
 female, enters into the internal abdominal ring, 
 immediately on the outer side of the epigastric Vag M ^ 
 artery. The vas deferens lies on the outer or iliac re ns. 
 side of this opening. The umbilical artery lies Umbi | ica! 
 nearly one inch to the pubic side of the crural artery. 
 ring. 
 
 Now proceed to remove the peritoneum, in order How tore- 
 to gain a more distinct view of those parts. For "f^tone? 
 this purpose cut through this membrane by an in- um. 
 cision, commencing at the spine of the ilium and 
 carried across the iliac muscle, and here begin to 
 raise the peritoneum. When you come near to 
 the spermatic chord or round ligament of the 
 uterus, carefully separate this membrane from 
 those parts with the knife, as its adhesion to them 
 is particularly close. You must be careful not to 
 raise any other membrane along with that portion 
 of the peritoneum which lines the abdominal mus- 
 cles. 
 
60 ANATOMY OF 
 
 hernia? 6 ^ 0U cannot Dllt observe that the peritoneum, as 
 sac is it descends to line the pelvis, covers that opening 
 formed. ca n e( j tj le crura i ring; an( j therefore you perceive 
 that this membrane will be pushed down by the 
 bowels as they enter this opening, and will conse- 
 quently form the peritoneal covering of such her- 
 niary tumour. You will often find a quantity of 
 \ soft fat lying on that surface from which you have 
 removed the peritoneum. By scraping this with 
 the handle of your knife you remove it readily and 
 without danger of cutting any of those membranes 
 which constitute a material part of the anatomy of 
 crural hernia. The peritoneum being removed, 
 again turn your attention to the crural ring. Pass 
 
 rin ge to° f y our fi n S er mt0 * ms aperture, and press it against 
 wards the the border of the ring, nearest to the symphisis 
 and firm rp P ums - You find it to present a very sharp and 
 But not vei T fi rm ea S e - This edge has hitherto been de- 
 formed by scribed as formed by the third insertion of the 
 S s e er J ' n d of external oblique muscle. With this opinion we 
 external can by no means agree. We must however defer 
 o iique. j. Q a f u t ure s tage of the dissection, the objections 
 which we have to offer against the validity of this 
 description, and shall now proceed to point out to 
 you that, which we conceive, to be Ihe real struc- 
 ture of these parts, confirmed by repeated dissec- 
 tions. 
 
 Before you detach or separate any part, examine 
 
 well the appearances and structure which present 
 
 themselves to your view. And first as you look at 
 
 crurai ring the crural ring, you see it occupied by a quantity 
 
 nOW OCCU- • • * • * 
 
 peid. of loose cellular substance, which in some instances 
 assumes the appearance of a distinct membrane, 
 and you occasionally find here one or two lym- 
 phatic glands. Pass your finger into this aperture, 
 and press it against its inner or pubic edge. You 
 different w iN find this edge extremely sharp, and unyielding, 
 postures of while the limb is extended, and the foot turned 
 crurai n ring outwards; but when the knee is bended, and the 
 
FEMORAL HERNIA. 
 
 61 
 
 limb rolled inward, this edge is relaxed, the aper- 
 ture widened, and those parts which border on the 
 opening, and, which had been drawn down into 
 it by the opposite position of the limb, are now ^ ^ 
 seen to rise up again into the abdomen. Among the ne j g h- 
 the parts which undergo such change of place, J^ u ™g 
 the most important are the epigastric artery on the 
 iliac side, and some vessels very variable in their 
 size, and origin, which pass in no very regular 
 course towards the symphisis pubis. 
 
 Next turn your attention to that aponeurotic Aponcuro- 
 
 • i i 11 r ii *r SIS ' ,nin g 
 
 expansion, which lines the hollow ol the ilium, the mum 
 and ascends upon the internal surface of the ab- JJ* ^^ 
 dominal muscles, over to the symphisis pubis and abdomen. 
 linea alba. The texture of that portion which 
 covers the iliac muscle, is pretty strong; that por- 
 tion which lines the abdominal muscles, in this 
 view, appears much more thin, except that part of 
 it which stretches across the tendinous portion of 
 the transversalis, abdominis, over to the rectus. In 
 this place the aponeurosis appears to be more 
 strong and thick, but this, in a subsequent stage 
 of the dissection, will be found to be a delusive 
 appearance. You see in this aponeurosis, a white £ ne w ^J, e 
 line passing in a direction nearly from the anterior m this a- 
 superior spine of the ilium, over to the pubic edge P oneuroas - 
 of the crural aperture. You may observe however, Where it 
 that it commences half an inch below the spine ofnesexter- 
 the ilium. In subjects that have been injected you nally ' 
 see a blood vessel (the arteria circumflexa ilii) 
 running in that part of this white line, which lies 
 between the outer side of the external iliac artery, 
 and spine of the ilium. This white line stretching How it 
 across the anterior edge of the crural ring, passes ^["2" 
 about half an inch beyond its pubic edge towards 
 the symphysis, and inserts itself by a very acute 
 angle into the crest of the pubis. Before you can 
 discover the uses, or appreciate the value of this 
 
62 ANATOMY OF 
 
 How her- aponeurosis, you should recollect the other means 
 
 mae are V • 1 i • c 
 
 prevented which nature has employed to prevent hernia from 
 
 to° m 0U P t a at" P assm g out of the cavity of the abdomen, to the 
 
 ail points top of the thigh. 
 
 ftigh P ° f The lower edge of the external abdominal mus- 
 cle, called Pouparts ligament, which constitutes the 
 lowest border of the abdominal parietes, is stretch- 
 ed across from the spine of the ilium to that of the 
 pubis; between these two processes, the anterior 
 edge of the os innominatum, is considerably though 
 not regularly excavated; in consequence of which 
 a considerable space intervenes between the liga- 
 ment and the edge of the bone. By. what parts is 
 this interstice occupied? and by what means are 
 we secured from hernia occurring along every 
 portion of it, except that which is called the crural 
 ring? 
 
 How the We find that a considerable part of this hollow 
 
 space be- , c , . „ . ... l . . ... 
 
 tween P ou- (trom the spine ot the ilium to the external iliac 
 pans iiga- vessels) is occupied bv the iliacus interims and 
 
 went and ' t J 
 
 edge of os psoas muscles, as they pass out ot the abdomen, 
 tSmu'oc- over the edge of the pelvis, to insert themselves 
 cupied. into the small trochanter. These, with the crural 
 vessels and nerves contribute to fill up this space. 
 But still we find, that by all these parts the hollow 
 is but imperfectly filled, that there is not only no 
 t connection between pouparts ligament, and the 
 pieteiy surface of these muscles, but that even a conside- 
 red, rable space intervenes between them, and that this 
 interstice is so large as would with facility admit 
 the escape of the bowels. By the following simple 
 expedient you may ascertain the extent of this in- 
 terval without removing any of the parts from their 
 Proof of situation. Make in the aponeurosis which covers 
 this - the iliac muscle, an opening capable of admitting 
 the finger. Pass it between the aponeurosis and 
 surface of the muscle, and you will be enabled 
 without much difficulty to push the finger under 
 pouparts ligament down to the forepart of the thigh. 
 
FEMORAL HERNIA. 
 
 63 
 
 What it is then which leaves one particular spot 
 alone subject to crural hernia, while all the rest of 
 the top of the thigh is completely secured against 
 the occurrence of this accident is an aponeurotic 
 membrane. This membrane under different names, 
 lines the hollow of the ilium and lower part of the The lining 
 abdominal muscles; anatomists in their descrip- *f s oneuro " 
 tions of this aponeurosis, have assigned different 
 names to so many different portions of this mem- 
 brane, and have descended into such a minute 
 detail of its various connexions and relations, as to 
 have rendered the study of this piece of anatomy 
 very difficult to the generality of pupils. I trust, 
 therefore, that I shall stand excused, if I attempt 
 to illustrate this description by a familiar compa- 
 rison. I think then that this fascia may be said ^ fi ^ 
 to resemble a funnel, the wide part or mouth of compared 
 which occupies the hollow of the ilium, and lower t0 a futmel 
 part of the abdominal muscles; and the narrow part 
 or pipe of which passes downwards on the thigh. 
 The mouth of this funnel may be supposed to rise 
 as high as the upper edge of the iliac muscle, and 
 to be turned towards the cavity of the abdomen: 
 the pipe joins the wide part where the external 
 iliac vessels are passing under pouparts ligament, 
 and it is continued down on the thigh so low, as to 
 reach the insertion of the saphena, into the femo- 
 ral vein. Its shape, however, differs from that of 
 an ordinary funnel, and must be supposed to be 
 flattened both in its body or wider part, and pipe. 
 The different parts of this aponeurotic funnel, have ^p* 11 ^ 
 received different names. That part is called iliac ous parts 
 fascia, which covers the muscle of that name, j^jjj 
 The term, transversalis fascia, is applied to that niac fascia 
 portion which lines the transversalis muscle. The ^KSa 
 narrow prolongation which descends on the thigh, 
 is termed the sheath of the femoral vessels; thesheathof 
 anterior part of which, again is described as the tiev 
 transversalis portion, from its being continuous with 
 
74 
 
 ANATOMY OF 
 
 the transversalis fascia, while the term of iliac 
 portion, is applied to the posterior part of this 
 sheath, because it is continuous with the part called 
 the iliac fascia, 
 close ad- At the junction of the narrower with the broader 
 usTecklo P art °^ funnel, we find the connexions of this 
 the sur- fascia to the surrounding parts to be particularly 
 parts^ 112 c l° se ana< strong so that where it is passing over 
 the anterior edge of the os innominatum, it adheres 
 very intimately to the ligamentous substance co- 
 vering the crest of the pubis, and to the periosteum 
 of that part of the ilium on which it lies. Anteri- 
 orly, its connexion with Pouparts ligament, is not 
 less intimate. The iliac vessels pass down within 
 the funnel, lying on that part of it which lines the 
 iliac muscle. When these vessels come into the 
 seViieV- narrower part of this aponeurotic funnel, they pass 
 wards the down, not along its centre, but towards the outer 
 
 li'13.C Sidf 01 ^^ 
 
 the sheath, or iliac side. It is partly owing to this position, 
 
 and partly to the shape of the tube (which is more 
 
 flat and extended on the pubic, than the iliac side,) 
 
 that we see those vessels, as they are passing out 
 
 of the abdomen, removed to a considerable distance 
 
 which a from the pubic side of the sheath. Jt is then, in 
 
 these her- the space between the femoral vein, and pubic side 
 
 ,ccur ' of the funnel, that crural hernia uniformly takes 
 
 place. 
 
 It may now be asked, why it is, that femoral 
 hernias do not pass down at every part of this 
 sheath which is represented as open towards the 
 abdomen; as it is a prolongation of that membrane 
 which lines the lower part of the cavity? why these 
 hernias do not push down along the front, or to the 
 iliac side of those vessels? For we know, that 
 they are constantly varying in their dimensions, and 
 that they are compressible by a slight force, both 
 of which circumstances should favour a protrusion 
 rai heS; of the bowels along their course. The possibility 
 do not oc- f sm^h an occurrence, is guarded against in this 
 
FEMORAL HERNIA. 
 
 65 
 
 manner. The external iliac vessels are covered ^jj^nt 
 anteriorly in the greatest part of their course, by mac side 
 a cellular substance only; but as they approach ^J* 
 Pouparts ligament, they are covered in front, by a 
 membrane of aponeurotic texture, which is reflect- 
 ed from their surface, and ascends to join the fascia 
 transversalis, at a short distance above Pouparts 
 ligament. This accessary membrane then, lining 
 that portion of the mouth of the sheath, which is 
 anterior to the femoral vessels, and at the same 
 time, stretching a little way on its iliac side, must 
 preclude the possibility of hernise pushing down 
 either in front, or on the outer side of these vessels. 
 In addition to this, we find the mouth of the sheath 
 still further secured; for we perceive interposed Furthci . 
 between the artery and vein, a pretty strong mem- security. 
 branous partition, and a similar partition on the 
 inner side of the vein. These partitions pass from 
 the anterior, or as it has been termed, the transver- 
 salis portion, to the iliac or posterior portion of the 
 sheath; and consequently serve not only to subdi- 
 vide the wide mouth of the sheath into smaller 
 compartments, but also to prevent it from being 
 stretched or widened by any slight force. It is 
 hardly necessary to remark, that the partition on 
 the inner side of the vein, will always be interposed 
 between this vessel and the crural hernia, which 
 passes down into the unoccupied portion of the 
 mouth of the sheath. 
 
 The space intervening between the spine of the sp** be - 
 pubis, and neighbouring side of the crural ring spine of 
 is secured by the following structure: The portion J^^jL 
 of the fascia transversalis which lines this space, how se- 
 is firmly attached to the ligamentous substance co- cured- 
 vering the crest of the pubis, and is still further 
 strengthened by the conjoined tendon of the in- 
 ternal oblique and transversalis muscle. This 
 tendon lies in close contact with the lining fascia, 
 and it also is attached to the crest of the pubis. 
 
66 ANATOMY OF 
 
 why this jjy the way, we may remark, that this portion of 
 
 portion of.*' • /• ■ i i • i i 
 
 fascia the aponeurotic tunnel appears thicker and stronger 
 STand tnan an y otner P ar t of it; an appearance which is 
 strong, owing to its close connection with the conjoined 
 tendon of these muscles. Pouparts ligament, the 
 third insertion of the external abdominal muscle 3 
 and a portion of the fascia lata of the thigh, com- 
 plete the defence, against the occurrence of hernia, 
 in this space. 
 
 That you may more clearly see the structure of 
 this part, and that you may ascertain how crural 
 hernias are circumstanced, after they have de- 
 How to scended through the crural ring, you should now 
 proceed in direct your attention to the anatomy of the upper 
 tion. part of the thigh; the dissection of which, you 
 should prosecute in the following manner: — 
 
 Raise the superficial fascia, which I formerly 
 
 described as passing down from the abdomen upon 
 
 the forepart of the thigh. Keep the back of the 
 
 knife towards the fascia lata, lest you cut away 
 
 any part of it; for in some subjects, a part of this 
 
 fascia lata, but little exceeds the cellular substance 
 
 Vena m d ens ity« You see the vena saphena major run- 
 
 saphena ning in the hollow on the forepart of the thigh, and 
 
 major " lying upon the surface of the fascia lata, until it 
 
 arrives within an inch and a half of Pouparts 
 
 ligament. Dissect this vein from the surrounding 
 
 How to cellular substance, cut it across at the distance of 
 
 dissect iti 
 
 two or three inches below the ligament, and turn 
 it up towards the ilium, removing a small quantity 
 of cellular substance, which connects the posterior 
 surface of this vein to the fascia lata. You per- 
 ceive that the vein sinks down through this fascia, 
 in order to enter into the pubic side of the femoral 
 vein, which lies under it. Where the saphena 
 vein is passing through the fascia lata, the latter 
 presents a well defined semilunar edge, the con- 
 cavity of which looks to Pouparts ligament. You 
 
FEMORAL HERNIA. 
 
 67 
 
 will often find a lymphatic gland at this spot, so Extraowtt- 
 situated, that one part of it lies below, while the ^ r n y fa a " 
 other lies above the surface of this fascia. At lymphatic 
 this point, (where the saphena dips deep, to gain g,and ' 
 the femoral vein) we observe, that the fascia lata, Fascia lata 
 which in all the lower part of the limb, had form- ^Vnto 
 ed one general covering or sheath for the muscles two parts. 
 of the thigh, divides into two parts. One of these 
 closely invests the muscles which arise from the 
 pubis, while the other covers those which lie on 
 the iliac or outer side of the limb. The former 
 we shall call the pubic or pectineal portion; the 
 latter, the outer or iliac portion of the fascia lata. 
 
 The pubic portion is closely attached to the Position of 
 
 its Dubic 
 
 muscles which it covers, and as these incline deeper portion. 
 and deeper in a line from the pubis to the femoral 
 vessels, so likewise does this portion of the fascia; 
 until it escapes from our view, by passing in be- 
 hind these vessels. The outer part of the fascia 
 lata covering the muscles on the external or iliac portion. 1M 
 side of the limb, lies above the plane of the pubic 
 portion, especially in the vicinity of the femoral 
 vessels; for here, the iliac portion will be found to 
 pass before, while the pubic portion passes behind 
 them; so that from Pouparts ligament down to the 
 place where the saphena vein enters, the femoral 
 vessels are interposed between these two portions 
 of the fascia lata. In the remainder of their course 
 down the limb, the undivided fascia lata gives one 
 general uniform covering to these vessels, together 
 with the muscles. 
 
 Of the pubic portion, we shall merely say, that Desmpti- 
 it is much more thin than the external part, that °^ the 
 It is attached superiorly to the anterior edge of the portion. 
 pubis, above the origin of the pectineus muscle; 
 that it gives a close covering to the muscles which 
 arise from the pubis, and that inferiorly, at the join- 
 ing of the saphena with the femoral vein, it is united 
 to the external portion of the fascia lata, so as to 
 
68 
 
 ANATOMY OF 
 
 constitute that aponeurotic expansion, which under 
 the name of fascia lata, is wrapped round the 
 muscles of the thigh. 
 
 The external portion demands more of our at- 
 tention; for it will be found so intimately connected 
 How the with crural hernia, as to have a material influence 
 u disponed on tne symptoms and treatment of the disease. 
 of between Let us now examine how that portion of the fascia 
 ligament l ata is diposed of, which lies between Pouparts 
 and the ligament, and the junction of the saphena with the 
 ve?n. ena femoral vein. The upper edge of this portion of 
 its connex- the fascia lata, is attached to Pouparts ligament, 
 
 ion with ,, .. n \ •£•*.! 
 
 Pouparts nearly along its entire extent, from the spine 01 the 
 ligament, iliuoi to the spine of the pubis. The connection 
 thus established, is such, that when the former is 
 stretched by the limb being extended or rolled out- 
 wards, the latter is made to describe a line convex 
 towards the thigh; and on the contrary, when the 
 limb is flexed or rolled inwards, the crural arch is 
 Passes made flaccid. It has already been stated, that the 
 before iliac portion of the fascia lata, passes before the 
 vessels, femoral vessels. We observe in this part of its 
 course, that it loses somewhat of its strength and 
 changes firmness of texture; however, in general, it retains 
 ' a good deal of its ligamentous nature, even when 
 it has reached the pubic side of these vessels; ex- 
 cept in the immediate neighbourhood of the vena 
 saphena, where it differs but little from the cellular 
 Attaches substance. Having passed before the femoral ves- 
 pectineai sels, we find it now to descend on their pubic side; 
 or pubic and here we see it attach itself very intimately to 
 Direction tne P ectn3ea l fascia. This attachment is made in 
 in which a straight line along the pubic side of the vein, from 
 menuakes tne P^ ace °f tne insertion of the saphena, to within 
 place. a quarter of an inch of Pouparts ligament. At 
 this place we observe, that the line of attachment 
 is curved ; and having here formed a sweep towards 
 the pubis, that the attachment now takes place in 
 a line across the top of the thigh. 
 
FEMORAL HERNIA. 
 
 69 
 
 The peculiar manner of this connection deserves Peculiarity 
 particular attention, and will be found to take place ejection 
 as follows: — _ _ ofPoulSts 
 
 That part of the iliac portion of the fascia lata, u ga ™en t r . 9 
 which runs between the femoral vein and sym- 
 physis of the pubis, has its upper edge blended 
 with Pouparts ligament, from which, as it descends 
 to the pubic fascia, it is seen to turn upwards under 
 Pouparts ligament, so as to touch the fascia, at a 
 point nearer to the crest of the pubis, than the line 
 of Pouparts ligament. The iliac and pubic fascia 
 united, then continue their course upwards, until 
 they insert themselves into the crest of the pubis. 
 Observe, the place where the iliac connects itself 
 to the pubic portion of the fascia, is distant from p]ace 
 the crest of the pubis, about two-eighths of an this con- 
 inch in the vicinity of the femoral vein, and three- nexion - 
 eighths in the vicinity of the symphysis pubis. A 
 correct knowledge of the extent and attachment of 
 the iliac portion of the fascia lata, is of such im- 
 portance to the surgeon, in operating for crural 
 hernia, that I was unwilling to run the risk of 
 having the description obscure, or imperfectly un- 
 derstood; and have, therefore, caused two engra- 
 vings to be made, which exhibit the parts, as viewed 
 both on the outer and inner side. From reflecting 
 on the effects which this structure must have on study of 
 crural hernia, I am led to propose a new mode of Jo'VTew 
 performing the operation, by which I am inclined mode ° f 
 to think, its object will be more easily obtained, and fwcturS 
 much of the danger attending it will be avoided. heinia - 
 This 1 shall mention after I shall have finished the 
 description of the structure. 
 
 In that portion of fascia which descends on the 
 pubic side of the vein you may observe three or 
 four small trunks of lymphatics with distinct masses 
 of soft fat. Draw out these with the forceps, and 
 cutting off* each of them close to the sheath, you 
 will perceive that each had come out through a 
 
70 ANATOMY OP 
 
 hole in the fascia. These openings are of such 
 'dimensions as scarcely to admit the blunt end of 
 a probe; they are not arranged in a regular line, 
 some being situated more superficially, or nearer 
 to the front of the thigh, whilst others are seen 
 deep-seated, close to the surface of the pubic fascia; 
 and in some subjects these holes are so numerous 
 as to give a cribriform appearance to this portion 
 of the fascia. 
 Wrai Should the account which I have ventured to 
 hemiais give of the fascia lata prove correct, it will then be 
 stanced. ^ oun ^ that crural hernia is thus circumstanced. 
 Having descended into the femoral sheath, it 
 escapes through one of those apertures in it, for 
 transmitting the lymphatic vessels, and also passes 
 through a corresponding opening in the iliac por- 
 tion of the fascia lata. As it passes through a 
 small aperture in each of these parts, at nearly the 
 same spot, it must there be liable to great constric- 
 tion; for these two layers of fascia will be corn- 
 Most fre- P resse d together, and thus their strength and resist- 
 quent seat ance be considerably augmented. Hence we should 
 Jj re stric " find the seat of stricture in strangulated femoral 
 hernia, frequently to be at some distance below, 
 and on the pubic side of the crural ring. The re- 
 sult of my comparatively limited opportunities 
 tends to strengthen this inference. For I have 
 not yet seen any instance of strangulated femoral 
 hernia, which was not liberated by a very slight 
 division of the most superficial of those parts 
 through which it had escaped. Now, were so 
 much of the fascia lata wanting, as is supposed, 
 by those who describe it to end in a falciform edge, 
 we could not so frequently find this to be the seat 
 of stricture. I think, that the neck or constricted 
 jpart of crural hernia, does not always appear at the 
 same depth from the surface; this may be readily 
 explained, by the description 1 have given of the 
 
FEMORAL HERNIA. 
 
 71 
 
 Dissection 
 
 fascia lata, and is not easily reconcilable with the 
 structure of a falciform edge. 
 
 Having carefully studied the structure of these 
 parts, as viewed externally, let us next examine 
 them as viewed internally. For this purpose, make £" obtain* 
 an incision through the fascia lata, in the line of * n e £ ternal 
 the femoral artery, commencing about two inches 
 below Pouparts ligament, and continuing it up- 
 wards until it divide this ligament, and the lower 
 portion of the tendon of the external oblique. 
 Divide this tendon by another incision, carried on 
 to the external abdominal ring Carefully raise 
 the fascia lata, and Pouparts ligament, from the 
 subjacent aponeurotic funnel, until you come to 
 the pubic side of the femoral vein, and lay this 
 raised portion of the fascia lata, and of Pouparts 
 ligament down on the adductor muscles of the thigh. 
 A quantity of loose cellular substance, which is 
 interposed between this fascia and the sheath, 
 will facilitate this piece of dissection. Next, pass 
 a pin perpendicularly through the sheath of the 
 femoral vessels, on the inner edge of the femoral 
 ring, and fix it into the bone of the pubis. This ( 
 dissection, carefully made, will exhibit to your importance 
 view, some of the most important points in the ° f this . 
 
 i x # dissection* 
 
 anatomy of crural hernia; and will serve to explain 
 some varieties occasionally met with in this disease. 
 
 In the first place, this view will convince you, Extent 
 that the iliac portion of the fascia lata, is con- ^n?"!?" 
 tinued across the front of the femoral vein, and is outer P or- 
 attached to the pubic portion of the same fascia, fa° s ' cia f ata 
 on the internal side of this vessel. You can see shown. 
 that in it are to be found, those openings which 
 were described as serving to transmit the superfi- 
 cial lymphatics of the thigh into the abdomen. 
 The curved line of its attachment to the pectineal 
 fascia, is seen as represented in fig. 2. 
 
 This dissection will, i trust, justify our dissent 
 
72 
 
 ANATOMY OF 
 
 from the descriptions given of the semilimated edge 
 of the fascia lata, by many modern anatomists. 
 Whence The following, I conceive, to be the circum- 
 scription stances which have led to the adoption of the re- 
 of semiiu- ceived opinion: — 
 
 of fascia ge ' n the ^ rst place, the fascia looses a good deal 
 lata. of its ligamentous texture, as it crosses the crural 
 Reduced vessels, except in the immediate vicinity of Pou- 
 tSfScia f P ar . ts l^ament. It is, therefore, liable to be destroy- 
 ed in dissecting away the lymphatic glands. Next 
 Crescentic we find, that the pipe of the ligamentous funnel, 
 sheath°of which constitutes the sheath of the femoral vessels, 
 femoral has this cressentic form on its pubic side. When 
 the limb is extended, this sheath is put on the 
 stretch, and not only exhibits this edge more plainly, 
 but imparts this appearance to the superincumbent 
 fascia lata; particularly as the firmness of its tex- 
 Dissection ture is here reduced: besides, it is probable, that 
 while limb ^ ie accounts which we have of the falciform edge 
 was ex- of the fascia lata, were drawn from the dissections 
 tended. ma( ] e w hile the limb was in a stretched state, as 
 we know that membranous parts are more easily 
 dissected, while kept tense. 
 Third fy this dissection, you also ascertain positively, 
 
 insertion how small a share the third insertion of the external 
 oblique™ oblique muscle can have in producing the stran- 
 does not gulation. You see that i^s attachment to the crest 
 thTcrurai 0I * the pubis, does not even extend half way be- 
 rin s- tween the spine of the pubis,' and the inner edge of 
 the crural ring. You observe, that it does not 
 expand so much at its insertion into the crest of the 
 pubis, as to reach over to the edge of the crural 
 ring, much less does it constitute this edge itself, 
 as a late writer describes, and delineates it. To 
 crurai refute this error, you have only now to examine the 
 feet 'even crural ring, from within the abdomen; and you 
 whenthird w ju fi n( } it still perfect in appearance, although 
 removed. Fouparts ligament, and the third insertion be both 
 thrown back upon the thigh. Nay, by passing 
 
FEMORAL HERNIA. 
 
 7» 
 
 your finger into this aperture, you will find its pubic 
 edge as sharp, firm, and unyielding, as it had been 
 before any of the parts were disturbed. Hence 
 it toll >ws, that the third insertion of the external 
 oblique muscle, has no share in forming the pubic 
 edge of the crural ring: that Pouparts ligament is 
 only stretched across the forepart of this ring, and 
 that its pubic edge is formed entirely by the liga- 
 mentous sheath of the femoral vessels, strengthened 
 on its outside, by the inverted portion of the fascia How its 
 lata. The pubic edge of the crural ring is ren- pubic edge 
 dered tense, by the close adhesion of the sheath of 1^, er 
 the vessels to the ligamentous covering of the 
 crest of the pubis, and by its connexion with the 
 conjoined tendon of the internal oblique and trans- 
 versalis muscles. , 
 
 Before we proceed to a practical application of 
 the results of this dissection, it may not be unsatis- 
 factory to turn our attention to the white line which white line 
 is described in page 61, as passing from the vici- ^^JJj 
 nitv of the spine of the ilium to that of the pubis, posterior 
 This white line has been considered as the internal ed s e of 
 
 , crural 
 
 or posterior edge of Pouparts ligament. To ob- arch. 
 tain a distinct view of its structure on the iliac side 
 of the femoral vessels, it only requires us to cut 
 through the fascia lata and Pouparts ligament, on 
 the outer side of the femoral artery, and then to its outer 
 Inok on this cut edge; you will see that Pouparts 2jftJjJ 
 ligament is intimately blended with the fascia lata, ed. 
 and that these two parts conjoined, or else the 
 fascia lata singly passes upwards for nearly an inch its depth. 
 from the line of Pouparts ligament, until it arrives 
 at the outer surface of the fascia iliaca, to which 
 it attaches itself. By the attachment of this pro- 
 duction to the fascia iliaca, is the white line, (alluded 
 to) formed; and in the angle of their junction the 
 arteria circumflexa ilii runs. 
 
 The distance between Pouparts ligament, as 
 viewed externally, and this portion of the white 
 
 K 
 
74 ANATOMY OP 
 
 line, as seen from the inner side of the abdomen, is 
 
 much greater here than where they pass across 
 
 its struc- tfj e f em oral vessels. In the latter place we shall 
 
 ture where ~ , , it i 1 v 
 
 it passes inid that the distance between these two lines is 
 femora? 16 vei 7 inconsiderable, the internal line being formed 
 vessels, at this part by the junction of Pouparts ligament 
 its struc- and the fascia transversalis. On the pubic side of 
 *T- 0D -? e the femoral vessels at the inner edge of the crural 
 e ' ring, this white line is caused by the fold or angle, 
 which the fascia transversalis makes, as it is about 
 to pass down on the thigh, to form the sheath of 
 these vessels, and by the attachment of this fold 
 to the ligamentous substance which covers the 
 crest of the pubis. We shall see this portion of 
 the white line very visibly, even after the fascia 
 lata and Pouparts ligament have been laid down, 
 as directed in the preceding dissection. 
 Diagnosis This species of hernia is liable to strangulation, 
 cannot be even before it can be felt externally. Hence it is 
 examinati" obvious, that we must establish our diagnosis prin- 
 on of the cipally on the preceding and concomitant symp- 
 toms of the case. Some fatal effects have resulted 
 from mistaking strangulated crural hernia, for in- 
 Crurai flammation of some of those lymphatic glands, 
 hernia which lie in the vicinity of the crural rinsr. The 
 
 mistaken . . _ J . , ". 
 
 for inflam- deep situation ol the hernia, together with its very 
 
 phatfc" 1 " sma ^ s i ze ? have contributed to render the mistake 
 
 gland. more frequent. In some instances the difficulty of 
 
 discriminating is considerably increased, uy an 
 
 enlarged lymphatic gland lying anterior to a very 
 
 small hernia. 
 
 _ , I have known psoas abscess, mistaken for crural 
 
 Psoas ab- . r < - , • * 
 
 scess.how hernia; but, in my opinion, these diseases may be 
 finished reatu ty distinguished from each other. The abscess 
 from crural is, in almost every instance, preceded by pain of 
 berma, ^ e loins; the tumour cannot be entirely returned 
 into the abdomen, by any degree of pressure, ap- 
 plied even when the patient is in the recumbent 
 posture. A fluctuation too, is often to be felt. But 
 
FEMORAL HERNIA. W» 
 
 there is one circumstance, which will, in every in- 
 stance, distinguish psoas abscess from crural her- 
 nia. In the former, a fulness, and sometimes a 
 fluctuation is to be felt above Pouparts ligament, 
 within the abdomen, stretching towards the spine 
 of the ilium, and obviously communicating with 
 the tumour on the thigh. Whereas, in crural her- 
 nia, no swelling or fulness is perceptible within 
 the abdomen. Even in those cases where the 
 hernia rises over Pouparts ligament, the tumor is 
 not only easily ascertained to be merely superficial, 
 but can actually be drawn down below this liga- 
 ment, upon the forepart of the thigh. To which 
 we may add, that when psoas abscess passes down 
 upon th? forepart of the thigh, the tumor is, even 
 on its first appearance, of a larger size, than what 
 the crural hernia ordinarily arrives at. 
 
 A varicose state of the crural vein, possibly of How to be 
 the saphena, at its insertion into the femoral vein, gU ished 
 might be mistaken for crural hernia. The distin- from *■*' 
 guishing characters are, a varicose state of the veins f femoral 
 of the lower extremity, and the re-production of vein - 
 the tumor when we press on the vein above the 
 crural arch, even though the patient be placed in 
 a recumbent posture. 
 
 Fatty tumors are not unfrequently found, on Fatty tu* 
 dissection, occupying the exact situation of crural mor * occu ; 
 
 i • t i i i . o • py <he seat 
 
 hernia. 1 have not had an opportunity or seeing of crural 
 any case of this kind in the living body; but have hcrnia - 
 had occasion to remark at least, five or six instances 
 of it every season, in the dissecting room; from 
 which, I presume, that such tumors are more com- 
 mon than is generally suspected. In all those in- 
 stances, the fatty tumor was connected with, or 
 rather seemed to grow from the outer surface of 
 the peritoneum lining the crural ring; and the inner 
 surface of this membrane, when viewed from the 
 abdomen, had a contracted, wrinkled, and thick- 
 ened appearance, resembling very closely the ap- 
 
'» ANATOMY OF 
 
 pearance of a reduced hernial sac. Whether the 
 
 peritoneum had been protruded in these instances, 
 
 I cannot pretend to say; nor can f venture to lay 
 
 down the symptoms which should guide us in our 
 
 diagnosis in the living body. This much at least 
 
 is obvious; that these stealomatous tumors will not 
 
 be accompanied by symptoms of strangulation. 
 
 Crural mis- ' nave known surgeons much divided in opinion 
 
 take., for whether a hernia was of the inguinal or crural 
 
 hernia!* species. However, I fancy, that this point can in 
 
 general be settled by the two following marks. 
 
 First, the neck of the inguinal hernia, is situated 
 
 above the tuberosity of the pubis, while the neck 
 
 of the crural hernia is situated below it, and lies 
 
 to its outer side. Secondly, if the tumor be drawn 
 
 down upon the thigh in crural hernia, Pouparts 
 
 ligament can be traced lying above its neck. 
 
 An intimate knowledge of the anatomy of the 
 parts concerned, is more necessary to guide our 
 practice in crural hernia, than in any other form 
 of the disease. The narrow opening at which the 
 bowels ultimately protrude; the firm and sharp 
 edge of this aperture; the great depth from the sur- 
 face at which the crural ring is placed; the super- 
 ficial situation to which the fundus of the tumor 
 often rises, must all conspire to render the prac- 
 tice difficult in the hands of the best informed ana- 
 tomists, and most dexterous surgeons; and must 
 considerably add to the dangers arising from the 
 errors of the ignorant, and the attempts of the 
 awkward. When we proceed to the taxis, the pa- 
 Katient ** ent snou 'd De placed in the same position, as was 
 directed for this operation in inguinal hernia. Par- 
 ticular attention should be paid to keep the knee 
 of the affected side turned inwards, in order that 
 the fasciae may all be completely relaxed, espe- 
 cially that part of the transversalis fasciae, consti- 
 tuting the pubic edge of the crural ring, i The 
 
FEMORAL HERNIA. Ti 
 
 surgeon should now endeavour to bring the entire how the 
 tumor (whether its fundus be lying upon the ab-JJ^J^J 
 domen, or across the top of the thigh) into the 
 hollow, or groove, on the forepart of the limb. He 
 should recollect, that the edge of os pubis consti- 
 tutes one-third of the circumference of the crural 
 ring. He should now, therefore, press the tumor 
 backwards, as if to sink it into the thigh. When 
 he thinks that the tumor is pressed so far back, as 
 to lie on a line with this opening, he should then 
 attempt to push it up into the cavity of the abdo- 
 men, having previously endeavoured to compress 
 the neck of the hernia into as small a compass as 
 possible. The intestine should not be pushed di-yvhy the' 
 rectly upwards towards the abdomen, because in this JJSbe 
 direction, it might encounter the pubic edge of the P usbed 
 crural ring, which is very tense and unyielding, and oat- 
 By directing the pressure on the intestine up- wards - 
 wards, and slightly out towards the spine of the 
 ilium, we shall avoid the resistance, which this 
 pubic edge of the ring might offer to the return of 
 the intestine. <» ^ 
 
 But the best directed eiforts to effect the taxis, 
 too frequently fail of success, and the operation by 
 the knife then becomes indispensably necessary. 
 
 The stricture in crural hernia, will be found in Three 
 one of the three following situations: — Surf 
 
 First, in the opening by which it passes through 
 the crural sheath, and that portion of the fascia 
 lata, which covers its pubic side. 
 
 Secondly, (as is said) in the posterior edge of the 
 crural arch. 
 
 Thirdly, in the mouth of the hernial sac. 
 
 As the operator cannot previously discover, in 
 which of these parts the stricture is formed, it must 
 obviously be of great importance, to adopt that 
 line of proceeding which shall enable him to di- 
 vide each and all of them, with the least possible 
 
7'8 ANATOMY Of 
 
 risk to those important parts, which lie in the 
 vicinity of the deepest stricture. 
 Operation ]\f r# Cooper recommends, that in performing 
 cooper', this operation " The incision should be begun an 
 External inch and a half above the crural arch, in a line 
 wcision. w j t jj t [j e middle f me tumor, and extended down- 
 wards to the centre of the tumor, below the arch. 
 A second incision, nearly at right angles with the 
 first, is next made; so that the two incisions will 
 represent the letter T, reversed. He has seen 
 great difficulties occur, where only a longitudinal 
 incision of the superincumbent parts was made; 
 the surgeon not enjoying a view of the parts, in 
 the progress of his operation. The superficial fas- 
 cia, if it had not been previously divided by the in- 
 cision through the integuments, is now to be di- 
 Fascia vided. A second fascia, the fascia propria, is 
 sometimes sometimes found interposed between the superfi- 
 met with c i a i fascia and hernial sac, and must be also divid- 
 ed. The hernial sac is to be opened in the same 
 cautious manner, as recommended in the opera- 
 tion for inguinal hernia. The stricture is now to 
 be divided by passing the finger into the sac, keep- 
 ing it close against it on its anterior part. On the 
 Division finger a probe-pointed bistoury is to be introduced, 
 stricture, and the sheath to be divided as high up as the an- 
 terior edge of Pouparts ligament. This division 
 if seconded by a favourable position of the limb, is 
 very frequently sufficient for the reduction of the 
 hernia. 
 
 " If, however, the intestine when slightly com- 
 pressed, cannot be easily returned, the finger must 
 be passed at least half an inch higher; and then 
 stricture * ne posterior edge of the crural arch, and the fas- 
 formed by cia that covers it, will be felt forming a sharp edge, 
 edge 6 "? strongly compressing the mouth of the hernial sac. 
 crurai arch To divide this edge, the knife must be carried 
 How to be within the stricture, and being inclined obliquely 
 divided. i nW ard and upwards, at right angles with the 
 
FEMORAL HERNIA. 
 
 79 
 
 crural arch, a cut may be very safely made in that 
 direction, sufficient for the purpose of liberating 
 the intestine from pressure. By the same incision, 
 any stricture arising from the contraction of the ^ n t ^ e ur s e ac 
 sac itself, will be removed." divided. 
 
 Having thus, described the most approved mode New mo d e 
 of practice, I shall now venture to propose a me- ?* °p^»*- 
 thod of performing the operation for strangulated JH. 
 crural hernia, different from any hitherto describ- 
 ed I must, however, premise that it is founded 
 solely on the anatomy of the parts concerned. ^T^f 
 For, since I first conceived the idea of this mode the anato- 
 of operating, I have not had an opportunity of put- jjjyjj the 
 ting it into practice on the living body. 
 
 Let the patient be placed on a table, with his Posture of 
 legs hanging over its edge, his body lying horizon- P atient - 
 tally, and his shoulders a little raised. 
 
 Divide the integuments by an incision on the External 
 pubic side of the femoral vein, parallel and close incisions. 
 to it; let this incision extend from an inch and a 
 half above Pouparts ligament, to an inch and a 
 half below it. Parallel to pouparts ligament, but 
 about half an inch below it, make a transverse 
 division of the integuments, extending from the 
 first incision to the spine of the pubis. Separate 
 the upper flap, and turn it up on the abdomen. 
 Next divide the fascia superficialis by similar in- 
 cisions. Thus you will gain a clear view of the Advantagt 
 hernial sac, of the place at which it protrudes ^eS 
 through the sheath of the femoral vessels, and cor- incisions 
 responding part of the fascia lata; and also of Pou- 
 parts ligament, and of the line along which the 
 adhesion between the pectineal and iliac portion 
 of this fascia takes place. Having opened the 
 hernial sac, in that cautious manner, recommend- 
 ed by Mr. Cooper; now proceed to divide the stric- 
 ture. To effect this, introduce a director into the H ow to 
 opening which you have made in the sac, and on jj ivide *«. 
 it pass a probe-pointed bistoury, and then divide stricture. " 
 
80 
 
 ANATOMY OP 
 
 this, the most superficial seat of the stricture, as 
 high up as Pouparts ligament, but in a direction 
 towards the spine of the pubis. 
 £ra the * n tms f° rm °f hernia, it is particularly neces- 
 imestine sary that you draw down the intestine, for the 
 mum T P ur P ose °f examining the strictured part; as it is 
 so very liable to be injured by the close constric- 
 tion which it has suffered. When the bowels are 
 in a proper state, proceed to return them, in the 
 same direction as recommended for the reduction 
 by the taxis. 
 
 If, after the division of the first aperture, you 
 find the strangulation still to exist, you must pro- 
 ceed to relax the tension of Pouparts ligament. 
 This you may effectually accomplish; and yet, not 
 allow your instruments to enter into the cavity of 
 the abdomen. Recollect, that the portion of fas- 
 cia, called fascia transversalis, lines this cavity 
 within Pouparts ligament; and that this fascia is 
 attached to the crest of the pubis; recollect also, 
 that the inflected part of the iliac portion of the 
 fascia lata, is connected to the pectineal portion, 
 at the distance of two-eighths, and even of three- 
 eighths of an inch below this ridge of the bone. 
 Hence you see the practicability of dividing the 
 How to latter, and yet leaving the former attachment un- 
 
 remove the , . rn ,- i i • i ■ i v 
 
 tension of hurt. 1 o accomplish this, introduce the director 
 KgaE without the sac on its pubic side. Pass the knife 
 without on this, with its edge towards the pubis, until its 
 thfcafity P oint nas entered about one-eighth of an inch with- 
 of abdo- in this attachment. Then keeping the flat side of 
 the knife, as close as possible to the surface of the 
 muscles, and carrying it on towards the pubis; di- 
 vide this attachment to whatever extent you may 
 Even judge necessary. This incision, even though it 
 though should not have been carried on so far towards 
 sertion ln f the spine of the pubis, as to reach to the third in- 
 external sertion, will vet serve most materially to relax 
 
 oblique be, n ' ,. J ._, . J . . 
 
 not divided Pouparts ligament For the connection between 
 
FEMORAL HERNIA. "* 
 
 this ligament and the fascia lata is such, that a 
 division of the one will render the other flaccid, as 
 may be understood, from what we have mentioned 
 already. But should the stricture be such, as to 
 require the most complete relaxation of Pouparts How fa 
 ligament — this can be obtained with the greatest cut the 3d, 
 facility. For you have only to carry on the knife inertion - 
 still nearer to the spine of the pubis, than midway 
 between it and the femoral vein. In this step of 
 the operation, in dividing the parts from the pubic 
 side of the hernia, towards the spine of the pubis, 
 you do not run the risk of wounding any import- 
 ant part unnecessarily; provided only that you be caution to 
 cautious, not to introduce your knife deeper than J* observ- 
 one-eighth of an inch within the external surface 
 of this attachment. This can with tolerable cer- 
 tainty be avoided, because you have this surface 
 fuliy exposed to your view, by the previous steps 
 of the operation. If you should not be able to re- 
 turn the bowels after the division of these parts, stricture 
 you must infer, that the stricture is seated in the f the sac. 
 neck of the hernial sac. You must therefore, now 
 introduce a director into the sac, and pass it up *j?T ! ° be 
 within its neck. On this, you introduce a probe- 
 pointed bistoury, taking care not to pass it unne- 
 cessarily deep, lest you should injure any of the 
 viscera in the abdomen. As the knife enters with- 
 in the neck of the sac, you are sensible of a cer- 
 tain resistance being surmounted; and this resist- 
 ance is occasioned by the constricted neck of the 
 sac. With the edge of the knife directed towards 
 the pubis, you now make the slightest division of 
 the stricture. The extent to which this incision 
 is required to reach, is so very trifling, as not at 
 all to endanger the obturator artery, even when, 
 in consequence of its unusual origin, it chances to 
 pass close to the crural ring. 
 
 It has been urged against the plan of dividing 
 the parts towards the symphysis pubis; that in or- 
 
 L 
 
ANATOMY OF 
 
 der to obtain a view of the seat of stricture, the 
 intestine (which in crural hernia descends in- 
 wards) must be drawn considerably to the outer 
 side, and that thus it is stretched at the strictured 
 part, and readily tears through. To this it may 
 be replied, That when a considerable quautity of 
 intestine is down, this suddenly expands as soon 
 as the hernial sac is opened, and conceals the first 
 seat of stricture from our view. For this reason, 
 the intestines require to be gently compressed, or 
 drawn aside, before we can pass a director or knife, 
 with safety into the sac. I have never observed, 
 that the intestine lay particularly over the internal 
 or pubic side of the stricture; and therefore, I con- 
 ceive, that the director or knife, can be introduced 
 within the seat of the stricture, as readily towards 
 the pubic side, as in any other direction. My ob- 
 servations would justify me in asserting, that in 
 those cases, where the volume of intestines sud^ 
 denly expands on opening the sac, they mount up 
 on the abdomen, and therefore tend to increase 
 the difficulty of introducing an instrument, rather 
 on the anterior, than on the inner side of the stric- 
 ture. — Another objection which has been urged, 
 is, that the difficulty of the operation is much in- 
 creased: for when the incision is to be made in- 
 wards, the knife must be buried so deep, as to be 
 entirely concealed by the surrounding parts. To 
 this I answer, that by making the division of the 
 integuments, and superficial fascia, and raising the 
 upper flap in the manner I have ventured to re- 
 commend, you will be enabled to obtain a clear 
 and satisfactory view of the opening in the fascia 
 lata, through which the hernia escapes to the sur- 
 face, viz. of the most superficial seat of the stric- 
 ture. You will have a distinct view of the fascia 
 lata, which descends from Pouparts ligament to 
 the pectineal fascia. This is next to be divided, 
 whenever you find that a division of the first seat 
 
FEMORAL HERNIA. 
 
 83 
 
 of the stricture, has not liberated the intestine. I 
 conceive that the opportunity afforded, of having 
 in your view, the parts which are to be divided, 
 constitutes one very material advantage in this 
 mode of performing the operation. A third ob- 
 jection made to the incision inwards, directed by 
 Gimbernat, does not apply to the method recom- 
 mended above. The objection is, that the intes- 
 tine is liable to be wounded, in passing the knife 
 into the mouth of the sac, or still higher into the 
 abdomen. This objection lies against every mode 
 of operating, in which it is required to pass the 
 knife deeply into the sac, before the more su- 
 perficial seats of the constriction have been set 
 free. The proposed operation seems calculated to 
 guard effectually against such an accident, be- 
 cause the division of the parts is made successive- 
 ly from without inwards. 
 
 Fourthly, It is objected to the division inwards, 
 that where the hernia is large, sufficient room 
 cannot be gained for the return of the protruded 
 bowels. 
 
 This objection, as far as my information goes, 
 has not been supported by a single fact. For I 
 have never seen or heard of any instance where 
 the operator was obliged, after the division of the 
 parts inwards, to have recourse to the division of 
 the parts behind the crural arch. The anatomy 
 of the parts, and the result of the operations on 
 the dead body, would lead me to expect, that even 
 in the largest crural hernia, very sufficient room 
 may be gained for the return of the bowels by the 
 proposed method of operating. 
 
 It is scarcely necessary to add, that this pro- Tbis dif . 
 posal differs very essentially from the operation c ™ s from 
 advised by Gimbernat. For, according to his di-nat'sope- 
 rections, the deeper seated and superficial parts ralion - 
 are all to be divided by one and the same motion 
 ef the knife. Besides, it is proposed by him, to 
 
84 ANATOMY OF FEMORAL HERNIA. 
 
 introduce the knife into the cavity of the abdomen; 
 by which the intestines are very liable to be wound- 
 ed, and the obturator artery, when it runs on the 
 pubic side of the crural ring, must inevitably be 
 divided. 
 
85 
 ANATOMY OF UMBILICAL HERNIA. 
 
 It is only by examining the umbilicus of the Examina . 
 foetus, that we can obtain a clear idea of its ana- tion of 
 tomical structure in the adult. In the fbimer, the , u n m ^ u> 
 vessels which pass through this opening are large r «tus 
 and pervious; in the latter, they become impervi- 
 ous, and shrink into thin chords. In the foetus 
 too, the skin is prolonged upon the chord, beyond 
 the surface of the abdomen, while in the adult it 
 is inverted, and so closely connected to the remains 
 of the vessels, as to render the examination diffi- 
 cult and unsatisfactory. For this reason, we shall 
 proceed to examine the structure of the umbilicus 
 in the foetal state. 
 
 The skin of the abdomen is continued along the ^ f na t j°™ y 
 chord, and terminates by an irregularly indented umbilicus 
 edge; its length in different points of the circum- J.^ e 
 ference of the chord, varies from half an inch to 
 nearly an inch. 
 
 The dense white membrane which envelops the 
 chord beyond this edge, appears to be continuous 
 with the cuticle of the integuments. The integu- 
 ments can easily be separated from the vessels, 
 being connected to them only by a loose cellular 
 substance. On cutting through the abdominal 
 muscles near the ribs, laying them down on the 
 pubis, and detaching the peritoneum, the umbilical 
 vein is seen of such a size, that it alone occupies 
 as much of the aperture of the umbilicus, as the 
 two umbilical arteries and urachus conjointly. A 
 slight membranous septum separating the vein 
 from the other vessels, seems to divide the opening 
 into two. The edges of this opening are distinctly 
 tendinous, not sharp. With this edge the arteries 
 and urachus appear to have more connexion than 
 
86 
 
 ANATOMY OF 
 
 the vein has. By drawing the umbilical vein up- 
 wards, or the arteries downwards, the integuments 
 of the foetus present an appearance exactly similar 
 How the to tnat °f tne adult navel. And thus it appears, 
 retraction that the shrinking of the vessels, as soon as they 
 naveMa cease to transmit blood, will cause the retraction 
 caused. f the skin of the navel. 
 
 All the chord which is anterior to the portion 
 covered by the integuments of the abdomen, will 
 shrink and fall off by mortification, while the skin 
 inverted will adhere to the remaining extremities 
 of the vessels, provided the ligature be not applied 
 on the portion of the chord covered by the skin. 
 Is it then a matter of such consequence, as ac- 
 coucheurs suppose, to fix the precise point at 
 which the umbilical chord of the foetus should be 
 tied? 
 in what From the preceding description, it is obvious, 
 differs** 1 * na * * ne opening in the linea alba, which is term- 
 frooi ed umbilicus, differs from those openings termed 
 r?ng. i0aI tne inguinal rings, particularly in this circum- 
 stance; that here the different layers of the abdo- 
 minal muscles being consolidated into one, the 
 aperture is made through all at the same point: 
 therefore this opening is direct, and consequently 
 this is the weakest point of the abdominal walls. 
 Why Protrusions of the bowels, however, do not oc- 
 
 herntae of cur nere so frequently as they do at the groin, pro- 
 nS muve bably because the action of the diaphragm, does 
 frequent. no i afifect this higher part so much as it does the 
 lower part of the abdomen. Hence it is, that the 
 umbilical herniae, are more generally produced by 
 an increased bulk of the contents of this cavity, 
 why the than by violent exertions. The adhesion of the 
 hernia inflected skin, to the remains of the umbilical ves- 
 protrudes se ^ s being very close, will, together with the liga- 
 at the mentous remains of these vessels, give greater 
 
 centre of ^^ ^^ 
 
 umbilicus, strength to the centre of this aperture; while the 
 space intervening between the borders of this open- 
 
UMBILICAL HERNIA. 
 
 87 
 
 ing, and the ends of these vessels, being occupied 
 only by cellular substance, will more readily yield 
 to the distending cause. Hence the mouth of an 
 umbilical hernia, seldom occupies the centre of 
 the umbilicus. As all the umbilical vessels had 
 originally lain between the peritoneum and abdo- Umbilical 
 minal muscles, it is obvious, that there never was must have 
 an aperture in this membrane for transmitting J^| tonMl 
 these vessels; and consequently, that the perito- 
 neum is as perfect at the umbilicus, as at any 
 other point. When hernias then occur at this 
 opening, they must push before them the perito- 
 neum, and must, like all other hernias, be covered 
 by a peritoneal sac. 
 
 This hernia appears in fat persons, as a fiat A PP^. ran " 
 broad swelling, the boundaries of which, cannot umbilical 
 be distinctly ascertained. In those of an opposite herm5E - 
 habit, the tumor assumes a pyriform shape, and 
 is distinctly circumscribed. The contents of this Contents 
 species of hernia, are sometimes omentum only, of umbiii- 
 more frequently omentum and a portion of intes- cal benna ' 
 tine; but there is scarcely any instance in which 
 the omentum does not form a part, 
 
 In attempting the reduction of this hernia, the 
 abdominal muscles should be relaxed, and the tu- Taxis, 
 mor should be pushed backwards, and a little up- 
 wards, as the opening through which the bowels 
 have passed, is generally situated above the centre 
 of the umbilicus. We cannot be surprised that 
 this species of hernia should so frequently be ir- 
 reducible, without strangulation, when we recol-f.eqLnSj 
 lect that a part of its contents so generally consists irreducible 
 of omentum. This, by its adhesion, or by morbid 
 alteration of its texture, becomes incapable of be- 
 ing returned into the abdomen. The seat of con- 
 striction in this species of hernia, when strangu- 
 lated, is in the edges of the umbilicus, or in the 
 neck of the sac, which is occasionally much thick- 
 
88 ANATOMY OP 
 
 Pecuianty ened. There is this peculiarity in umbilical her- 
 
 of umbiii- n j aj that some instances have occurred, in which 
 
 ' the peritoneal sac was wanting, either entirely, or 
 
 in part. Whether this was caused by the rupture, 
 
 or by the absorption of this membrane, I cannot 
 
 sac and pretend to determine. The sac, when present, is 
 
 mS seldom found thickened, except at its neck. The 
 
 generally parts which cover the sac, are also generally thin. 
 
 caution in Hence we see the great caution necessary to be 
 
 making observed, in performing the operation for strangu- 
 
 indsion. lated umbilical hernia, lest the intestine should be 
 
 wounded, even by the first incision. There is not 
 
 D ' v ! s f on any thins: in the anatomy of those parts, to prevent 
 
 oi stricture •' .• *? , t . . . /» i • • 1 
 
 either u P - our making the division or the stricture, either up- 
 wards or warc j s or downwards. We should, however, bear 
 
 downwards . .'--'... n , 5 n • <? 
 
 in mind this important tact, that an adhesion oi 
 ofinSnethe intestine to the peritoneum, within the abdo- 
 to perito- men, often occurs. The intestine is, therefore, in 
 frequent, great danger of being wounded, unless the finger 
 be introduced before the knife, during the division 
 of the stricture. Should the omentum be so alter- 
 omentum ec [ m texture, as to render its reduction inexpe- 
 
 now to be ,...,,, & T 1 i« t 
 
 treated, dient, it should be cut on. 1 have seen tedious and 
 profuse discharges, which even endangered the 
 life of the patient, to follow, in cases where a con- 
 trary practice had been adoptedc ~ 
 
89 
 ANATOMY OF THE ABDOMEN. 
 
 This cavity is bounded superiorly by the dia- Bounda- 
 phragm, inferiorly by the levators ani, anteriorly ™ s . t of tllis 
 by the abdominal muscles, ana posteriorly by the 
 lumbar vertebras, and os sacrum. 
 
 The shape of this cavity varies considerably Shape 
 with the various postures of the body, and is also JJ^J 
 different at different periods of life; circumstances ages and 
 which should be held in recollection, when we^™' 
 examine it externally, to feel whether the contain- 
 ed viscera be in a sound or morbid state. For in- 
 stance, when we stand erect, the lumbar vertebras 
 form a convexity, which projects into this cavity; 
 the lowest region of the abdomen becomes more 
 prominent; the superior aperture of the pelvis is 
 turned forward; the os sacrum is turned upwards 
 and backwards; and the acetabula are drawn 
 downwards. These alterations in the form of its T *»s 
 walls are accompanied by some, though less mark- l^f ° 
 ed alterations, in the position of its different visce- produces 
 ra. The liver and spleen,a re found to descend the^Son 
 somewhat lower, when the body is in an erect, ° f * e ab - 
 than when in a horizontal posture. When we lie vis™, 
 on either side, the lumbar vertebras form an arch, Lumb ar 
 the convexity of which looks downwards, and the vertebra? 
 concavity upwards, so that the false ribs of the fecLdYy 
 lower side, are removed further from the crest of P ostuie - 
 the ilium, while those of the upper side are made 
 to approach it. Hence it follows, that those pa- Practical 
 tients who labour under a lateral curvature of the ]" f cui"a- 
 lumbar vertebras, should be directed to lie on that ta«« of 
 side of the body towards which the hollow of this b '!i vei 
 curve is situated. 
 
 The cavity too of the abdomen, varies much in capacity 
 the different periods of life. In young infants, it cavity at 
 
 M 
 
$/* ANATOMY OF 
 
 d fZT l f * s P ro P ort ionably greater than in adults. The 
 life space between the sternum and the pelvis, is in 
 onab° rti " tne f° rmer about one-third, but in the latter, scarce- 
 larger in ly one-fifth of the length of the body. This excess 
 children. m ^ ca p ac jty of the abdomen of infants, is found 
 The excess principally in the umbilical region, which is not 
 fmbiUca!" only longer but larger in every direction. It is 
 region, deeper from before backwards, because the verte- 
 bral column is, at this age, almost straight; it is 
 wider from side to side, because infants have their 
 ribs turned more outwardly. The pelvis is very 
 small, not being yet developed. The arches form- 
 ed by the alse of the diaphragm, are proportiona- 
 bly less deep, than in adults. We should not, 
 inference, therefore, consider a prominence and fullness of 
 the umbilical region in young children, as a mark 
 of disease. 
 situation The situation of the abdominal viscera, is also 
 oLw ,1 different from what we find in the adults. The 
 
 abaoiEinal . _. 
 
 viscera in stomach, instead of being placed transversely, lies 
 children. a i mos t perpendicularly, descending into the umbi- 
 lical region. The omentum is consequently placed 
 more to the left side of the cavity. The liver lies 
 very much in the middle region of the abdomen, 
 being proportionably much larger than in the adult, 
 and not having the deep concavity in the right ala 
 of the diaphragm, which exists at a more mature 
 age. The spleen too, is to be felt at this early 
 period of life, below the false ribs. The uterine 
 organs in females, and the bladder in both sexes, 
 rise up nearly to the umbilicus. 
 No vacant The parietes of the abdomen possess the power 
 the C abdo- °f accommodating themselves so completely to the 
 men. quantity of their contents, that no space or inter- 
 stice is naturally found between them. However, 
 we observe, that when any large blood vessel is 
 opened by a wound of this cavity, the extravasated 
 How ex- blood lodges between the anterior surface of the 
 
 travasati- r 1 t r> i* .i 
 
 ons of viscera, and the corresponding surface of the pe- 
 
THE ABDOMEN. 91 
 
 ritoneum, which lines the abdominal muscles. It b,ood a ™ 
 
 . * ■, ,./v» I/- ^i confined to 
 
 is not, in general, found to diftuse itsell over the the vicinity 
 entire surface, or fall to the lower part of the ab-^™™*" 
 domen; as might be supposed, if a cavity really ex- 
 isted. On the contrary, we observe, that unless the 
 quantity extravasated, be very considerable indeed, 
 the effusion is confined to the vicinity of the wound- 
 ed vessels. In these cases, we observe a fullness 
 in the seat of the extravasation, but no tension. This Jjj- 
 The circumscribed limits of the effusion, and the attended 
 speedy coagulation of the blood, prevent us from ^ i0) J uctu ' 
 ascertaining the nature of the injury by the test of 
 fluctuation. 
 
 In a state of health, a secretion of a serous fluid 
 takes place, sufficient merely to bedew the internal 
 surface of the abdomen. This fluid is sometimes 
 accumulated in considerable quantities, and then Ascites 
 constitutes the disease of ascites, or dropsy of the 
 abdomen. In this instance, the water is lodged 
 between the peritoneum, which lines the muscles 
 of the abdomen, and that which covers the intes- 
 tines; and, therefore, when we make an opening Tapping 
 through the abdominal parietes to evacuate this a safe 
 fluid, there is no danger of our wounding the in- operat,(Vl 
 testines; for these are removed from the reach of 
 our instrument, by the interposition of the effused 
 fluid. It not unfrequently happens, in the opera- 
 tion of paracentesis abdominis, that the stream 
 
 r n • i i i i n , /■ Stream ot 
 
 of fluid suddenly ceases to now, even before one- fluid SU d- 
 half of the collection shall have been discharged. den, y st0 P s 
 This sudden stoppage is caused by the omentum How 
 entering into the extremity of the canuls, and some- ca 
 times also insinuating itself into tte eyes of the 
 instrument, where these are very Jarge. We are 
 directed in such cases, to push b^ck the omentum, 
 by running a probe through tb^ canula. This ac- 
 cident must cause delay in the operation; and the 
 means generally adopted for remedying it, may in effects 
 subject the patient to peritoneal inflammation, of " 
 
92 ANATOMY OP 
 
 MrDease'sfrom the violence done to the omentum. We are 
 !E!' ed indebted to the late Mr. Dease, for a form of this 
 instrument, which most effectually guards against 
 this accident; and so completely does it answer the 
 purposes for which it was designed, that it seems 
 scarcely possible for human ingenuity to improve 
 it further. 
 
 The abdominal muscles, are in many instances, 
 
 rendered very thin by the distention which they 
 
 have suffered. Yet, in many cases, to plunge the 
 
 trocar through them at once, requires great effort, 
 
 incision and has at least the appearance of much rough- 
 
 jSiTto ness > on tne P art °f tne surgeon. You may avoid 
 use of tro- this, by previously making with a lancet, an inci- 
 sion through the integuments, large enough to ad- 
 mit the trocar. The peculiar cautions necessary 
 to be observed, in tapping ovarian dropsy, shall 
 be reserved, until we come to describe the struc- 
 ture and diseases of the female organs of genera- 
 tion. 
 Conse- It may not be unworthy of remark, that, in pe- 
 
 ^g t c r e a s t . of uetrating wounds of the abdomen, although no 
 wg wound protrusion of the bowels shall have taken place 
 me*n bdo " during the treatment, yet this consequence always 
 follows, when the wound is completely healed, and 
 the patient resumes his ordinary occupation. It is 
 necessary, therefore, to apprize the patient, dur- 
 ing the treatment, of the probability of such an 
 event, and to enjoin the early use of a truss. When 
 the bowels have pushed out through a wound in- 
 flicted in the site of the recti muscles, we should 
 Caution ta ^ e care la re pl a cing them, that we mistake not 
 when re- the sheath of those muscles for the cavity of the 
 Suded e abdomen.— This error is more likely to"occur from 
 intestines, the very loose connection which the posterior sur- 
 face of those muscles has with the corresponding 
 part of its sheath. Considerable danger must arise 
 from this mistake; for even in the very attempt, 
 the bowels will be subjected to such a degree of 
 
THE ABDOMEN. 
 
 i 
 
 violence as must necessarily prove injurious. But 
 should this error pass unnoticed, and the lips of 
 the wound be closed by suture, while the bowels 
 remain in this unnatural and confined situation, 
 the death of the patient must speedily and inevita- 
 bly ensue. I am the more particular in guarding 
 you against this mistake, because I have seen it 
 committed in an instance, where a lacerated wound 
 was so very extensive as to reach nearly the en- 
 tire length of the abdomen. How much more 
 careful then should you be in wounds of less ex- 
 tent, where all the parts are so much less favoura- 
 bly situated for examination? 
 
 Having thus described the external walls of the 
 abdomen let us next turn our attention to the vis- 
 cera which it contains. When we undertake to External 
 ascertain by external examination the state of the t^nte 
 abdominal viscera, we should not only bear in viscera in- 
 mind the variations in the form of its different re- 
 gions induced by the posture of the body, but must By pos . 
 also take care that the state of tension of the ab- »■»- 
 dominal muscles shall not prevent us from making 
 this examination in the most satisfactory manner. 
 We must be cautious that we mistake not thatjj t ** f 
 state of rigid contraction into which the abdominal abdominal 
 muscles are thrown by very slight causes, for indu- muscles - 
 rations of the viscera. It is obvious, then, that 
 these muscles should be relaxed as far as this can 
 be done by the position of the body. The mode 
 of accomplishing this has been already mentioned 
 when speaking of hernia, and therefore it is unne- 
 cessary to recapitulate it here. — You must, how- 
 ever, take care that the patient's head shall be 
 raised forwards, and supported in that position by 
 pillows: for if you allow it to be supported by the 
 action of the sternomastoid muscles, these will Action of 
 draw the recti abdominis into a sympathetic state tri/ren- 8 " 
 of contraction, and thus the anterior surface will ders! j bdo - 
 be made tense, and feel as if subdivided into dis- Sense. 
 
94 
 
 ANATOMY OF 
 
 tinct compartments. This state of the abdominal 
 Senior" P ar * etes nas > ' am persuaded, deceived some prac- 
 induration titioners, and led them to pronouce that the pa- 
 of the liver. t j ent i aDourec [ unc [ er an enlargement and indura- 
 tion of the liver, where no such disease existed. 
 When an adult subject is laid in an horizontal 
 oSh" P osture > tne anterior edge of the liver cannot be 
 in horizon- felt to descend below the edges of the false ribs, 
 tai postmc. until you come within three or four inches of the 
 xiphoid cartilage. In the epigastric region you 
 can feel the left lobe of the liver; along the edge 
 of the left hypocondrium the liver cannot be felt, 
 in the When the subject is placed in an upright pos- 
 erect P os- ture, the liver is found to descend at least two 
 inches lower than while the body remains hori- 
 zontal. 
 
 These remarks on the situation of the liver in 
 the dead subject, will apply, in some degree, to its 
 situation in the living body, and should influence 
 our mode of examining into the state of this viscus 
 Liver said D y the touch. Some authors assert, that the liver 
 to descend descends considerably into the abdomen during in- 
 tionT™" spiratiun; and therefore they advise us to direct 
 our patient to make a full and long continued in- 
 spiration, while we are engaged in our examina- 
 tion. L cannot help thinking that this rule is found- 
 ed on an extravagant idea of the influence which 
 Slbted. me m °ti° n of the diaphragm has on the position 
 of the liver, an influence which I have never been 
 able to observe in practice. The relations of the 
 liver to the neighbouring parts will point out the 
 Different different outlets, by which the matter of an abscess 
 which aL formed in this organ may effect its discharge, 
 scess of u- Should the seat of inflammation and suppuration 
 dScharge. De near to the convex surface of this viscus, an 
 adhesion may take place between the abscess and 
 fnto thorax the diaphragm. The adherent parts, thus conso- 
 lidated, being absorbed, the contents of the abscess 
 will escape into the cavity of the thorax. In such 
 
THE ABDOMEN. 95 
 
 abscesses, however, we often find that while the 
 diaphragm on its lower surface adheres to tne !" to nchi;!u 
 liver; it also adheres on its upper surface to the 
 superincumbent lung, and thus the matter of the 
 abscess may be poured into the bronchise. If this 
 be in large quantity, it may suddenly destroy the 
 patient by obstructing the passage of air through 
 the trachea. When the abscess is seated in the 
 convex surface near to the anterior edge of the 
 liver, it may induce an adhesion with the abdo- 
 minal muscles, and thus point externally in thejj p0 r j^ 
 right hypochondriac or true epigastric region, dmc or 
 Should the abscess be seated in the concave sur- ^f^ 1 " 
 face of the right lobe, adhesion between the seat 
 of the abscess and the colon as it passes under this lnto fte 
 lobe may take place, and by subsequent absorp- co ion. 
 tion of the adhering parts, the matter may be pour- 
 ed into this intestine. 
 
 In this way the matter of an abscess of the liver 
 is discharged by stool. Sometimes the matter of [Jjjjjj^ 
 an abscess of the liver is rejected by vomiting. 
 We must presume that such had been seated near 
 the lower surface of the left lobe, and that the suc- 
 ceeding processes of adhesion and absorption had 
 formed a communication between the cavity of the 
 abscess and the stomach. 
 
 J. L. Petit has written a long essay in the me- 
 moirs of the academy of surgery at Paris, in which Distention 
 he describes the over-distension of the gall bladder bladder 
 with bile, states the injury which had resulted from ^|. st a ^" ss 
 an opening made into this viscus, under an impres- of Hver. 
 sion that the case was an abscess of the liver, and 
 endeavours to lay down a series of symptoms by 
 which such dangerous mistakes may in future be 
 guarded against. 
 
 Biliary concretions are often found in the gall 
 bladder, these in general are small, and in consi- 
 derable numbers, but in some few cases it has ston es. 
 happened that some one of these concretions has 
 
06 ANATOMY OF 
 
 arrived to a very great size, and has excited in- 
 flammation in the coats of the gall bladder, which 
 How very terminated in adhesion with the colon, and sub- 
 
 Jarge ones . . , ' 
 
 get into sequent ulceration ot the adherent parts. By these 
 nai canal!" means > this very large calculus has been discharg- 
 ed by stool. Some overlooking this mode of es- 
 cape, have supposed that these large calculi pas- 
 sed along the cystic and common duct into the 
 duodenum, and have reasoned a good deal on the 
 degree to which these ducts may be enlarged by 
 distention. 
 
 The ductus communis choledicus passes behind, 
 
 and close to the head of the pancreas, in its course 
 
 to the duodenum. From this we infer, that a 
 
 Jaundice schirrous enlargement and hardness of this portion 
 
 SSsed 7 of the gland may cause an obstruction to the flow 
 
 pancreas. f the bile along this duct, and thus give rise to 
 
 the jaundice. We also observe two or three lym- 
 
 By eniarg- phatic glands lying close to this duct before it has 
 
 phatic" 1 yet reached to the pancreas. The enlargement of 
 
 glands, these glands I have known to produce in one case 
 
 a permanent obstruction, and a jaundice of some 
 
 years duration. 
 
 The pancreas is subject to become hardened and 
 enlarged, constituting the disease termed schirrus 
 scWrrus of that gland. From its situation between the 
 cresTat- aor t a an ^ superior mesenteric artery, such a con- 
 tended dition of this gland may cause the pulsations of 
 ™tion. ul " either of these vessels to be so very perceptibly 
 felt through the parietes of the abdomen, as to im- 
 press us with a belief that the patient labours un- 
 der aneurism of the aorta. While on one hand we 
 are liable to suspect the presence of aneurism of 
 tfTo"T tne a °rta when no such disease exists; we are, on 
 liable to the other hand, subject to overlook this disease 
 lookedT when it really takes place. For, in some instan- 
 ces, the pulsation could not be felt during life, and 
 the attendant symptoms being such as generally 
 accompany other morbid conditions of the abdo- 
 
THE ABDOMEN. 
 
 97 
 
 minal viscera had not pointed out any aneurismal 
 affection. 
 
 It is obvious, that all aneurisms in the abdomen Aneurism 
 must be behind the peritoneum, yet I have found, |" e J, m ^ st 
 on opening the bodies of such patients after death, be behind 
 a large quantity of bloody fluid, lodged in the ca- um ! ton - e " 
 vity of the peritoneum; although no rupture of this 
 membrane could be discovered, by which the fluid 
 could have had access to this cavity. 
 
 Each orifice of the stomach is occasionally con- 
 tracted, its coats being at the same time much 
 thickened, and sometimes indurated. — This affec- 
 tion, which is termed schirrus, (perhaps impro- 
 perly) occurs much more frequently in the lower 
 than in the upper orifice. When the cardiac ori- Schl h rrus ar 
 fice is the seat of this disease, the solid food is de- diac ori fi ce 
 nied access into this cavity, and is either instantly 
 rejected, or else lodges in the inferior portion of 
 the oesophagus, where a pouch is often formed. 
 In this, the food is allowed to remain for some 
 time, and is then rejected very little changed. 
 When schirrus of the pylorus occurs, the food is Schirrus of 
 received into the stomach; but in the latter stages pyor 
 of the disease, the solids, which have been retain- 
 ed for some time, seem to excite considerable dis- 
 tress, and are rejected by vomitings. In general, 
 the interval of time between their reception and 
 rejection is pretty uniformly the same in each in- 
 dividual. 
 
 The deep situation of the cardiac orifice and its Former 
 proximity to the diaphragm precludes us from ac- 5 t en- 
 quiring, by external examination, any knowledge na "y- 
 of its schirrous state. The pylorus being situated Lattercan. 
 more superficially and further removed from the 
 concavity of the diaphragm may, by external exa- 
 mination, be discovered to be schirrous; but from 
 the facility with which it can be moved in this 
 cavity, it is liable to be mistaken for a tumor of 
 the omentum. omentum. 
 
 N 
 
98 
 
 ANATOMY OF 
 
 The omentum is frequently found on dissection 
 
 S C 9d- to to * iave ^ een ^ e sea * °f disease. ' n many of those 
 
 hesions. who have laboured under affections of the uterine 
 
 system, the lower extremity of the omentum has 
 
 formed adhesions to the posterior surface of the 
 
 uterus or its appendages. — The texture of this 
 
 J^Jj j°" " membrane is subject to such morbid alterations, 
 
 solid tu- that we find it at different points converted into 
 
 mours. g^-^ £ rm t U n lourSj f t ne s j ze f an e gg ? wn ii e t ne 
 
 membrane in the immediate vicinity of such tu- 
 mors retains that delicacy of texture for which it 
 is so remarkable. — These tumors are generally 
 moveable, and always seem to lie superficially in 
 the cavity. They are not unfrequently, attended 
 with anasarca or ascites. This circumscribed 
 form, and the facility with which they can be mov- 
 ed with the hand, will serve to distinguish them 
 from induration and enlargement of the liver, but 
 will not serve in every instance, to point out the 
 real nature of the disease with unerring certainty. 
 Dropsy of the abdomen is so very frequently ac- 
 companied by enlargement of the liver as to have 
 given rise to the rule of tapping on the left side of 
 the cavity, lest the trocar should be plunged into 
 a diseased liver. 
 
 The spleen on the other side is subject to en- 
 SmTthnes I ar g ement > but much less frequently than the liver. 
 much en- In one case (a cast of which is preserved in our 
 larged. museum) this viscus had increased to such a size, 
 that it descended into the hollow of the ilium. 
 practical Hence the necessity of distinctly feeling a fluctua- 
 in tapping, tion in that spot, which you select as the point for 
 Fiuctua- tapping. It is hardly necessary to say, that this 
 £ guide fluctuation will be less sensibly felt in cases of 
 anasarca, combined with ascites; for there the in- 
 terposition of the fluid in the cellular substance 
 must render the walls of the cavity more thick, 
 and must transmit the undulation with diminished 
 distinctness. NL^ 
 
THE ABDOMEN. 99 
 
 On each side of the abdomen, that portion of 
 the colon which lies between the crest of the ilium 
 and lowest part of the false ribs, is, in general, co- 
 vered with peritoneum on the anterior third only 
 of its circumference; while the two remaining thirds 
 of it are attached by cellular substance to the mus- 
 cles upon which it lies. Large concretions or 
 balls have (though rarely) lodged in these portions Proposal 
 
 • for cuttiii 0, 
 
 of this intestine; and it has been proposed as an concre- 
 oprration in surgery, that we should make an in-jj^ 13 ^ 0111 
 cision through the muscles of the loins, then cut 
 into the intestine, and so extract these balls. To 
 this operation two strong objections lie: — First, objections 
 we cannot ascertain the existence and seat of these t0 th ' s 
 
 . . operation. 
 
 concretions by unequivocal symptoms. Secondly, 
 the relation of the peritoneum to these portions of 
 the colon varies, in different subjects. In some, 
 it not only gives a complete covering to this por- 
 tion of the intestine, but it even forms a mesoco- 
 lon, which allows it to approach more or less to- 
 wards the vertebrae. In such irregularity of struc- 
 ture, it would be rashness to hazard an operation 
 fraught with so much danger, 
 
 The records of surgery furnish us with instan- Abscess 
 ces of abscesses, in the substance of the kidneys. — in ' mes 
 Some of these, excited by calculi, have pointed ex- 
 ternally on the loins, and the calculus has been 
 discharged through the opening, either when made 
 by art, or caused by the efforts of nature. Be- 
 ware, however, of considering every collection of 
 matter which appears in such situations as of this 
 description. For, not unfrequently, the matter of 
 psoas abscess makes its way through the mus- 
 cles, and appears externally on the loins. While 
 the early and free opening of the former procures 
 immediate relief, a similar treatment of the latter 
 too generally tends to hasten the death of the pa- 
 tient. 
 
100 ANATOMY OF THE ABDOMEN. 
 
 The psoas abscess may be distinguished from 
 an abscess of the kidney, by its preceding and con- 
 comitant symptoms; by its more flattened form; 
 and by its freedom from discoloration of the in- 
 teguments, until it arrives at its latest stage. 
 
101 
 ANATOMY OF THE THORAX 
 
 Of the conical form of this cavity, and of the Form am i 
 manner in which it is divided by the mediastinum, subdivision 
 
 ... J ,' , • of thorax. 
 
 into two distinct compartments, you cannot be igno- 
 rant. 
 
 You know that the diaphragm forms the floor 
 of this cavity, that to its tendinous part the peri- 
 cardium and mediastinum are attached, and that 
 the lungs lie upon its lateral portions having their 
 base shaped, so as to correspond accurately with 
 the surface upon which they rest. In consequence 
 of the different heights at which the diaphragm is JJj*" 
 attached, it is obvious, that the floor of this cavity inclines 
 represents an inclined plane, which descends con- finback? 
 siderably lower at the posterior, than at the ante- wards. 
 rior part. From the height to which the arch of 
 the diaphragm rises in the thorax, while its ori- 
 gins are from the lowest part of the sides of this j s c i 0S eiy 
 cavity, it is obvious that this muscle, in its most jw lied 4 ° 
 natural state, lies closely applied to the lower ribs. ribs. 
 Hence it follows, that a wound of the side, passing Thorax 
 straight across the body, may at once, wound the JjJ ^ 
 viscera of both the cavity of the thorax and of the injured by 
 abdomen. ^ 
 
 Hence too, it follows, that when the operation ln the ope . 
 for empyema is performed, at the place of election, ration for 
 (as it is termed) if a fluid does not flow out where 3£ a ' 
 the thorax is opened, the operator may think that resulting 
 he has not penetrated into the cavity. And finding n'eiTL 
 at the point of his finder, a fleshy plane close ap- J"*' of 
 
 i. j ,',, , i • ■ i • • diaphragm 
 
 plied to the pleura, he continues his incisions more 
 deeply; and often mistakes the liver for the lungs, 
 from which, most fatal consequences have followed. 
 Of such mistakes, Ravaton says, that he has fre- 
 quently been an eye-witness. 
 
102 
 
 ANATOMY OP 
 
 ofThorax d ^^ e "PP er en( * °f this cavity has been compared 
 to the end of a truncated cone; this presents an 
 opening of very confined dimensions, through which 
 we observe a number of very important parts to 
 pass. 
 terJ'^'r ^^ l atera l Potions of this opening, are occupied 
 are oS- 8 by the narrow extremities of the pleuras. These 
 P ied - are found to rise above the level of the first ribs. / 
 The trunks of the subclavian arteries, are seen run- 
 ning from the central to the lateral parts of this 
 cavity, and rising still higher above the ribs, as they 
 pass towards the superior extremities. 
 How the A s these membranes and arteries ascend above 
 subclavian the level of the first ribs, they would be exposed 
 arteries f muc h danger, were they not protected by the 
 
 are here , . . ° 7 j r j 
 
 protected. Clavicles. 
 
 When you raise the sternum, study well the re- 
 Parts situ- lative position of the different parts which lay be- 
 hind the hind the upper end of this bone. You first see the 
 sternum, venous trunk, formed by the conflux of the inter- 
 nal jugular and subclavian veins, passing across to 
 ImTk* the right side, in a direction obliquely from above 
 crossing downwards. This vein then, is more exposed to 
 Sde! ' eft danger, from a punctured wound towards the left, 
 than towards the right side of the cavity. In its 
 course, this vein passes across the roots of the left 
 carotid and common trunk of the right carotid and 
 right subclavian arteries. 
 Arch of The superior curve of the arch of the aorta, rises 
 up so high as to be on a level with the upper edge 
 of the first ribs. When this portion of the artery 
 is distended by aneurismal dilatations, we may ex- 
 pect that it will press against the upper edge of the 
 sternum, or the cartilages of the first ribs, cause an 
 absorption of these resisting parts, and make its 
 appearance by pointing externally. It is surpris- 
 ing that the venous trunk just mentioned, is not 
 thereby so compressed as to obstruct the flow of 
 
THE THORAX. 
 
 10S 
 
 blood through it, yet, we rarely find symptoms of 
 such obstruction in the living body. 
 
 The common trunk of the right carotid and sub- Relative, 
 clavian arteries arises from this arch on the left j^' " c 
 side of the trachea, runs across in front of this 
 tube, lies along its right side, and ascends to a level 
 with the clavicle, before it divides into its two 
 branches. The left carotid arises from the arch, 
 after it has passed to the left side of the trachea, ^'jj 
 and runs up along the left side of this tube. 
 
 In some instances the right subclavian has had Unusual 
 an extraordinary origin and course. For it has JJ J g u h r t se c 
 arisen from the descending aorta, below the origin carotid. 
 of the left subclavian, from this it has passed over 
 to the right side, running either behind or in front 
 of the assophagus. This course of the artery is 
 suspected to have been the cause of a particular Supposed 
 Species of dysphagia, termed lusoria: the difficulty to cause 
 of swallowing being experienced, when the food dysp ag,a * 
 had arrived at that part of the aesophagus, crossed 
 by this artery. Having carefully searched for an 
 instance of this irregular course of the artery, dur- 
 ing the present season, 1 was surprised to find four 
 cases of it in the dissecting-room. The subjects 
 of two of those cases were adults; the two remain- 
 ing instances occurred in the bodies of children, 
 but in none of them were there any traces of ob- 
 structed deglutition. 
 
 From the position of these large vessels, it is ob- JjJJJ'jJ 
 vious, that a punctured wound inflicted on the top top of ster- 
 of the thorax (if the instrument be directed down- 53,^ 
 wards) may divide some of those vessels, and thus these ves- 
 prove instantly fatal. 
 
 The trachea descending behind the arch of the Trachea 
 aorta, and having arrived opposite to the second or 
 third dorsal vetebra, there bifurcates. At the place where it 
 of forking, a number of these glands, termed bron- 
 chial, are situated. May not these glands, when*^?* 
 enlarged and indurated, press on the aesophagus, glands. 
 
104 
 
 ANATOMY OP 
 
 JrelsA?" anc * constitute a particular cause of difficult deglu- 
 
 assophagus. tltlOn. 
 
 The breasts of females are so frequently affect- 
 Mamma. e( j w j tn di seasej as t ren der the study of their 
 Their structure highly interesting to the surgical prac- 
 structure. titioner. We find that the body of this gland is 
 composed of a congeries of small glandular bodies. 
 These are enveloped in one common dense mem- 
 brane, which sends productions inwards, among 
 the minuter glands, serving to support and keep 
 them distinct from each other. This coat, by its 
 internal surface, adheres so very closely to the 
 gland, that we cannot detach them from each other, 
 without wounding either the gland or the mem- 
 brane. Externally the portion of this coat, which 
 covers the anterior part of the gland, is overspread 
 with a quantity of fat, which is collected in large 
 masses; while the portion of this coat, which co- 
 vers the posterior part of the gland, is connected 
 mTpec- 011 10 tne pectoral muscle, by the medium of a very 
 torai mus- loose cellular substance. This conformation al- 
 lows the gland to be moved freely on the surface 
 why ab- f fljj s musc i e< The dense texture of this invest- 
 
 SCCSS 01 
 
 breast ing membrane, will explain, why abscesses of the 
 ukerate. mamma are so late in being discharged outwardly. 
 cancer of Among the diseases to which this part is subject, 
 breast, none is more formidable than cancer, whether in 
 its schirrous, or ulcerated state. For it so ge- 
 nerally resists every mode of treatment hitherto 
 proposed, that surgeons in general, consider the 
 extirpation of the diseased part, as the most like- 
 ly to afford permanent relief to the patient. It is an 
 established principle in the treatment of cancer, 
 wherever situated, that extirpation should not be 
 attempted, unless the entire of the diseased parts 
 can be removed; both these which were primarily 
 the seat of the disease, and those which become 
 subsequently affected by absorption. It has, how- 
 ever, in some instances occurred, that where an 
 
THE THORAX. 105 
 
 operation had been undertaken, with the hope of 
 being able to extirpate all the diseased parts, the 
 surgeon has discovered, when too late, such a firm 
 adhesion of the mamma to the pectoral muscle, 
 and even to the ribs, as to prevent the completion 
 of this painful operation. 
 
 Richter lays down the following judicious rules, h°* t0 
 for discovering the degree of adhesion of the breast Shesion 
 to the subjacent parts: ° f b, f? st 
 
 " If the breast can be moved backwards and cent parts, 
 forwards, whether the shoulder be advanced for- 
 wards, or drawn back, there is no preternatural 
 adhesion. If the breast can be moved backwards 
 and forwards when the shoulder lies forward, but 
 is fixed when the shoulder is drawn back, it ad- 
 heres to the external pectoral muscle. If it be 
 firm and immoveable, whether the shoulder lie for- 
 ward or be drawn back, the adhesion is in a high- 
 er degree. Again, the breast may adhere very 
 firmly to the pectoral muscle, and yet be quite 
 moveable, even when the shoulder is strongly re- 
 tracted, if only the breast be moved in a direction, 
 transverse to that of the fibres of the pectoral mus- 
 cle. And so it happens, that the breast is thought 
 perfectly moveable, while in the operation, it is un- 
 expectedly found to be adhering and quite firm. 
 But, with care, this may be perfectly ascertained 
 before the operation, merely by moving the tumor 
 backwards and forwards, in a direction parallel to 
 the fibres of the pectoral muscle." 
 
 Having in this manner satisfied yourself, that the 
 mamma does not adhere to the pectoral muscle, 
 your attention should next be turned to the con- 
 dition of those glands, through which the lympha- 
 tic vessels of the breast pass, in their course to the 
 thoracic duct of the heart. 
 
 These glands then may be discovered (when Three dif _ 
 diseased) in three different situations. Sometimes ferent sit »- 
 they will be found lying along the edge of the ster-£« 
 
 o 
 
106 ANATOMY OF 
 
 lymphatic num; but this is the situation in which the enlarg- 
 
 glands. e{ j g] an( J s are mos j rare ly me t with. 
 
 Some of the lymphatic vessels of the breast pass 
 First along j n t glands, which are situated on one side of the 
 sternum. neck, immediately above the clavicle, and on the 
 outer edge of the sterno mastoid muscle. Among 
 the glands situated here, some lie superficially, 
 others lie far removed from the surface. The mor- 
 bid enlargement and hardness of the former, can 
 readily be ascertained, but when the latter are dis- 
 eased, we cannot with certainty determine what 
 number of them is affected; we cannot determine 
 whether this disease may not even have seized 
 upon some of these glands, which pass down into 
 the chest. If we could be assured, that only the 
 superficial glands were diseased, we might under- 
 take their removal, as we should only have to en- 
 counter hsemorrage, from the division of some of 
 remSg the scapular arteries. But as we cannot be certain 
 these. f the extent to which the deeper seated glands 
 are affected, and as we know that an attempt to 
 remove these, will be attended with the risk of 
 wounding the subclavian vessels, we must alto- 
 gether abandon the idea of such an attempt. Hence 
 we may lay it down as a rule of practice, in the 
 treatment of cancer, not to undertake the removal 
 of the breast, when we find the lymphatic glands 
 above the clavicle, affected by the absorption of the 
 cancerous virus. 
 Third, in The lymphatic glands leading to, and lying in 
 the axiiia. ^ ax jjj aj are a ff e cted much more frequently than 
 those in either of the former situations. As a 
 . chain of these glands lies under the edge of the 
 , pectoral muscle, they might pass unnoticed in a 
 How to superficial examination. You should, therefore, 
 thcsf search for enlargements of these glands, while the 
 giaads. arm of the patient is drawn forwards, for by this 
 expedient, the edge of the pectoral muscle is re- 
 laxed, and an opportunity afforded, of passing the 
 
THE THORAX. 
 
 107 
 
 finger further under its edge. The propriety of 
 removing the breast in such cases, will rest prin- 
 cipally on the practicability of removing all the 
 diseased glands from this cavity. Of course, we 
 can only be enabled to form a correct opinion on 
 this subject, by a knowledge of the anatomy of the 
 axilla. 
 
 The axilla, if considered as a cavity, may be Form aad 
 said to be of a triangular shape, the vertex of which boundaries 
 
 • t f* 01 flXlllT. 
 
 reaches up to the base of the coracoid process ot 
 the scapula, the sides being constituted by the ribs 
 on one part, and by the humerus on the other, 
 while the base is formed by the edges of the pec- 
 toralis major, and latissimus dorsi muscles; the 
 former bounding its cavity anteriorly, the latter, 
 posteriorly. The space thus bounded, is occupied 
 by blood-vessels, nerves, and lymphatic glands, 
 with some interposed fat, and a very large propor- 
 tion of cellular substance. Many of the lymphatic J^JjJ" 
 glands are found to lie under the edge of the pec- lymphatic 
 toral muscle, some occupy the middle of the axil- ^ n a d ^j" a 
 lary space, while others are situated along the pos- 
 terior border of the axilla, near to the neck and 
 inferior costa of the scapula. Matter absorbed 
 from a cancer of the breast, may affect any or all 
 of those lymphatic glands, and, therefore, the re- 
 moval of them oftentimes forms a part of the ope- 
 ration of extirpating a cancerous mamma. The 
 feasibility and safety of this operation, must of 
 course, depend on their depth in the cavity, and 
 their relation to the nerves and blood vessels which 
 lie there. The opening of this cavity between the a f terj?ot 
 edges of these muscles being so narrow, in pro- the only 
 
 x« , •. i ,i x t xi l rone liable 
 
 portion to its depth, must render the removal ot t0 be 
 the deeper seated glands, a task of some difficulty, wounded 
 But their depth in those cases, though the cause 
 of difficulty, is not the cause of danger: the de- 
 gree of danger is to be estimated by their prox- 
 imity to some large blood vessel in the cavity. We 
 
108 ANATOMY OF 
 
 are generally cautioned against attempting the 
 removal of those glands, which lie close upon the 
 trunk of the axillaiy artery; and this rule is laid 
 down in such a manner, as might induce you to 
 suppose, that no other large vessel is endangered 
 in this operation. Let us then examine how far 
 the trunk of the axillary is liable to be divided, 
 and whether we do not run a risk of wounding 
 some branches so large, as to give rise to a fatal 
 haemorrage. 
 course and The axillary artery in its course, from the top 
 pinion of of the thorax to the neck of the scapula, runs 
 axillary obliquely across the cavity of the axilla. In this 
 course, it is gradually approaching nearer and 
 nearer to the scapula, and at the same time, tend- 
 ing to apply itself to the lower surface of the pec- 
 toral muscle. When it has arrived at the neck of 
 the scapula, it then lies close to the under surface 
 of this muscle. From this point, the artery pur- 
 sues its course contiguous to the muscle, and pro- 
 tected by its edge. N^w, as the breadth of this 
 muscle rapidly decreases in the interval between 
 the neck of the scapula, and its insertion into the 
 humerus, it is obvious that the arteiy, in its course 
 along the humeral part of the axilla, is more super- 
 ficially seated. From this view of the course of 
 the axillary artery, it is plain that it will be endan- 
 gered when we carry our incisions at the humeral 
 part of the axilla, close to the edge of the pectoral 
 muscle, even though these incisions be but super- 
 ficial. When our incisions are made into the 
 axilla, near to the thorax, the axillary artery is 
 endangered, as often as these are carried deeply 
 towards the apex of the axillary cavity. It is 
 scarcely necessary to observe, that the axillary vein 
 is liable to be wounded before we reach to the 
 artery, as the former is less deeply situated in the 
 Gavity than the latter. 
 
THE THORAX. 
 
 109 
 
 We sometimes find diseased lymphatic glands, Glands 
 lying along the posterior border of the axilla, and ^SdT 
 these being far removed from the direction of the of scapula. 
 axillary artery, may be supposed to admit of extir- 
 pation without any risk. However, we shall find 
 that the trunk of the sub-scapular artery is endan- 
 gered by their removal. For this branch leaves la u r s ^ 
 the axillary artery opposite to the glenoid cavity, ^ d b an ^' ir 
 and runs transversely towards the lower border of e rem0 vai! U 
 the scapula. Hence it is plain, that its course lies 
 across the humeral end of the cavity, and conse- 
 quently it is liable to be wounded in extirpating 
 any glands which are situated towards this extre- 
 mity of the axilla. Now, the subscapular artery 
 is so large, that a division of it must be dangerous 
 to a patient, of any habit of body whatever, and 
 must instantly prove fatal to a delicate female, re- t hh artery 
 duced by previous sufferings of pain, and hectic pay prove 
 fever, and exhausted by the preceding steps ofU^ 7 
 such a painful and terrifying operation. 
 
 Many glands lie at a distance from either edge GIa «d s 
 of the axilla. Their removal cannot cause a"°theredge 
 haemorrage immediately fatal, but may be follow- 
 ed by some troublesome bleedings. For the tho- 
 racic arteries are liable to be wounded in removing 
 those glands. 
 
 These arteries lying in a deep cavity, and sur- Their re- 
 rounded by loose cellular substance, can with diffi- mo * al ma y 
 culty be secured by the tenaculum and ligature, biesome 
 For they will recede instantly on being divided, bleedin s s - 
 and shrinking in among the loose cellular sub- 
 stance, will inject it with blood. Thus the extre- 
 mity of the divided artery will be buried in the 
 distended cellular substance, so that its open mouth 
 cannot be distinctly seen. Hence secondary has- 
 morrage is much to be dreaded under those cir- 
 cumstances. To prevent all these ill effects, which 
 might result from a division of the thoracic arteries, 
 you will only have to observe this rule. Before 
 
no 
 
 ANATOMY OP 
 
 How to you dissect out any large gland, or cluster of glands, 
 thesT* search for any large veins connected with them. 
 bleedings, if any such be visible; catch the vein between your 
 finger and thumb, you will feel the pulsation of 
 the artery, pass a needle and ligature round the 
 vein, and this will also include the artery; for the 
 thoracic arteries and veins accompany each other 
 with wonderful regularity. Having thus secured 
 the artery, you may cut it across in the interval 
 between the ligature and the diseased gland. 
 A species Although the diagnosis between schirrus and 
 In fte" °t ner diseases of the breast, be not founded on the 
 breast re- anatomical structure of this part, and consequently 
 schirris 8 c ' oes n0 * come within the scope of this work, yet 
 I cannot refrain from stating the symptoms of 
 another species of tumor, which is occasionally 
 to be met with in the breast, as it is not described 
 by any author I have hitherto seen. 
 Descripti- This is a distinct tumor or hardness in the 
 disease, breast, generally seated deep in the substance of 
 this gland, and towards the axilla. This is usually 
 traced by the patient to some slight hurt. In size, 
 it scarcely ever exceeds a walnut. Its surface 
 seems rough; but this is caused by its being felt 
 through the gland. It is occasionally attended with 
 some slight pains; these are induced by any distress 
 of mind — by wearing the clothes tight across the 
 breast — and by a costive state of the bowels. On 
 the approach of the menstrual period, these pains 
 increase, and cease on this evacuation being com- 
 pleted. A temporary enlargement of the tumor 
 attends these attacks of pain, and retires on their 
 cessation. 
 
 The subjects of this complaint are young women, 
 generally under thirty years of age. In one in- 
 stance, the patient was nearly forty years old, and 
 unmarried; in another, the lady was married, but 
 had not any children, and was irregular in men- 
 struation. These tumors disappeared in such of 
 
THE THORAX. Ill 
 
 these patients as became nurses, and in the others 
 have remained stationary for many years. The 
 only treatment I conceive they require, is such as Treatment 
 tends to restore the general health. A lotion of 
 aqua ammoniae acetata; or camphorated spirit of 
 wine applied with a feather, and allowed to evapo- 
 rate, are the topical applications which 1 have em- 
 ployed with most relief to the patient. 
 
 I have introduced the mention of this disease, Why in _ 
 not for the purpose of laying down a plan of treat- jj^ uced 
 ment, but of preventing this kind of tumor from 
 being mistaken for a true schirrus. 
 
 We shall defer any further observations on the 
 diseases and accidents to which the parts connect- 
 ed with the axilla are subject, until we come to 
 speak of the diseases and injuries incident to the 
 extremities. 
 
112 
 
 ANATOMY OF THE NECK ANI> 
 THROAT. 
 
 Mode of Begin the dissection of this part by an incision 
 £rST" through the skin, along the clavicle and top of the 
 direction, sternum — then make another incision from the top 
 of the sternum to the chin, and continue this along 
 the side of the face to the upper part of the ear. 
 Dissect back the skin, taking care not to injure a 
 superficial, but pretty strong fascia which lies 
 immediately under, and closely connected with the 
 skin. 
 Fascia of Expose in this way, the fascia of one side of the 
 throat By pinching up and drawing this fascia 
 lis extent, with your forceps, you observe, that it passes from 
 the neck down upon the thorax, without having any 
 attachment to the clavicle or sternum. You also 
 observe it stretching over the surface of the parotid 
 gland, passing above the upper end of this gland, 
 and blending itself with the aponeurosis of the 
 temporal muscle, on and above the zygomatic pro- 
 cess. This fascia is very closely connected with 
 the cartilaginous tube of the ear, being of a close 
 and firm texture where it joins the inferior portion 
 of this tube; but where it joins the anterior part 
 of the tube, it is of a more loose and open texture 
 — being here perforated by many holes, obviously 
 for the transmission of nerves and blood-vessels. 
 Anteriorly to the masseter muscle, this fascia seems 
 to be implanted into the base of the lower jaw. 
 While this fascia lies exposed to your view, con- 
 sider well what influence it may have upon the 
 diseases and operations to which the different parts 
 lying under it are subject. And, first, in inflamma- 
 ence in ?n U " ti° ns ana " suppurations of the parotid gland. In 
 abscess of such cases, even though the quantity of matter be 
 
THE NECK AND THROAf. 113 
 
 great, yet this fascia will prevent the elevation of parotid 
 the swelling from being considerable, especially gland ' 
 towards the upper end of the gland, because here 
 the attachments of the fascia are of very consi- 
 derable extent and firmness. The nature and 
 unyielding texture of this fascia, will not permit 
 the matter to point as soon as formed in the upper 
 extremity of the gland; nor will it allow us to as- 
 certain satisfactorily, the presence of the fluid by 
 the unequivocal test of fluctuation. If, then, we 
 be ignorant of the structure and connexions of 
 this fascia, we shall probably hesitate to make an 
 opening into the tumor, and by our indecision and 
 timidity, shall subject our patient to sufferings, as 
 intolerably severe as unnecessarily protracted. 
 To what a pitch these may arise, judge from the 
 following statement: 
 
 A young and delicate lady was affected with a Example. 
 swelling, situated at the lower and back part of 
 the cartilaginous tube of the ear. This, from its 
 commencement, was attended with excessive pain, 
 and redness of the integuments; she soon became 
 unable to chew, and swallowed fluids only with the 
 greatest difficulty; her nights were passed without 
 sleep, even when she took opium in large doses; 
 her strength and health were at length reduced to 
 the lowest ebb; and now part of the matter was 
 spontaneously discharged, by an opening near the 
 angle of the jaw; but this did not occur until after 
 a series' of sufferings, protracted for four weeks. 
 Before this event took place, the swelling had ex- 
 tended down below the clavicle; and the integu- 
 ments of the entire side of the neck, and even 
 those on the upper part of the breast, were red 
 and inflamed. In this case, from an early period, 
 a small quantity of matter was daily discharged 
 through the external ear: but was too inconside- 
 rable to afford relief to the patient, and unlbrtu- 
 nately did not excite in the mind of her attendant. 
 
 p 
 
114 ANATOMY OP 
 
 that inquiry into its source, which must have led 
 him to a judicious and decisive mode of treatment 
 incisions ft is not my intention by this statement, to en- 
 hastily courage the young practitioner to make deep in- 
 "arotid"* c i s * ons m ^° tms gland, immediately on the first 
 gland. attack of inflammation, lest he should wound some 
 of the branches of the temporal artery, which are 
 distributed to it in abundance. I only wish to 
 convince him of the impropriety of waiting for a 
 distinct fluctuation, such as be has been in the 
 habit of feeling in abscesses immediately under 
 the skin, unconnected with a fascia or aponeu- 
 rosis. 
 Abscess of We meet, however, with some instances of sup- 
 sometimes purations in this gland, which, though not timely 
 bursts into opened by the surgeon, have yet a favourable, and 
 Srextern". spontaneous termination; for the matter makes its 
 way into the meatus auditorius externus by an 
 opening sufficient to discharge the contents of the 
 abscess in a short time. Such openings probably 
 take place through some of those fissures, which 
 are found in the cartilaginous portion of the 
 tube. In this way I have observed many of those 
 abscesses, supervening an acute fever, to termi- 
 nate. 
 
 Some remarks on the morbid conditions of this 
 
 fascia shall be made when we come to speak of 
 
 the fascia investing the limbs; at which time we 
 
 shall also consider what benefits may be derived 
 
 from a division of this fascia and the platysma 
 
 myoides in cases of contraction from burns and 
 
 scalds in the throat and neck. 
 
 Lympha- Close to the upper edge of the parotid gland, 
 
 l^ng 31 ^^ an d in contact with the anterior part of the mea- 
 
 parotid. tus auditorius externus, lie two or three small 
 
 lymphatic glands, distinguishable by their colour 
 
 from the parotid. Some few lymphatic glands are 
 
 also seen on the surface and on the lower edge of 
 
 the parotid. 
 
THE NECK AND THROAT. 
 
 115 
 
 May not the chronic enlargement of some of Eniarge- 
 these lymphatic glands have been mistaken for a J 1 , 1 ^ n ° is . 
 schirrus of the parotid itself, and the removal of taken for 
 
 cliirrous 
 
 such by the knife been boasted of as the extirpa- parotid 
 tion of the parotid gland? When you contem- 
 plate the nerves and blood-vessels which pass 
 through the substance of this gland, and also the 
 depth to which it sinks, as it is imbedded between 
 the ramus of the lower jaw and the mastoid pro- .. 
 cess of the temporal bone. When you reflect on 
 the very firm and almost inseparable attachment 
 of the gland to these parts, you will be very tardy 
 in giving credit to the stories of extirpation of a 
 schirrous parotid gland. 
 
 To ascertain the practicability of such an ope- 
 ration, let us investigate more minutely, the anato- 
 mical structure and relations of the parotid gland. — 
 This gland extends from the zygomatic process Anatomi _ 
 of the temporal bone to about a quarter of an cai s tr uc- 
 inch below the angle of the lower jaw. Its breadth Ztiom 
 in the vicinity of the zygomatic process, extends of parotid. 
 transversely from the meatus auditorius externus JJJ^J^ 
 to the anterior edge of the masseter muscle, at extremity. 
 least some part of the gland accompanies the duct 
 until it has reached to the anterior edge of this 
 muscle. The depth to which this gland here sinks, ^Jfy? 
 is such as renders it difficult, on the dead body, to extremity. 
 dissect out that portion which lies between the 
 temporal and lower maxillary bones; and this, with 
 the advantages of having the skin previously strip- 
 ped off, and the view undisturbed by any haemor- 
 rage. — When such difficulties occur in the dead, 
 how can we hope to surmount those which must 
 be superadded in the living body. — The lower end 
 of this gland sinks very deeply from the surface, D e P th of 
 so that it lies on the digastric, where this is about lower end - 
 to pass through the stylo-hyoid muscle. The depth 
 then of the lower end of this gland is not much 
 less than that of its upper end, although it is not 
 
116 ANATOMY OP 
 
 here confined within such narrow limits by its an- 
 terior and posterior boundaries. 
 
 We shall, however, find still stronger objections 
 Extirpa- ( t n j s operation than those which arise from these 
 tw" gLid difficulties. We shall find it attended with such 
 cannot be unavoidable destruction of important parts as must 
 without render the attempt most certainly fatal. First, the 
 wound of. portio dura of the seventh pair of nerves, which 
 Portiodura passes out of the stylo mastoid hole, and then runs 
 through the body of this gland to its destination 
 on the face and neck, the trunk of this nerve must 
 necessarily be cut across. A paralysis of this side 
 of the face would be an inevitable consequence of 
 External the division of this nerve. The termination of the 
 carotid carotid artery, which is yet to give off" the tempo- 
 ral and internal maxillary arteries, enters into the 
 lower extremity of this gland. Unless this be 
 tied before the lower part of the gland is raised, 
 a violent hasmorrage must instantly carry off the 
 patient. 
 Difficulty The difficulty of dissecting down to this artery, 
 a ligatur? and then passing a ligature round it, need not be 
 round this pointed out to any one who reflects that it passes 
 from under the digastric and stylo-hyoid muscles, 
 as it is about to enter into this gland. 
 
 Some, aware of the danger and difficulty of this 
 part of their supposed operation, assert, that they 
 finished the removal of the parotid by tying a liga- 
 ture round this portion of the gland, and thus 
 causing it to slough away. But, granting for a 
 moment, the practicability of this step, yet it must 
 Difficui- appear inconceivable how they could dissect out 
 ties of dis- e ven the upper portion of the gland. For, inde- 
 nt upper pendently of its position, and the depth to which 
 it sinks between the temporal and lower maxillary 
 bones; independently too of the embarrassments 
 which must attend the hasmorrage from the un- 
 JjJ e ™ al avoidable division of many small arteries and large 
 Sery ary veins in the first steps of the operation, the sur- 
 
 end of 
 parotid. 
 
THE NECK AND THROAT. 
 
 117 
 
 geon has to cut across the trunk of the internal would be 
 maxillary artery; for this artery passes off from wounded; 
 the continued trunk of the carotid completely 
 across the substance of this gland. So that this 
 gland cannot be detached from one half of the 
 ascending ramus of the lower jaw, without the 
 certain destruction of this artery. The end of 
 the divided vessel shrinking in under this bone, 
 cannot afterwards be secured by ligature or by 
 compression. Should the operator leave behind 
 him any part of the schirrous gland, he must be 
 aware that his operation will be followed by a re- 
 turn of the disease. — If to avoid this error, he 
 should dissect at all deeper than the seat of the 
 upper part of this gland, he will almost inevitably 
 wound the trunk of the internal carotid artery, f n 3° 
 which runs anterior to the root of the styloid pro- carotid 
 cess, or of cutting into the internal jugular vein, f a n r V J 2J" 
 which runs immediately behind this piocess. Lympha- 
 
 Behind the root of the mastoid process a pretty tic giand 
 large lymphatic gland lies between the bone and ^2* 
 the fascia of the neck. This gland is not unfre- process. 
 quently in children the seat of inflammation, which often SU P- 
 
 *:.•' iii x- j.u purates. 
 
 sometimes proceeds slowly to suppuration; tne 
 matter, being bound down by this fascia, an early JJfSy 
 opening is required. opening. 
 
 On detaching the fascia and platysma myoides 
 from the base of the lower jaw, the submaxillary submaxii- 
 
 ii. i-ni i ■ • i lal 7 gland. 
 
 gland is seen stretching from the os hyoides near- 
 ly to the base of the chin. Between the upper 
 end of this gland and the base of the chin are in- with two 
 terposed two lymphatic glands, corresponding to ^f d h s atic 
 the two lobes of the submaxillary. The extirpa- dose to it. 
 tion of one or both of these glands when enlarged, 
 has passed with some, for the extirpation of the 
 submaxillary gland itself. 
 
 The impracticability, however, of removing an submaxii- 
 enlarged submaxillary gland may be readily con- c^Ke 
 ceived, by observing, that the angular or labial cut out. 
 
118 ANATOMY OF 
 
 artery runs along the groove in the body of this 
 Sued S' an ^5 an d also by recollecting the depth to which 
 the gland penetrates; a portion of it turning in un- 
 der the mylohyoideus, while the body of the gland 
 lies on the stylo and hyoglossi muscles. 
 
 The anatomy and diseases of the sublingual 
 gland shall be reserved for the description of the 
 tODgue. */-■ 
 
 When you raise the sterno-mastoid muscle, es- 
 I Q hatic P ec * a 'ty m votm g subjects, you find all the side of 
 fide of° n the neck, from the great blood-vessels back to the 
 neck. edge of the trapezius, thickly covered by an im- 
 mense number of these glands. You must have 
 a recollection of the great number of these, and 
 of the space which they occupy, in order to corn- 
 caused t./ prehend the cause of that great deformity which 
 these eu- j s observed when an enlargement of all those 
 glands occurs at once. 
 
 This disease, which I believe to be of rare oc- 
 currence, is of a chronic nature, and is productive 
 of much less distress to respiration and deglutition 
 than you might expect, from the increased bulk of 
 the parts. The exemption from such distress, 
 may be owing to the situation of these glands on 
 the sides of the cervical vertebras. 
 Lymphatic From the thyroid gland, down to the sternum, 
 vicinity 1 of a large number of lymphatic glands are found, 
 esophagus, some lying before, and some behind the carotid 
 and subclavian arteries. Many of these lie so close 
 to the sides of the trachea, and oesophagus, that 
 when enlarged, they may press on the latter, espe- 
 cially in the vicinity of the top of the sternum, and 
 cause difficulty of deglutition. 
 The ex- The external jugular vein lies covered by the 
 temai ju- fascia and by the platysma myoid.es, the course of 
 n " the vein corresponding very much with the direc- 
 tion of the fibres of this muscle. 
 Line of This coincidence of direction points out the 
 incision propriety of opening this vein, when we wish to 
 
THE NECK AND THROAT. 119 
 
 draw blood from it, by an incision wbich shall be Jj;* j* r it 
 more or less oblique with respect to those fibres. 
 
 Cautiously raising the fascia from the forepart 
 of the neck, you find a vein descending from each 
 side of the face, and running along the side of the superficial 
 throat by the anterior edge of the sterno hyoid ™™ " 
 muscles. These veins acquire a considerable size 
 by the time they come down to the base of the 
 thyroid gland, and they are connected together by 
 a large venous trunk, which crosses the throat at 
 a greater or less distance below the base of this 
 gland. 
 
 It is obvious, then, that in cutting through the 
 integuments in the operation of bronchotomy, this 
 connecting venous trunk may be opened. This Wounds 
 accident would embarrass the operator, by con- SfJ^f 
 cealing the parts from his view; but can hardly be some in 
 supposed to prove dangerous, by pouring blood Jf 6 ™^ " 
 into the trachea after the opening has been made chotomy. 
 into this tube- For, observe that all these veins, 
 the lateral branches, as well as the connecting 
 trunk, lie immediately under the common super- 
 ficial fascia of the neck, and above that fascia 
 which invests all the small muscles, passing be- 
 tween the sternum and larynx. — Now make a 
 slight incision through the internal fascia, where it J^P^'J 
 lies between the sterno-hyoid and thyroid muscles trachea. 
 of the opposite sides; and separating these muscles 
 from each other, the thymus gland will be seen in 
 young subjects, stretching with its cornua up to 
 the base of the thyroid gland. 
 
 The thyroid veins are seen collecting their Thyroia 
 branches from the gland, and then running down veins * 
 along the middle of the trachea in one or more 
 trunks of very considerable size 
 
 Here again reflect on the difficulties which are Difficulties 
 likely to occur when you perform bronchotomy on ^opera- 
 patients under the age of puberty; for, if youjj on ° f 
 make your incision only so low down as midway tomy. 
 
120 
 
 ANATOMV OF 
 
 between the sternum and larynx, your instrument 
 may pass through the substance of the thyroid 
 gland, which is proportionally larger in children 
 than in adults. And perform it at what part of 
 the trachea you may, still you are in danger of 
 opening the thyroid vein when it runs single, or 
 either of the thyroid veins when there are two 
 trunks. Should this accident occur, the blood 
 will readily flow into the trachea, close to which 
 the vein runs, and will be prevented from escap- 
 ing through the external wound, by all the mus- 
 cles and the integuments which cover the trachea. 
 This stage of the dissection, however, affords us 
 spot where a view of that spot in which the operation may be 
 J![j* opera_ performed without any of these inconveniences; 
 be per- and with the additional advantage of performing 
 
 Sgreat ** on a P art wn * cn nes much more superficially; 
 advan- for we see between the cricoid and thyroid car- 
 tages- tilages a triangular space, bounded on each side 
 by the crico-thyroidei muscles, and filled up by a 
 membrane, which connects the cricoid to the fis- 
 sure in the base of the thyroid cartilage. — This 
 space, in its widest part, near to the thyroid car- 
 tilage, measures five eighths of an inch. The 
 distance between the cricoid and thyroid cartilage 
 is three-eighths of an inch. — This spot can be 
 readily discovered in the living body, the promi- 
 nence of the thyroid cartilage, serving as a guide. 
 Between this membrane and the integuments a 
 small depth is interposed, and no large vessels run 
 on its surface. As this membrane is situated along 
 the inferior margin of the thyroid cartilage, an 
 opening made through it will enter the larynx be- 
 low the rima glottidis, and thereby secure all the 
 advantages which result from an opening made in 
 any part of the trachea. /• 
 
 Another, but a more slight inconvenience in the 
 ordinary operation of bronchotomy, arises from the 
 
THE NECK AND THROAT. 
 
 121 
 
 difficulty of keeping the trachea in a fixed position. ^^^ 
 This, however, applies principally to those modes a trocar a 
 of operating in which it is proposed to plunge an ^ a tra " 
 instrument into the trachea without having previ- 
 ously laid it bare. 
 
 It is only by careful examination and repeated operation 
 study of the anatomy of the neck and throat that Jj[ e ty C a r g otid 
 you can be prepared for the bold operation of ty- artery. 
 ing the carotid artery in cases of aneurism of the 
 trunk or of a wound in its deep branches. You 
 know that the common carotid bifurcates a little 
 above the top of the larynx; and therefore you see 
 that an incision to uncover this trunk should not 
 begin much above that point. If the incision be^.V^ 
 continued down to the clavicle along the anterior 
 edge of the sterno-mastoid muscle, it will be found, 
 particularly at its upper part, to run very much in 
 the line of the artery, though a little anterior to it. 
 In order then to expose the fascia which envelops 
 at once the jugular vein, par vagum and carotid 
 artery, you must draw backwards the exposed 
 edge of this muscle. The omohyoideus muscle is 
 seen crossing this incision about two inches, or two 
 inches and a half above the clavicle. The artery ^ e is the 
 is deeply covered as it ascends to the larynx, and most easily 
 can, therefore, be more easily tied in proportion as tied - 
 it has risen above the clavicle. The desceodens Dweii- 
 noni, is more liable to be wounded in the upper W h en most 
 than in the lower part of the incision, as this nerve ganger- 
 advances forward on the sterno hyoidei muscles, 
 in its course down along the side of the throat. 
 
 On cutting through the fascia which invests the jugular 
 carotid artery with the jugular vein and eighth pair ^J 1 *"" 
 nerves; the vein will be found alternately to advance pands and 
 and recede, according as its state of distention is recedes 
 influenced by the different states of respiration: 
 and, therefore, it should be held back by the finger 
 of an assistant, while the operator is exposing the 
 artery, and detaching it from its connexions. 
 
122 AN atom r OP 
 
 The eighth pair of nerves is more intimately 
 connected with the vein than with the artery, lying 
 ^ t0 under the former; so that when you are to pass 
 eluding your needle, it will be more prudent to introduce 
 nerves" ° f ^ on tne outer side of the artery. By this mean 
 the nerve will be secured against injury, as it is 
 easy for the surgeon to introduce the instrument 
 between the nerve and artery: while on the con- 
 trary, if the needle be introduced on the inner side 
 of those vessels, the operator can with difficulty 
 avoid including the nerve and artery in the liga- 
 ture. By using an aneurism needle of silver un- 
 alloyed, such as is recommended by Mr. Aber- 
 nethy, which admits of bending with a very slight 
 touch, this step of the operation will be much faci- 
 litated. 
 
 When you consider the parts which cover the 
 carotid artery, and the manner in which these are 
 connected together by the fascia of the throat, you 
 S-'disci? ma y conce ive now difficult it must be to form a 
 veringan decided opinion of the existence of an aneurism 
 ofcarS °* tms artei T- And yet these are not the only 
 artery, causes of difficulty. For the vein and artery are 
 accompanied down the neck by a chain of lym- 
 phatic glands, the enlargement of one or two of 
 which, would be productive of symptoms nearly 
 the same with those which attend aneurism of the 
 artery. ")C 
 
 In many instances, those unfortunate persons 
 who attempt to commit suicide, inflict the wound 
 Parts most m the upper part of the throat. In the majority 
 frequently of such cases, the os hyoides is separated from its 
 by°a°. e connexion with the thyroid cartilage, and the epi- 
 tempts at glottis detached from its connexions with the la- 
 rynx, still continues its attachment to the base of 
 the tongue. This is rather a wound of the mouth 
 than of the throat, and through it the food comes 
 out along with the saliva, because the anterior wall 
 of the mouth is no longer entire. The trunk of the 
 
THE NECK AND THROAT. 
 
 123 
 
 superior thyroid artery, will probably be opened by 
 such a wound. At all events, some of its branches ^' he ™; e 
 
 n 1 *11 P 
 
 must; and the ha3morrage from these vessels will fuse h*- 
 be profuse, if not suppressed by the fainting of the morrage 
 patient, as is often the case. It is asserted that 
 the ha?morrage from these vessels, has even prov- 
 ed immediately fatal. The profuse bleeding which 
 attends such wounds, has induced some surgeons 
 to mistake these cases for wounds of the carotid 
 arteries. You may, therefore, be assured, that al- 
 most every history which has been recorded, of 
 wounds of the carotid's terminating favourably, 
 has been founded on this mistake. 
 
 The carotid arteries, you may remark, cannot Why the 
 be affected by a wound, of this part of the throat, J™^ 
 unless it be carried very deeply; because you see escape 
 them lying at the sides, and almost behind the la- un ur ' 
 rynx. These arteries you observe, are, from their 
 situation, much more endangered by a wound made 
 in the lower part of the neck. 
 
 The nature of the wound made in these at- These 
 tempts is such, as generally leaves room to hope betimes 
 for a favourable termination. In some cases, how- fatal from 
 ever, that morbid condition of the system which ° au e S e S . 
 preceded, and which in all human probability, pro- 
 duced the attempt, prevents the wound from ever 
 assuming a healing appearance. A remarkable 
 instance of this occurred in the following case: 
 
 A middle aged man attempted to commit suicide, 
 by cutting his throat with a razor; the wound was Exam P le 
 supposed to have passed between the os hyoides 
 and thyroid cartilage, and was about two inches 
 and a half long. Three points of suture were pass- 
 ed through the lips of the wound, and these were 
 supported by adhesive plaster and posture. He 
 refused to take any nourishment until the second 
 day; when he attempted to s-vallow a little milk, 
 one half of which was observed to escape by the 
 wound. On the fourth day all the sutures gave 
 
124> ANATOMY OF 
 
 way. A cough, with which he had been previ- 
 ously troubled, became much more severe, after 
 the infliction of this wound. He had no appetite 
 — complained of constant thirst — and sweated pro- 
 fusely in the nights. The wound never put on any 
 appearance of healing; on the contrary, ulceration 
 extended down along the thyroid cartilage, and 
 this soon became bare and carious. Opiates serv- 
 ed to mitigate the severity of his cough. He daily 
 declined in strength — some of his drink continued 
 to escape by the wound, until the period of his 
 death, which took place in nine weeks after the 
 infliction of the wound. 
 Appearan- Q n examining the parts after death, it was found 
 
 ccs on o t * 
 
 dissection, that a considerable portion of the upper and an- 
 terior part of thyroid cartilage had been removed 
 by absorption ; that the wound which now appear- 
 ed as a round opening, led into the upper part of the 
 larynx, and that the epiglottis still preserved its 
 connexions with the larynx. How shall we ac- 
 count for the escape of his drink through a wound 
 of the larynx, as this really was? 
 Enlarge- That enlargement of the thyroid gland, called 
 Syroiof goitre, we know to be but little affected by any 
 fciand. medicines or external applications hitherto em- 
 ployed. This disease, though not of a painful na- 
 ture, yet induces such deformity as to render the 
 mind of the patient miserable. He sometimes im- 
 plores the surgeon to undertake any operation, 
 however hazardous, for his relief. But to such 
 solicitations nothing should tempt you to yield; for 
 why it you should recollect the large supplies of blood 
 cannot be which this gland enjoys, even in its healthy state, 
 extirpated. ^^ ^ ^ ree commumca ti n between its different 
 arteries. You should also recollect that the infe- 
 rior laryngeal artery lies very deep on the forepart 
 of the cervical vertebrae, behind the trunks of the 
 carotid artery and eighth pair of nerves. It is not 
 necessary to say, that under such circumstances 
 
THE NECK AND THROAT. 125 
 
 the surgeon must find it extremely difficult, if not 
 absolutely impossible, to secure the end of the ar- 
 tery when divided. 
 
 When you are to pass an instrument from the j^jjjj" 
 nose into the oesophagus, be careful to make the during in- 
 patient keep his tongue within his mouth, This ^^ 
 will prevent the instrument from passing into the phagus. 
 larynx; for in this position of the tongue, the epi- 
 glottis is laid down on the glottis. Whereas, if the 
 instrument be introduced while the tongue is push- 
 ed out of the mouth, the epiglottis is raised up, so 
 as to expose the opening of the larynx for the re- 
 ception of the instrument. The same rule should 
 be observed when you are to introduce the instru- 
 ment by the mouth. 
 
 Inflation of the lungs, by a tube that passes inflation 
 through the nostrils into the top of the pharynx, is ° 
 one of the principal means employed for the resus- 
 citation of drowned persons. The object of the 
 practitioner, however, is often defeated, it having J?2 rated 
 been found in many instances, that the air had dis- 
 tended the stomach, while an inconsiderable quan- 
 tity (if any) had entered into the lungs. Such dis- 
 
 J ' . J . i ii • . i • How these 
 
 appointments may be guarded against, by passing failures 
 this tube only so far down, that its points shall reach may be 
 nearly to the base of the tongue, and then pressing prei 
 the trachea gently backwards against the cervical 
 vertebras. For by this expedient the oesophagus 
 will be compressed between the bodies of the ver- 
 tebrae, and the broad posterior part of the cricoid 
 cartilages, while the opening and passage of the 
 larynx remain perfectly pervious. 
 
 It has been said, that foreign bodies stopping in ^JJjJf 1 
 the oesophagus, have caused immediate death. This lodged in 
 event has been ascribed to the pressure made by S^. 9 
 such body on the larynx, or trachea, so as to in- posed to 
 tercept the passage of air through this cartilaginous Jjeatb. 
 tube. But a moment's reflection on the structure ™ s a ^ 
 ©f the larynx, must convince you, that no pressure LTappit 
 
126 
 
 ANATOMY OF 
 
 h b M to *° wn i cn ^ can De subjected, by any body lodging 
 behind it in the oesophagus, can have the effect of 
 compressing its walls so as to close its canal. 
 trachea Again, should the foreign body stop in a lower 
 part of the oesophagus, it cannot cause compres- 
 sion of the trachea to a dangerous degree. For 
 the connexion of the trachea and oesophagus to the 
 surrounding parts, is made by means of such loose 
 cellular substance, as will permit either to elude 
 the danger arising from the pressure of any body 
 lodged in the other. Besides, by bending forward 
 the neck, the compression of the muscles against 
 the anterior part of the trachea, will be removed; 
 and thus the pressure made against the posterior 
 part of this tube, by a foreign body lodged in the 
 oesophagus will be evaded. To what other cause 
 death in those cases is to be ascribed, I shall not 
 pretend to say; as it has not fallen to my lot to exa- 
 mine the bodies of such patients. v 
 bo°Ein Sometimes a foreign body slips into the larynx, 
 larynx, from which, if it is not instantly rejected, almost 
 immediate death ensues. In some instances, how- 
 ever, the foreign body descends into the trachea, 
 and lodging there, produces such severe irritation, 
 that the patient is certainly though more slowly 
 carried off. 
 stricture The oesophagus is but too often the seat of stric- 
 o^oesop a- ^ re rp^ contraction of this tube creeps on so 
 slowly, that in some cases the canal has been com^ 
 pletely closed before any effort has been made for 
 the relief of the patient. Under these distressing 
 circumstances, the surgeon might feel himself jus- 
 tified in using a considerable degree of violence, 
 for the purpose of forcing open the passage. But 
 to this practice many objections occur. For the 
 objections instrument instead of being pushed down through 
 instrument the constricted part of the canal, may be forced 
 them gh out tnrou gh i ts side, immediately above the seat of 
 the disease. So that if the stricture occupy any 
 
THE NECK AND THROAT. 127 
 
 part of the oesophagus, which lies in the thorax, 
 the instrument may be forced into the mediastinum, 
 or even into the thorax, and thus a passage for li- 
 quids, at least, be opened into either of those ca- 
 vities. Should the stricture be seated in the upper 
 part of the oesophagus, we run the risk of wound- 
 ing the carotid artery, the jugular vein, or eighth 
 pair of nerves, by the instrument forcing a pas- 
 sage through the coats of the tube. 
 
 The dangers which beset every attempt mecha- Dangers of 
 nically to destroy strictures of the oesophagus, are tempt in- 
 most materially increased, by the changes which "^f ( by 
 the disease induces on that portion of the tube, im- oesophagus 
 mediately above the seat of stricture. For here a 
 remarkable dilatation takes place, so great in fact, 
 that we find it described by different writers, as a 
 pouch formed by the oesophagus above the seat of 
 stricture. It is obvious that any instrument em- 
 ployed for the purpose of forcing a passage through 
 the stricture, will almost inevitably be pushed into 
 this pouch, and forced through the sides. 
 
 The objections to which an attempt to force open ° b c "s t °j ni 
 the constricted portion of the oesophagus is subject, in such 
 apply with equal force to the use of caustic bougie cases " 
 in such cases. 
 
128 
 ANATOMY OF THE PELVIS. 
 
 The anatomy of the pelvis is an object of no 
 less difficulty to the surgical student, than of utili- 
 ty to the surgical practitioner. 
 
 The advantages derived from a thorough know- 
 anceofan ledge of this piece of anatomy; the light which it 
 EoSe tnrows u P°n the nature of some obscure diseases; 
 of this the confidence which, in a variety of circumstan- 
 anatomy ces > ^ must nn P ar t to the operator, will more than 
 repay him for all the pains and labour which he 
 must necessarily bestow on the many intricate and 
 varied dissections of the same part. For instance, 
 a knowledge of the anatomy of those parts, can 
 alone enable the surgeon to perform, with safety, 
 ia uthoto- the arduous and hazardous operation of lithotomy. 
 For the incisions are to be carried through a space 
 so confined, and so surrounded by important parts, 
 that the slightest deviation of the knife may be at- 
 tended with the most serious consequences, ^or 
 can the surgeon, without an intimate knowledge 
 of the anatomy of the pelvis, understand the causes 
 inreten- of the many failures he may meet with, in attempt- 
 urine, ing to relieve his patients from retentions of urine; 
 and consequently he must be indebted to blind 
 chance for those instances in which he may hap- 
 pen to accomplish his object. An ignorance of 
 the anatomy of those parts, not only subjects the 
 surgeon to the disgrace of total failure, but like- 
 wise subjects the patient to the probable loss of 
 life. In many cases of affections in the urethra or 
 bladder, the life of the patient, which would have 
 been spared by the disease, has fallen a sacrifice 
 to unnecessary and ill-directed force used in the in- 
 fn passing troduction of a catheter or bougie. For in many 
 
 b iugie or ,» , . . ° . , . J 
 
 catheter, ot those cases, the constitution is sympatnyzing 
 
THE PELVIS. 
 
 129 
 
 strongly with the diseased condition of the urinary 
 organs; and at the same time is so much affected, 
 that it cannot, without danger, admit much addi- 
 tional irritation. How often do we find the sur- 
 geon indebted for a short lived success, rather to 
 chance than to skill. How often do we find that 
 the same surgeon has been in the habit of passing 
 the same instrument fordays together; but at length, 
 from some accidental alteration in the position of 
 the patient, or some unobserved deviation in the 
 direction of his instrument, he meets a resistance, 
 which his anatomical knowledge does not enable 
 him to comprehend or surmount? 
 
 Do not attempt to dissect the soft parts of this Review of 
 cavity, without refreshing your memory by a view ^udieof 
 of its more solid boundaries. Examine the pelvis pelvis ne- 
 of an adult stripped of every softer part, even f cessary ' 
 its ligaments. Next study the pelvis with its liga- 
 ments. Compare the pelvis of the adult male with 
 that of the female; of the adult with that of the 
 child. You must next examine this cavity as con-particu- 
 nected with the trunk of the body, and carefully JJ^^SJ 
 mark the relative position of the one to the other, ject. 
 Make this examination on the recent subject, and 
 not on the preserved skeleton. For should you 
 examine it only on the latter, you will be misled 
 in a matter of the greatest consequence to the prac- 
 tising surgeon. For in this way only can you ac- 
 quire an accurate knowledge of the relative posi- 
 tion of the axis of the pelvis to that of the trunk of 
 the body. This knowledge affords the greatest as- 
 sistance in ascertaining the nature of some obscure Advanta- 
 diseases, and is particularly subservient to the dis- £*! Re- 
 covery of some injuries to which the pelvis and curate 
 lower extremities are occasionally exposed. But nb P e rc .fa- 
 its utility is of still more considerable extent. For >" e p° s j- 
 
 t -ii i i i i r ,i • lion of th< 
 
 I will venture to assert, that a knowledge ot this pc i vis . 
 single point will explain to you the most frequent 
 cause of unsuccessful operations for the stone, will 
 
 R 
 
 the 
 
130 ANATOMY OF 
 
 guard you against similar errors, and open the road 
 to improvements in some of the most delicate and 
 most difficult operations which the surgeon is call- 
 ed upon to perform. We shall not now enter into 
 a detail of ail the varieties in the position of the 
 pelvis, which depend on age or sex. We shall 
 confine ourselves at present to the consideration 
 of the changes induced in the position of the pel- 
 vis of the adult male, by the different postures of 
 the body. 
 C b s K S of n When the body is erect, the pelvis is so placed, 
 pelvis that a line passing from the third lumbar vertebra, 
 afferent 7 w ^* * a N nearly upon the superior edge of the sym- 
 positions of physis of the ossa pubis. For in this position the 
 iSection cavity of the pelvis is projected so far backwards, 
 of pelvis that the ossa pubis become the part, against which 
 Z erec? 7 tne abdominal viscera press. You see, therefore, 
 that in those positions of the body, wherein these 
 viscera could gravitate against the cavity of the 
 pelvis, its oblique position protects it. And, there- 
 Advanta- fore, you will cease to wonder how it comes to pass, 
 direction^ tnat the muscles of the pelvis, so slight in texture, 
 pelvis in should be calculated to counteract the pressure of 
 ture. P ° the abdominal viscera, and the action of the abdo- 
 minal muscles and diaphragm. For, you now see, 
 that it is the action of the diaphragm only, which 
 they are required to counteract; and by referring 
 to the oblique position of this muscle, you observe, 
 that the direction of its force in any other position 
 (except when the body is bended forwards) is not 
 to press into the pelvis, but against the lower part 
 of the abdominal muscles. 
 Direction When the body is laid horizontally, the axis of 
 hoiuzontai the pelvis forms with the axis of the body, an angle 
 posture, of nearly sixty degrees; but this angle is not inva- 
 riably the same in all adults. In females, it is more 
 in chiidren'ootuse than in males. In children, this angle is so 
 extremely obtuse, that the axis of the pelvis, and 
 
THE PELVIS. 
 
 1S1 
 
 that of the trunk, almost coincide, on account of 
 the straight form of their vertebral column. 
 
 When the patient is laid horizontally, and the 
 pelvis raised, we find, that in proportion to the de- 
 gree of its elevation, the angle formed by the axis 
 of the pelvis with that of the trunk, is rendered 
 more and more obtuse, until at length, by a consi- 
 derable elevation of the pelvis, the axes of both ca- 
 vities are made to coincide. 
 
 The effects which other positions of the body 
 have on the viscera contained in, and connected 
 with the pelvis, shall be reserved until we have 
 spoken of the structure and attachments of each 
 of these organs. 
 
 This one point, the direction of the axis of the 
 pelvis being established, you will be ready to ad- 
 mit these inferences. That in extracting a stone 
 from the bladder in the lateral operation, your pa- 
 tient being placed horizontally, you should endea-^ 
 vour to withdraw the forceps in the direction of 
 the axis of the pelvis, and not in the line of the axis 
 of the trunk. For in this last direction, the for- 
 ceps and stone would be brought in contact with 
 the arch of the pubis, by which the urethra and 
 all the soft parts in the vicinity of this arch must 
 be so severely contused, that this injury would pro- 
 bably terminate in the death of the patient Nay, 
 if the stone were large, it would be impossible for 
 the surgeon to extract it in this direction. 
 
 The influence which the position of the pelvis 
 has on catheterism, and the operation of litho- 
 tomy, will be mentioned after the organs of gene- 
 ration have been described. 
 
 The pelvis in the male, contains the bladder with contents 
 
 " ' of pelvis. 
 
 its appendages, and the rectum. 
 
 The rectum entering the pelvis, descends along Rectus. 
 the anterior surface of the os sacrum, keeping, 
 however, a good deal to its left side. Although 
 
132 
 
 Dilatation 
 
 ANATOMY OF 
 
 it this intestine be cylindrical and contracted in its 
 upper part, yet we always find it dilated in that 
 portion which is behind the bladder, between it and 
 the anus: so that there a sort of sac is formed, the 
 mouth of which is shut by the muscles of the anus. 
 (This dilatation is more evident in adults than in 
 children, however it will be found in children, ex- 
 cept those of one or two years old ) Therefore 
 the rectum above its sphincter, does not form a 
 cylindrical cavity, but a flattened pouch, of which 
 the part next to the bladder is longer — the opposite 
 part is the shorter. Hence it is plain, that the in- 
 
 <iii s e formin testme cannot be moved from its place by the fin- 
 
 lithotomy. ger being introduced into the anus, and therefore 
 this proceeding is not sufficient to secure this in- 
 testine from being wounded in the lateral operation 
 of lithotomy; nor can we facilitate the introduction 
 
 ca1Er. ng °f tne catheter into the bladder, by attempting with 
 the finger introduced per anum, to draw down the 
 rectum. 
 
 conect of Carefully observe the relations of the rectum 
 
 peritoneum , , J . .„ . , 
 
 with rec- and the peritoneum. In some cases you will tind 
 tum - this membrane completely surrounding the gut, and 
 attaching it to the sacrum, by a sort of mesentery, 
 which anatomists have termed meso rectum. In 
 ^ e h Jf f"' ts general, however, the peritoneum covers only the 
 connected anterior half of the circumference of this intestine, 
 toneum! 1 an d consequently binds it firmly to the os sacrum. 
 Nor does the peritoneum afford this partial cover- 
 ing to the entire of the length of the intestine. For 
 having descended on the gut, so low as to be near- 
 ly on a level with the upper extremities of the ve- 
 siculas seminales, it is then reflected from it to the 
 posterior surface of the bladder. Thus a consi- 
 This part derable length of the rectum is left uncovered by 
 be cut ^n the peritoneum, between the place of its reflection 
 operating; an( j the an us. This therefore is the only part of 
 inano." a the gut which can with safety be divided in the 
 operation for fistula in ano. J udge then, whether 
 
THE PELVIS RECTUM. 
 
 133 
 
 we are to consider as improvements, those instru- 
 ments, or directions which would enable us to di- 
 vide this intestine so high up as to reach the part 
 where it is covered by peritoneum. Consider well Lest abdo 
 the risk you would thereby run, of cutting through me n be 
 this membrane, and thus laying open the cavity of °P ened - 
 the abdomen. JNor is the subsequent peritoneal 
 inflammation the only evil to which the patient is 
 exposed, by such incisions. The internal has- And inter- 
 morrhoidal artery is also liable to be wounded, ^^ 
 where it is yet of considerable size. It is scarce- ai artery. 
 ly necessary to add, that the haemorrage from such 
 a wound, will be more serious when the incision 
 is made in the posterior part of the intestine, along 
 which the undivided trunk of the artery takes its 
 course. 
 
 The haemorrage in these cases, is not always f g *™^~ 
 manifested by a discharge of blood externally. For this not 
 it sometimes happens, that the sphincter ani per- ^/ex- 
 forms its office so perfectly, that while some con- temaiiy. 
 siderable branch of the haemorrhoidal artery, which 
 has been wounded, pours its blood freely into the 
 cavity of the intestine, not a drop of it is allowed 
 to escape externally. The accumulation of blood Conse _ 
 in the lower portion of the gut, produces an irn- quences of 
 tation on the neck of the bladder, with frequent thls 
 and unavailing attempts to pass urine. At length, 
 the over-distention of the gut causes such an irrita- 
 tion, that the patient is seized with an irresistible 
 desire of going to stool. By this, the entire of the 
 accumulated blood, is suddenly discharged, and the 
 patient is seized with an immediate fainting. 
 
 This disease of fistula in ano, is sometimes in-^s^ 1 ". 
 duced by the presence of some solid body, which times eaus- 
 having been swallowed by the patient, had passed r eignbod y , 
 along the internal canal, without causing much ir- ; vhich had 
 
 ., ,? . . , ,, ' . , ,, ° ., been svval- 
 
 ritation. At length, entering into the rectum, it lowed. 
 there begins (from what cause is unknown) to ex- 
 cite irritation; this sometimes ends in ulceration 
 
131 ANATOMY OF 
 
 of the coats of the intestine, by which that extra- 
 neous body is removed from its cavity. And now 
 lodging in the cellular substance, which surrounds 
 the extremity of the rectum, it there excites a con- 
 stant suppuration. In one case of this kind, I found 
 on laying open the sinus, that a long piece of the 
 bone of a goose's wing lay transversly in the but- 
 tock. In another case, I saw Mr. Obre extract 
 a small round stone. This latter case was not pre- 
 ceded or attended by any urinary distress, and the 
 patient got well in the ordinary time after such an 
 operation. 
 Prolapsus '^ ne l ()Wer ena * °f tne rectum is subject to an in- 
 ani. version through its extremity, where it is surround- 
 ed by the sphincter ani. This has been improper- 
 ly termed prolapsus ani. For the anus or lower 
 How pro- extremity of the rectum, remains unmoved from 
 duced. -£ g situation, and unaltered in its connexions with 
 the surrounding parts. It is, in fact, the portion 
 of the gut immediately above its termination, that 
 descends in an inverted state through the anus. 
 This inverted portion in time, increases in length. 
 It is capable of being returned, but is, however, 
 generally found to descend again on the patient's 
 straining to stool, and sometimes even on his using 
 Remarka- anv bodily exertion. This state of the gut is often 
 
 1)16 circurn™ * 
 
 stances in attended with a very remarkable circumstance. 
 thisdis- 'j'bg patient cannot discharge the foeces, unless he 
 suffer the bowel to come out. This Morgagni at- 
 tempts to explain in the following manner: 
 How ac- " It remains, therefore, that the relaxation of the 
 Jy U £. for intestine must be supposed so considerable, that 
 gagni. descending when pushed down by the excrements, 
 in a great number of large rugae laid one upon an- 
 other, it forms something like a valve; especially 
 as often as being retained by any kind of artifice, 
 it cannot altogether extend and unfold itself, and 
 by this means give an open passage to the excre- 
 ments." 
 
THE PELVIS — RECTUM. 
 
 135 
 
 This disease, so frequent in children, has been ^p 8M 
 ascribed to relaxation of the sphincter ani alone, caused by 
 or to a relaxation of this muscle, combined with a relaxat,on 
 relaxed state of the levatores ani. But to this opi- ^f " 3 
 nion we shall feel some reluctance to subscribe, opinion. 
 when we reflect that we have not only no proof 
 adduced, of the existence of this state of relaxation 
 in the muscles of the rectum; but that in cases of 
 paraplegia, where extreme weakness of all the 
 muscles of the lower extremities and lower part of 
 the trunk takes place, and even continues for years, 
 we yet cannot observe any appearance of prolap- 
 sus ani manifesting itself, during any part of this 
 period. In fact, the disease termed prolapsus ani, it is a true 
 is strictly an introsusception of the rectum. In JJJJf rf 
 confirmation of this, we find that in many instan-theintes- 
 ces, it has been induced by some irritation of the bne ' 
 upper portion of this intestine. I have lately had 
 an opportunity of examining this disease, in two 
 subjects of about six years of age. In both, the Appearan . 
 protruded bowel was about two inches long. Onceson 
 opening the abdomen, the colon appeared natural, 
 not at all stretched, without any appearance of its 
 having been drawn down into the pelvis. The me- 
 sorectum with the internal haemorrhoidal artery 
 appeared tense, and as if drawn into the prolapsus. 
 
 On cutting through the outer fold of the prolap- 
 sus, the branches of the interna! hsemorrhoidal ar- 
 tery were exposed to view, and were easily traced; 
 the subject having been previously injected. The 
 external adhered, though not very closely, to the 
 internal fold of the prolapsed intestine. 
 
 The finger was more readily passed through the 
 prolapsed intestine, when entered from above, than 
 when introduced from without. By pulling the 
 mesocolon upwards, the prolapsus was much short- 
 ened; and then it was obvious that the portion of 
 the gut which had been thus disengaged, was of a 
 purple or red colour. This colour did not extend 
 
136 
 
 ANATOMY OF 
 
 to a higher part of the intestine. However, some 
 slight marks of inflammation were perceptible in 
 distinct patches along the gut, up as far as the co- 
 lon. On drawing up and cutting open that part of 
 the rectum, which formed the upper portion of the 
 prolapsus, a number of small, distinct, round, white 
 ulcers were seen. These were as thickly set as 
 they could well be, or as thick as apthas appear 
 on the tongue. 
 
 The colon, on being cut open, exhibited many 
 distinct ulcers of the same size and form; but not 
 with the same white surface. Around some of 
 them an increased vascularity denoted the exist- 
 ence of inflammation. The ulcers became less 
 deep, and less frequent, and the mark of inflam- 
 mation less strong, as you passed backwards to- 
 wards the cascum. No marks of inflammation 
 were observable on the external surface of the 
 onES smau " intestines. We may, therefore, call in ques- 
 ease in tion the validity of that opinion, which ascribes the 
 noJcauled f re q uen cy of this disease, in early periods of life, 
 by want of to the want of support from the os coccygis. Will 
 Butby ex- n °t * ne extreme irritability of the bowels, at this 
 treme irri- early period of life, account for the greater fre- 
 boweis. quency of this disease in children? 
 
 The cure of this disease is, therefore, not to be 
 sought for in mechanical contrivances, for prevent- 
 ing the descent of the intestine. It is rather to be 
 looked for in those means which remove or dimi- 
 nish the causes of irritation in the bowels. X 
 teTanuT" Children are born sometimes with the defect of 
 an imperforated anus. In some instances, while 
 there is no passage for the fceces in the natural di- 
 Varieties rection, they are capable, notwithstanding, of being 
 of this dis- discharged from the body. For the extremity of 
 the gut opens into the vagina in females, and into 
 the urinary bladder in males. In other instances 
 there is no outlet whatever for the fceces, the intes- 
 tine terminating by a blind extremity, which in dif- 
 
THE PELVIS — RECTUM. 
 
 137 
 
 ferent cases lies at different depths in the pelvis, or 
 along the sacrum. Sometimes the gut descends 
 so low, that its extremity is covered only by the 
 cutis, or by a membrane of no great thickness. 
 The precise nature of such cases will be indicated 
 by a fullness and tension of this membrane, in con- 
 sequence of the pressure of the meconium against 
 it. Here an incision made through this membrane *° *«« 
 
 C5 _ case ope- 
 
 will be perfectly safe, and uniformly successful. In rations 
 other instances, where there is no outlet for the s^^fu) 
 foeces, and where the intestine terminates higher 
 up in the pelvis, the surgeon will feel himself call- 
 ed on to make some effort for the preservation of • 
 the child. He will therefore make an incision operation 
 through the integuments, at the spot which the ^Ve* 
 wrinkled and folded appearance of the skin, indi->™tde- 
 cates to be the natural situation of the anus; he will to e anus neai 
 then carry his instrument deeper and deeper into 
 the pelvis. These incisions he will carry on in a 
 straight line, because he knows that the intestine 
 as far as it reaches, lies on the face of the sacrum, 
 and that the bone is perfectly straight at this period 
 of life. He will feel less hesitation in making those Biadde* 
 very deep incisions, by recollecting that the bladder ^byta 
 does not press backwards on the rectum; but when form- 
 distended rises, of a pyriform shape, into the abdo- 
 men. Therefore he is not in great danger of 
 wounding this viscus, after his knife has passed 
 beyond the region of the prostate gland. 
 
 It is to be observed, that in some cases of male 
 infants, although a communication of the gut with 
 the bladder, be manifested by the discharge of a 
 small quantity of foeces along with the urine, yet 
 the condition of the child is not less deplorable, 
 than if no such communication existed. For the 
 quantity of foeces which is discharged in this way, 
 being very inconsiderable, the infant suffers the 
 same distress, as if no outlet whatever had been 
 given. 
 
138 ANATOMY OF THE PELVIS RECTUM. 
 
 By the following extract from Morgagni, we 
 
 may learn how feeble should be our hopes and how 
 
 fhS ? g uar ded our prognosis in all cases of imperforated 
 
 guarded. anUS. 
 
 " Sometimes by introducing the finger per anum, 
 for some little space, which is sufficiently pervious, 
 the surgeon naturally conceives the hopes of a suc- 
 cessful incision, as if nothing but a kind of mem- 
 brane, which was interposed, cut off this commu- 
 nication with the upper part of the rectum; and yet 
 this remaining part is in fact no where: but the 
 other rectum is an intestine, which being full of 
 fceces, is inflected at a considerable distance from 
 the anus to the upper part of the os sacrum, and 
 being shut up and firmly connected to that part, 
 terminates there. For sometimes the rectum has 
 in the whole extent of it no passage at all, but is 
 solid like a rope; and sometimes even the whole of 
 this intestine is wanting. Wherefore, when any 
 other passage is sufficiently open, although attend- 
 ed with great inconveniencies; and it is not cer- 
 tain, that the rectum comes down so far between 
 the buttocks, that its canal is covered only by the 
 cutis, or a membrane of no great thickness; we 
 must not search in that part for what, perhaps, 
 terminates in some other place, as for instance, in 
 the upper part of the vagina. For unless the in- 
 cision penetrates thus far it can have no effect in 
 removing the complaint; and if it does really pene- 
 trate thus far, two other dangers remain behind, 
 besides that of hasmorrage or convulsions. One 
 of which is lest the passage formed by nature into 
 the vagina, may never be quite closed up, notwith- 
 standing the incision: and the second, lest that 
 which is opened artificially by another way, should 
 from the want of a sphincter to shut up the orifice 
 not remove, but double the inconvenience. 
 
 " But if there be naturally no exit at all to the ad- 
 dominal fceces, a doutbful method of cure ought to 
 be preferred to the certain death of the infant." 
 
139 
 
 ANATOMY OF THE EXTERNAL OR- 
 GANS OF GENERATION. 
 
 It is unnecessary for me to remind you that the 
 penis is composed of two cylindrical bodies, the 
 corpora cavernosa, which, arising from the rami 
 of the ischia, join together at the lower edge of the f penis. 
 symphysis pubis to constitute one body, terminat- 
 ing at the base of the glans. The body of the 
 penis constructed thus of two cylinders applied to 
 each other must, of course, have along the line of 
 their union two grooves, one on its upper, the other 
 on its lower surface. In the former of these the 
 trunks of the blood-vessels and nerves are situated. 
 The lower is occupied by the canal of the urethra, of urethra 
 This canal, designed for conveying the urine from 
 the bladder, is surrounded in the greatest part of 
 its course by a cellular texture, replete with blood, 
 and called its corpus spongiosum. — This com- 
 mences in the perinaeum by a bulbous swelling, 
 and terminates anteriorly in that dilatation called 
 the glans penis. The remaining part of the urethra, 
 between the bulb and neck of the bladder wants 
 the corpus spongiosum; a portion of which, in the 
 immediate vicinity of the bladder is surrounded 
 by the prostate gland. What remains of the canal 
 between the anterior point of the prostate gland 
 and the bulb of the corpus spongiosum is termed 
 the membranous part of the urethra. 
 
 We shall now proceed to a more particular 
 examination of the structure of each of these 
 parts. 
 
 The skin is connected to a ligamentous covering 
 of the corpora cavernosa penis by cellular sub- 
 stance destitute of fat; and is continued over the 
 lans without being attached to it. Having reach- 
 
140 ANATOMY OF 
 
 Prepuce, ed to the point of the glans, it turns inwards, and 
 structure of term | nateg ^ attaching itself to the body of the 
 penis immediately behind the base of the glans. 
 Between the internal and external portion of skin, 
 thus forming the prepuce, a quantity of cellular 
 substance is interposed. 
 Lteamen- On raising the skin, we find a ligamentous 
 of U peniT. c membrane, which invests the penis, and which is 
 derived from the suspensory ligament. This liga- 
 Suspensory merit begins about an inch and a half above the 
 olFpenSs. pubis, by an origin of nearly an inch in breadth. — 
 It becomes more thick and raised as it passes down 
 over the pubis, and is so wide that some of its 
 outer fibres are blended with the fascia lata of the 
 thigh, and yet is not sufficiently wide to cover the 
 abdominal rings. It terminates on each side close 
 to the rami of the pubis, by being blended with 
 the fascia, covering the adductor muscles of the 
 thigh. This ligament where it lies on the abdo- 
 men, does not possess a perfectly ligamentous tex- 
 ture; for here it is blended with a considerable 
 portion of fatty substance. From the abdomen it 
 descends along the symphysis pubis, to which it is 
 very firmly fixed. Here it assumes a perfectly 
 ligamentous texture. This ligament, adhering by 
 its upper edge to the symphysis pubis descends 
 and fixes itself by its lower edge to the dorsum 
 penis; but it does not cease here, for it can be 
 traced, expanding itself over the crura of the pe- 
 nis, and the urethra until it terminates at the base 
 of the glans, thus constituting one of the envelops 
 of the penis. 
 structure From the structure of the prepuce, constituted 
 explains 06 of two layers of skin, with a quantity of cellular 
 the effects substance interposed, we can easily explain the al- 
 ca on it. terations which this part undergoes in cases of 
 anasarca. 
 
 For the fluid distending the cellular substance 
 will not only contract the orifice of the prepuce. 
 
THE ORGANS OF GENERATION. Hi 
 
 but by elongating the skin beyond the glans, will 
 cause this unsupported part to assume a tortuous 
 form. 
 
 This elongation and distortion of the prepuce is inconve- 
 sometimes productive of no inconsiderable obsta- °f tbis. 
 cle to the discharge of urine. The obvious remedy 
 for this inconvenience is, occasionally to introduce ^Jj?Jb e 
 into the orifice of the prepuce, a bit of prepared ie 
 sponge or other substance, which expanding, will 
 enlarge this opening. It is scarcely necessary to 
 remark, that in these dropsical habits of body, any 
 attempt to unload the cellular substance by punc- 
 turing the skin, is attended with much risk. 
 
 It too frequently happens that chancres seated ch ^res 
 behind the corona glandis, are attended with in- J^"*! 1 ^ 
 flammation and suppuration, which pass backward 
 along the dorsum penis. These present a small 
 ulcerated surface behind the glans, from which a 
 considerable discharge flows, particularly when 
 pressure is applied to the body of the penis. The 
 seat of such inflammation is under the ligamentous ^ e f 
 covering of the penis. Sometimes the matter not Sometimes 
 only burrows unaer this covering, but even passes pa ssup on 
 up to the pubis, and there forms an abscess, which P ubls - 
 ultimately opens externally. Your knowledge of 
 the origin and extent of this fascia will explain Their 
 why the inflammation takes this course. When course ac- 
 the abscess happens to be seated under the thicker countedfor 
 portion of this ligament, near to the linea alba, and D £ h they 
 there opens externally; you might imagine from its open near 
 depth, that it was seated 'among the abdominal 2J| mea 
 muscles or even under them. This portion of the 
 ligament is here naturally so thick, and this thick- 
 ness is so materially increased by the previous in- 
 flammation, as to cause this deception. 
 
 In some few cases, where these abscesses along Sometimes 
 the penis and pubis, have been numerous and long Eiions 6 
 continued, it has happened that, on their healing of the P e- 
 this fascia has been so contracted as to produce 
 
142 
 
 ANATOMY OF 
 
 distortion of the penis when turgid. In such in- 
 stances, the thickened and contracted state of this 
 ligamentous covering keeps the penis drawn up 
 towards the abdomen. This distressing effect I 
 have known spontaneously to wear off, after consi- 
 derable lapse of time. It admits, however, of a 
 How to be more speedy remedy: for this purpose, let an in- 
 remedied. c j s j on g e ma( j e through the hard ridges formed in 
 this fascia, and let the edges of the wounds be kept 
 separate by interposed dressings. 
 Effects of j n caS es of chancres, where rapid ulceration has 
 
 destruction , ' r , 
 
 ofgians seized on and destroyed the glans penis, we ob- 
 chaicres serve that during the progress of ulceration, the 
 prepuce inflames, becomes thickened, and incapa- 
 ble of being retracted . When the ulceration ceases, 
 the prepuce becomes less thick; and now admit- 
 ting of retraction, presents the following appear- 
 ances: — 
 
 aSes 3 to ^e s ^ m °^ ^ le P re P uce * s seen covering and 
 opening of adhering to the extremity of the penis, so as to 
 urethra. j eave on jy a small opening coi responding with that 
 of the urethra. The circumference of this open- 
 ing is much less than that of the healthy urethra: 
 so that a considerable obstruction is given to the 
 flow of the urine, even at this early period of their 
 Tending adhesion. We remark also, a very alarming ten- 
 jo narrow dency in this small orifice, to contract itself still 
 ' more every day, so as to threaten a complete oblite- 
 ration of the extremity of this canal. This ten- 
 dency to contraction, appears to be communicated 
 Also gives to ^ Qj-jjgj. parts f the canal, and thus give rise 
 stricture, to strictures of the urethra, A similar union of 
 simitar the integuments to the surface of the stump, takes 
 cesser"" place after amputation of the penis, and is fbllow- 
 amputation e( j Dv a like tendency to contraction, and the for- 
 mation of strictures. Hence we may call in ques- 
 tion the propriety of that rule which directs us in 
 this operation to retract the skin, in order that we 
 
THE ORGANS OF GENERATION. 14S 
 
 may save as much of it as will be sufficient to 
 cover the end of the stump. 
 
 The strong membrane which forms the walls of 
 the corpus cavernosum penis, sometimes yields so 
 as to produce a swelling analogous to aneurism. Aneuris- 
 From a knowledge of the structure of the penis, ™* n y a " 
 we are prepared for those symptoms which charac- corpus ca- 
 terise this affection, and which have been so accu- JeSs?" 1 
 rately laid down by Albinus, in the history of -the 
 case which he relates. The tumor is rather soft, symptoms 
 and the skin which covers it, is as moveable on 
 that as on the other part of the penis. While the 
 penis is flaccid, the tumor is smaller and softer, 
 and becomes larger and harder during the state of 
 erection. 
 
 In the early part of the disease, the tumor rea- 
 dily subsides on the application of pressure; in the 
 progress of the complaint it subsides less easily 
 and less perfectly. This disease has been mistaken 
 for an abscess, and opened by the surgeon. It is 
 scarcely necessary to say, that an attention to the 
 preceding history, together with the want of dis- 
 coloration of the integuments, and of the pointed 
 form so characteristic of abscess, will enable us to 
 avoid such dangerous mistakes. 
 
 The scrotum is composed of the skin, under scrotum. 
 which is found a thin layer of cellular membrane. 
 This envelops the dartos, which many suppose to 
 be of a muscular nature. Between the dartos and 
 testicles is found a cellular substance of a very loose 
 texture. This surrounds the testicle in such large 
 quantities as, by facilitating its change of place, 
 enables this gland to elude the effects of blows, or 
 other external injuries. We observe a great num- 
 ber ot veins, and some of these of a large size, 
 distributed among the various layers of which the 
 scrotum is composed. 
 
 By attending to the vascular condition of the 
 scrotum, you may judge what effects are likely to 
 
144 
 
 ANATOMY OF 
 
 Effects 
 from 
 
 wounding 
 any large 
 vein. 
 
 Large 
 hydrocele 
 burst by 
 external 
 violence, 
 
 follow, when one of its large veins are cut in the 
 operation of tapping a hydrocele of the tunica 
 vaginalis testis* For when you have closed the 
 anterior part of the wound by sticking plaister, 
 the blood may still flow from the wound in the 
 opposite or posterior surface of the vein, and may 
 insinuate itself widely among the cellular substance 
 of the scrotum. This will produce a swelling of 
 the scrotum, of a black or livid color, assuming 
 much of the appearance of gangrene. 
 
 Next, you will readily see how it happens in 
 cases of old and large hydroceles, that by a blow 
 on the scrotum, the tunica vaginalis testis shall be 
 burst, and the water of the hydrocele effused into 
 the cellular substance of the scrotum. As this 
 must be accompanied by rupture of some vessels 
 of the skin and tunica vaginalis, the case will be 
 complicated with effusion of blood. The swelling 
 thus produced, will assume much of the character 
 of gangrene, but not any of the dangers. For the 
 effused fluid will be gradually absorbed, and the 
 bulk of the parts reduced nearly to the natural 
 standard, while the rent in the tunica vaginalis 
 testis, will unite again, and the sac be again ren- 
 dered capable of holding the water which still 
 continues to be secreted into it, and thus the dis- 
 ease will again be renewed. 
 
 The structure of the scrotum will also enable 
 you to foresee the enormous size to which it may 
 be distended, in cases of anasarca, and to which it 
 is particularly subject, by its low and pendulous 
 situation. This structure too, will enable you to 
 judge of the facility with which ingenious impos- 
 tors blow up the scrotum, for the purpose of coun- 
 terfeiting ruptures. For by a blow-pipe introduc- 
 ed into a very small opening, made in its posterior 
 part, the entire of one side of the scrotum is rea- 
 dily inflated, and the part assumes many of the ap- 
 pearances of inguinal hernia. 
 
145 
 ANATOMY OF PERINEUM 
 
 Now proceed to dissect the perinaeum. Raise Perinffiuni 
 the skin of the perinaeum, extending the dissection J? s ° s d ^ t ° n f 
 beyond the tubera isehii to the thighs. This ex- j t , . sse ' 
 poses to view a strong fascia, which, on dissection, 
 will be found to cover the entire of the perinaeum, Fas .^ u ^ 
 and to blend itself with the structure of the scro- per 
 turn. This fascia, although on a superficial view 
 it appears continuous with the fascia of the muscles 
 of the thigh, will yet be found, on closer exami- 
 nation, to attach itself very firmly to the rami of 
 the ischium and pubis. The texture and connex- 
 ions of this fascia, will serve to explain many of 
 those phaenomena, attendant on the effusion ofinfluence 
 urine into the perinaeum, by rupture or ulceration effusion"of 
 of the posterior part of the canal of the urethra. « rine - 
 
 First, then you will find that this fluid, when so 
 effused, although it forms a tumor in perinaeo, 
 rarely terminates by suppuration and ulceration in 
 this spot; being here resisted by the dense and un- 
 yielding texture of the fascia, diffusion laterally 
 towards the thighs, is prevented by the close at- 
 tachment of this fascia to the rami of the pubis 
 and icschium; while its progress forwards, is fa- 
 voured by a quantity of cellular substance, inter- 
 posed between the surface of the perinaeal muscles 
 and this fascia. In general, then, we find that the Pnenome- 
 urine having caused some tumefaction in perinaeo, "^JjJ" 011 
 passes on into the scrotum. Here meeting with Distention 
 only a very feeble resistance from the lax texture «i scrotum. 
 of this part, it quickly distends it to a very consi- 
 derable size. In some instances the mischief does 
 not extend further, for suppuration takes place in 
 the scrotum, and a quantity of very foetid fluid, 
 composed of urine and pus, is discharged as soon 
 
 T 
 
146 ANATOMY OF 
 
 as the abscess spontaneously bursts, or is opened 
 by the surgeon. In other cases, the effused urine 
 continues its progress until it arrives at the pubis. 
 Here it causes a swelling, which becoming red, 
 
 Ulceration • • • 
 
 of pubis, tense, and painful, at length ulcerates; and giving 
 exit to a large and foetid discharge of urine mixed 
 with pus affords some relief to the patient. As 
 often as the patient attempts to pass urine, some 
 of it filters through this opening. In process of 
 time, considerable sloughs of cellular substance 
 are drawn out through it. After this the swelling 
 subsides, the orifice contracts, and the disease ter- 
 minates in an urinary fistula. 
 
 In some cases, besides the opening on the pubes, 
 an extensive gangrene seizes on the integuments 
 of the perinasum or scrotum. During the progress 
 
 Constitu- of this local mischief, the constitution of the pa- 
 
 tionai tient suffers very materially. He is from the corn- 
 symptoms. /VT -I • 1 • I 
 
 mencement afflicted with severe pain, and some 
 degree of fever. By the continuance of this, his 
 life is brought into imminent hazard. 
 Most of By making an incision into the perinaeum, in the 
 these evils early stage of the disease, the patient will be saved 
 by an ear- from many of these evils; the painfulness of the 
 iy opening. dj sease w \\\ De diminished; the period of its con- 
 tinuance shortened; and the ravages of the malady 
 confined within much more narrow and circum- 
 scribed limits. 
 influence In cases of abscess in perinseo, the dense, tex- 
 of this t ure anc j unyielding; nature of this fascia, will pre- 
 
 1 3 SCI 3. Oil *-» ' X 
 
 abscess of vent the fluctuation from being sensibly felt, and 
 
 in perinaeo w j|j a ] so re t ar d me spontaneous discharge of the 
 
 matter. An early opening made into the abscess, 
 
 is therefore necessary, to free the patient from the 
 
 protracted state of suffering, which the confinement 
 
 of the matter in this situation will cause. 
 
 Dissection Before you raise this superficial fascia of the 
 
 of perin£E-p erm8ei]m ft ma y De f use to make a transverse 
 
 iuii conti- ' * 
 
 rmed. incision through it, midway between the tuberosi- 
 
THE PERINEUM. 
 
 147 
 
 ties of the ischium and the arch of the pubis. This 
 incision will enable you to see the muscles of the 
 perina3um, lying in their natural situations. From 
 this view you observe, that these muscles are closely 
 joined to each other, that no interval exists between No intcr- 
 the erector penis and the accelerator urinas. Hence J ween ^ 
 you learn that it is not possible to make your inci- muscles of 
 sion in the lateral operation for lithotomy, so as pe " 
 to avoid wounding some fibres of the erector penis, 
 or accelerator urinas. However, these muscles 
 will only be wounded in the direction of their fibres, 
 so that the capability of performing their respec- 
 tive offices will not be materially injured. Pro- 
 
 ■r v _« Dissection 
 
 ceeding in the dissection, now remove the super- continued. 
 ficial fascia of the perinasum, and then clear away 
 some cellular substance covering the muscles, so 
 as to give a distinct view of them. Next remove 
 these muscles, taking care not to cut another fascia 
 which lies under them, and which we shall pre- 
 sently examine, under the name of the anterior 
 layer of the triangular ligament of the urethra, or 
 membranous septum of the perinasum. 
 
 The perinasal muscles being removed, the bulb 
 of the urethra is exposed to view. This, you ob- Ba, J of 
 
 . y i urethra. 
 
 serve, has its anterior part corresponding to the 
 angle of the pubis, from which it extends back- its extent. 
 wards on the perinasum, so as to reach nearly to 
 the anus. In this course it gradually swells into Andfonn " 
 that bulbous extremity which lies near to the rec- 
 tum. Press the bulb of the urethra a little to one 
 side with the handle of your knife, and then ob- 
 serve more accurately, the attachment of this layer Triangula,. 
 of the triangular ligament of the urethra. It is li p m ^ t 
 seen to fix itself to the anterior edge of the arch its attac*' 
 of the pubis, to continue its attachment to the rami ments - 
 of the ossa pubis, and to the rami of the ischia: 
 the place of its attachment being behind that of 
 the crura penis to the same bones. On this liga- 
 ment we observe the bulb of the urethra to rest. 
 
148 ANATOMY OF 
 
 Xraiies an( * we snan * ^ n ^ m tne se P tum > a hole for trans- 
 on it. mitting the meoibranous part of this canal. 
 How to The following dissection will enable you to dis- 
 SoSb cover tms opening, and to examine more satisfac- 
 which e it y torily the anterior layer of the triangular ligament 
 thTmem- °^ tne uretnra - Cut across the urethra at the 
 btanous distance of an inch anterior to the arch of the 
 wethra. P ums - Separate it carefully from the corpora 
 cavernosa penis, and turn it down on the perinaeum. 
 In doing this, you must avoid cutting the parts too 
 close to the anterior surface of the symphysis 
 pubis, lest you cut away the upper end of this 
 ligament, in subjects where it is but thin and weak. 
 cdTs of 6 ^ tn * s P rocee( ling, you discover that the edges of 
 this open- the opening for transmitting the urethra, are con- 
 poleTof! 8 " tmue d onwards upon the surface of this canal to a 
 small distance. This attachment requires to be 
 separated by the knife; for it is this which prevents 
 us from seeing a regular well-defined border to 
 Buib of this opening. The bulb of the urethra does not 
 connected *' e l° ose an <* unconnected upon the surface of this 
 wnh this ligament. On the contrary, you find it to be fixed 
 igament. j n ^j g ^\, ACe ^ an( j connec t e d with the anterior sur- 
 face of this ligament, by an attachment of an al- 
 most ligamentous nature, so that even the largest 
 and most posterior part of the bulb, although it 
 pass backward towards the anus, cannot be said to 
 lie loose or pendulous in the perinasum. Since then 
 the membranous part of the urethra lies so much 
 nearer to the arch of the pubis, while the bulb 
 why buib passes so far backward in the perinaeum towards 
 
 IS SO ilHulG i 
 
 to be the anus; and since our incisions in lithotomy, 
 SnTth 6 ? snou 'd begin at the seat of the membranous part 
 my. of the urethra, it follows that we are in danger of 
 w r ounding the bulb, as we carry our incision down- 
 wards between the tuber ischii and anus. As it is 
 adviseable that in lithotomy, our division of the 
 urethra should commence on the membranous part; 
 tagcs of and as it will afford us much satisfaction to have 
 
THE PERINEUM. 
 
 149 
 
 our judgment of the depth at which this lies, J^'j^ 
 guided by some certain rule, we should carefully at which 
 study the depth at which the opening in the tri- j^Tga- 
 angular ligament lies from the surface of the peri- ment lies. 
 nasum. 
 
 We should also carefully observe the height at 
 which the aperture in this ligament is situated, place of 
 Mark that it is not immediately under the arch of Jj^jJJJ? 
 the ossa pubis, but about an inch below it. A strong ligament. 
 ligament occupies the space between this opening 
 and the inferior edges of these bones. 
 
 This ligament, which may be called the pubic p UD i C 
 ligament, lies between the layers of the triangular ligament 
 ligament of the urethra. It is about half an inch 
 deep, having its lower edge thick and perfectly 
 straight. This ligament is of great strength, and 
 thickness. Hence it is obvious that the membra- 
 nous part of the urethra does not lie close to the 
 lower edge of the symphysis pubis; its course is 
 half an inch below this edge. 
 
 Very slight reflection will convince us that much whence 
 difficulty must occur in making the catheter or^2 g 
 sound enter into the anterior part of the membra- catheter 
 nous portion of this canal, as it is not only sur- branlJuT" 
 rounded by the edges of the aperture in the trian- P art of 
 gular ligament, but also lies under the edge of the ur 
 pubic ligament. 
 
 It is against this ligament, and not against the ^'Jete / 
 pubis, that the end of the catheter is pressed, when, is not 
 in attempting to introduce it, the point of the in- J™^ e g J 
 strument is turned upwards too early. pubis. 
 
 If in attempting to extract the stone, we should Resistance 
 withdraw the forceps horizontally, this firm liga- 5gj£j 
 ment will oppose a very considerable resistance to in uthoto- 
 its extraction. my ' 
 
Bladder. 
 
 ,150 
 ANATOMY OF THE PELVIS— BLADDER 
 
 Now turning your attention to the bladder, ob- 
 serve well its form and place. When empty, it pre- 
 itsfomi sents the form of a flattened oval, its dimensions 
 when emp- from side to side being greater than from front to 
 back. The lower and posterior part of this viscus 
 swells out into a sort of pouch, which rests on the 
 rectum. The upper and round end has been called 
 the fundus of the bladder, the middle part, its bo- 
 dy, and the lower part, its base; the lower part has 
 been subdivided into two, the posterior large and 
 capacious, called the base or lower fundus, and the 
 anterior part narrow and of a funnel shape, called 
 the neck of the bladder. When empty, it lies with- 
 in the pelvis; the upper edge of the ossa pubis be- 
 ing on a level with, or above its fundus: the anterior 
 surface of the bladder being connected to the inter- 
 nal surface of these bones, by a loose cellular sub- 
 stance. When the bladder is distended with urine, 
 the increase of the capacity is greater at its fundus 
 and base than in its body. 
 
 In a state of distention, the fundus of the blad- 
 der rises above the pelvis; its anterior surface lies 
 How af- * n contact with the recti muscles of the abdomen, 
 fected by while its base descends and rests on the rectum, 
 distension. ^ a b roa( j triangular surface. 
 
 The peritoneum is connected with the bladder 
 in the following manner: This membrane leaving 
 the recti muscles of the abdomen, meets and ad- 
 How con- heres to the fundus and edges of this viscus in its 
 wkhperi- contracted state, passes down on its posterior sur- 
 toneum. face, closely adhering to it, until it descends so low 
 as the upper extremity of the vesiculae seminales; 
 here leaving the bladder, it passes backwards to 
 cover the anterior surface of the rectum. 
 
ANATOMY OF THE PELVIS — BLADDER. 151 
 
 As it is a matter of great moment to the safe 
 performance of some operations on the bladder, 
 that you possess a clear idea of the relations of the 
 peritoneum to it posteriorly, you should examine 
 their connexions here, with great care. This will 
 be done to most advantage, by the following dis- 
 section. 
 
 Turning the subject on its face, raise the glutei 
 muscles from the surface of the sacrociatic liga- 
 ments, cut out the lower half of the sacrum, together 
 with the os coccygis; but do not separate this lat-^ n to best 
 ter from its connexions with the rectum: cut this view of 
 intestine across at the lower edge of the remaining JjJJJ" 
 piece of the sacrum, lay back the intestine, and 
 carefully raise the peritoneum from its anterior 
 surface. Now stretching the detached peritoneum, 
 you will gain a most satisfactory view of the place, 
 and line of its attachment to the bladder. — You see 
 that the peritoneum having descended to the upper 
 end of the vesiculse seminales, on each side, at- 
 taches itself there while it descends lower in the 
 interval between these bodies; so that its inferior 
 connexion is by a semicircular line, the convexity 
 of which looks towards the neck of the bladder. 
 This stage of the dissection enables you to ob- 
 tain a most useful view of the relative situation of 
 the vesiculse seminales to each other, and to the 
 prostate gland. From it you learn, that the vesi- Relative 
 culae seminales lie more parallel, and more close position of 
 to each other than is generally imagined; that they lemJnaTes. 
 lie in contact with each other for some length, be- 
 fore they reach the prostate gland, that in the in- 
 terval between them, the peritoneum descends very 
 low towards the base of the prostate, and that 
 consequently, a small portion only of the bladder 
 remains naked, included between the vesiculse se- tion a ofp°o7- 
 minales, the lower attachment of the peritoneum tenor part 
 and base of the prostate. — Examine now the depth 
 at which this naked part of the bladder lies from 
 
152 
 
 ANATOMY OP 
 
 the anus, and then judge whether it be probable, 
 
 that in puncturing the bladder from the rectum, 
 
 the instrument can be unerringly entered at this 
 
 n u- .• s P ot 3 or whether it be not more probable that it will 
 
 Objections v -, ■, . ■, , , . r ... « i 
 
 to punctup- oe pushed through the anterior extremities 01 the 
 bifdder vesicu ^ seminales, where they lie in close con- 
 through the tact with, and parallel to each other. Does not the 
 rectum. p a]n w hj C h j s f e j t m the g i ans p en i s? a t the mo- 
 ment of the puncture, tend to strengthen this sus- 
 picion? Should the operator, from solicitude to 
 avoid the vesiculas seminales, pass the trocar still 
 higher up in the rectum, he must then be in con- 
 siderable danger of wounding the peritoneum. 
 
 It is scarcely necessary to say, that you can now 
 
 form an opinion of the length of incision, which 
 
 may be safely made in the lateral operation of 
 
 lithotomy, into this back part of the bladder, from 
 
 Sadde^ ed ^ le membranous portion of the urethra. When the 
 
 m ay be bladder, in its distended state, rises above the pubis, 
 
 cut into its anterior surface being applied to the recti mus- 
 
 above the 1 ., . , . . .» ,rr . 
 
 pelvis. cles, it is plain, that an incision may be made into 
 these muscles, without the peritoneum being en- 
 dangered, provided only, that the bladder ascend 
 high enough above the pubis. 
 
 Now separating the peritoneum from the walls 
 of the pelvis, and with the handle of the knife 
 scraping off some loose cellular substance, you ex- 
 pose to view a fascia which merits your particular 
 study. 
 
 To lay down a plan of dissections which will 
 enable you to obtain a knowledge of the extent, 
 relations, and uses of this fascia, is all that I can 
 pretend to do at present. JNo verbal description 
 can possibly convey a clear idea of this structure; 
 and to add such a number of plates as would be 
 necessary to elucidate a description, would raise 
 the price of this work, so as to put it beyond the 
 reach of pupils. 
 
THE PELVIS — BLADDER. 
 
 153 
 
 First, Observe the extent of this fascia; it is ^fnaicting 
 seen to line the walls of the pelvis, from the sacro- the biad- 
 sciatic notch forwards to the edge of the symphy- J v e a l iis° f e 
 sis pubis. It descends from the ileo-pectinea line, pelvis. 
 to about midway in the depth of the pelvis: here it 
 is reflected from the surface of the muscles, and 
 applies itself to the prostate gland and bladder; 
 on the body of which it is ultimately lost. At the 
 angle of its reflection, this fascia appears particu- 
 larly strong and white, but becomes more weak 
 and thin, as it lines the muscles and covers the 
 bladder. 
 
 This fascia fixes itself into the edge of each os Manner of 
 pubis, on the side of the symphysis, and at a very lionT'the 
 little height above the lower edge of these bones. ossa P" bis - 
 This attachment is made by a pointed production 
 of the fascia inserting itself into the bone: and these 
 productions of the fascia, from their form and 
 greater thickness, having particularly excited the Anterior 
 attention of anatomists, had obtained the name of '"gJJ"" 18 , 
 anterior ligaments of the bladder. 
 
 The descriptions given of these ligaments of the Former 
 bladder, you must now be convinced, were not d . escr 'P; 
 
 j v j tions oi 
 
 drawn from the parts lying in situ, but as they these er- 
 appeared when detached. So completely does this roneous - 
 fascia connect the bladder to the walls of the pel- 
 vis, that it is not interrupted in the interval, between 
 what were called the anterior ligaments of this vis- 
 cus. For here we see this fascia passing from the 
 bladder, so far forwards under the symphisis pubis, This fas- 
 as to form a small recess or pouch, capable of re- apoSciT 
 ceiving the end of the little finger. Now, as this under 
 production of the fascia advances so far forwards pub£, ysiS 
 under the symphysis pubis, it must approach close 
 to that which I have termed the pubic ligament. *£ here 
 We shall find, however, that it is separated from t0 pubic 6 
 this ligament by the interposition of some veins, ligaments 
 which take their course in the small interval left 
 between these two ligaments. 
 
 u 
 
154 ANATOMY OF 
 
 neck of 6 ^lS ^ rSt V * eW °^ tne * asc i a W ^ l ea( * y 0U to 
 
 bladder suppose, that the membranous part of the urethra 
 Sndmem- tne P rostate gland, and neck of the bladder, are 
 branous held closely connected to the symyhysis and arch 
 Jrethraare ^ tne P UD i s - This opinion will be most strongly 
 cioseiy confirmed by the next plan of dissection. 
 arch of° To make this in the most satisfactory manner, 
 pubis. you must saw through both ossa inominata a little 
 above, and behind the acetabula, and cut down to 
 proce^dbg the middle of the sacrosciatic notch, still retaining 
 in the the rectum and os coccygis attached to the bladder, 
 
 dissection * o - ■*■ 
 
 and leaving the levator ani untouched. By making 
 this section, you have an easy access to the deepest 
 part of the cavity, and you enjoy the benefit of ex- 
 amining the connections and extent of the levator 
 ani muscle. 
 
 Now proceed to raise the fascia from the internal 
 surface of the levator ani. For this purpose, make 
 an incision through this membrane, from the sym- 
 physis pubis back to the sciatic notch, and about 
 half an inch above the place of its reflection; care- 
 fully separate the fascia from the surface of the 
 muscle, as low down as you can. 
 
 You now observe that this muscle has, as is 
 generally described, a very wide origin, commenc- 
 ing on the side of the symphisis pubis, and running 
 round till it arrives at the spinous process of the 
 ischium. But the termination and the relations 
 of this muscle deserve your serious attention. — In 
 order that you may obtain a satisfactory view of 
 them, it will be necessary to dissect carefully its 
 outer surface, or that which looks towards the 
 perinaeum. You find a quantity of fat and cellular 
 substance filling up the space interposed between 
 the edge of the glutaeus maximus and the levator 
 ani — a thin fascia more immediately covers the 
 outer surface of the levator. Having carefully 
 removed this fascia, and cleared away the fatty 
 substance which ljes on the muscle, you see the 
 
 Levator 
 ani. 
 
THE PELVIS — BLADDER. 155 
 
 posterior portions of these muscles from the oppo- 
 site sides join together, and constituting but one Ho f ! ts 
 
 i i i • i ii-ii posterior 
 
 muscular band, which passes behind the rectum ; part ends. 
 while the largest and most posterior fibres are ulti- 
 mately attached by a tendinous insertion into the 
 lateral parts of the os coccygis. — The portions of die W fibres~ 
 these muscles which descend by the sides of the e « d - 
 rectum, are said to terminate by uniting with the 
 sphincter ani; however, these fibres rather insert 
 themselves between the upper edge of the sphincter 
 and coats of the intestine, being more closely con- 
 nected with the latter. 
 
 The most anterior fibres of the levator ani, pass " owits 
 
 cin ten or 
 
 down before the rectum, and are ultimately con- fibres end. 
 nected with the perinaeal muscles, at the place of 
 their common junction, behind the bulb of the 
 urethra. We remark, that these anterior fibres do 
 not descend perpendicularly from their origin, to 
 reach the perinaeum; but proceeding downward 
 and backwards for the space of one inch and a 
 half from the symphysis pubis, lose considerably 
 of their muscular appearance when they arrive at 
 their termination. 
 
 These muscles then, while they allow the rectum 
 to pass down between them, are united to each 
 other, both behind and before this intestine; and 
 hence they have been said to close the lower aper- 
 ture of the pelvis. But as we have seen that they 
 extend from the os coccygis, only to the posterior 
 part of the bulb of the urethra, it is obvious that 
 they do not close the anterior part of this aperture. 
 It is therefore necessary for us to examine how the 
 interval between the arch of the pubis, and the 
 anterior edge of these muscles, is occupied and 
 secured. This can be more satisfactorily effected, 
 by cutting through the levatores ani transversely, 
 about half an inch below their origin, and then 
 raising ttie lower divisions from the fascia upon 
 which they had lain. 
 
156 ANATOMY OF 
 
 This exposes to our view that ligament which 
 has been called the triangular ligament of the ure- 
 thra, or the ligamentous septum of the perinaeum. 
 The important purposes which this ligament an- 
 swers, require a particular study of its structure, 
 extent, and connexions. 
 Triangu- Let us first examine it as seen from the pelvis. 
 ment ig o a f ^ ms n g am ent then is attached to the arch and 
 urethra, rami of the ossa pubis, descending along these 
 bones, for the length of an inch and a half from 
 the symphysis, and blending itself with the fascia 
 which covers the internal obturator muscles. This 
 portion of the ligament is consequently of a trian- 
 gular form, the apex of which is at the arch of the 
 pubis; the base stretching across the perinaeum, 
 behind the bulb of the urethra, is not rectilinear, 
 but of a crescent form, the concavity looking to- 
 wards the anus. Through an aperture in this 
 ligament, the membranous portion of the urethra 
 passes. This aperture is situated at the distance 
 of one inch below the arch of the pubis, and some- 
 what less than half an inch above the lower edge 
 or base of this ligament. 
 
 On the pelvic surface of this ligament, we can- 
 not, without further dissection, discover the aper- 
 ture for transmitting the membranous part of the 
 urethra. In fact, this ligament does not merely 
 present itself, as a partition placed in the angle of 
 the pubis, separating the pelvis from the perinagurn, 
 and transmitting, through a distinct opening, the 
 membranous portion of the urethra. On the con- 
 trary, we remark, that this ligament is continued 
 tions of from the place of this aperture, backward along 
 th ent' sa " ^ ie s ^ es °f tne membranous part of the urethra 
 and prostate, that it adheres very closely to the 
 surface of this gland; and consequently, that it 
 serves so to connect these parts to the ossa pubis, 
 that they must follow the motions of these bones. — 
 It is this production of the triangular ligament, 
 
THE PELVIS — BLADDER. 157 
 
 which some anatomists have described as a strong 
 membranous capsule, investing the prostate. It 
 is this fascia, adhering firmly to the gland, which 
 gives that resistance so sensibly felt, when we are 
 dividing the prostate in the lateral operation of 
 lithotomy. 
 
 Since this production of the triangular ligament 
 is continued in a very tense state, over the sides 
 of the membranous portion of the urethra, it is 
 plain, that it secures this portion of the canal 
 from being immediately affected by the action of 
 the levatores ani. It appears, probable, however, 
 that this muscle, by its connection behind the buib, 
 can produce some effect upon the membranous 
 portion of the urethra. 
 
 Along the lower edge of the triangular ligament, 
 we observe an appearance of muscular fibres, 
 which by their direction and attachments, answer 
 to Winslow's description of the inferior prostatic inferior 
 muscles. These fibres are certainly not parts of muscled 
 the levatores ani; but it is not equally certain, that 
 they are of a truly muscular nature. 
 
 If we attempt in conformity to the custom of 
 anatomical writers, to describe all these continuous 
 fascia?, which connect the bladder and urethra to 
 the pelvis, as productions of one and the same 
 fascia, we might say, that the triangular ligament 
 by its outer edges, is fixed into the rami of the 
 pubis, and is there continuous with the ligament 
 lining the obturator muscles; that the edges of the 
 opening for receiving the membranous portion of 
 the urethra, are produced backward along the 
 prostate, and having ascended as high as the arch 
 of the pubis, it there splits into two lamina? — one 
 continuing its course over the upper surface of the 
 gland and bladder — the other lining the upper por- 
 tion of the levator ani muscle. 
 
 Hitherto we have, for the sake of perspicuity, 
 described this ligament as consisting of one lamina 
 
158 ANATOMY OP THE PELVIS BLADDER. 
 
 only; but that portion which is stretched across 
 Triangu- ^ e interval between the ossa pubis, and which 
 
 lot' Il0"9— * 
 
 ment con- separates the perinaeum from the cavity of the 
 
 tw ° f pelvis, will be found to consist of two laminae, 
 
 lamina;, very distinct from each other — the posterior being 
 
 that which is visible within the pelvis — the anterior 
 
 that which we have described as being produced 
 
 upon, and giving a firm position to the bulb of the 
 
 urethra; between these two laminae the strong 
 
 What P UD i c ligament is situated, and between these many 
 
 gives a blood-vessels run. These give to this ligament, 
 
 muscular w i len divided, some appearance of muscularity, 
 
 appear- \ f p, , . v 
 
 ance to pretty much the same with that appearance which 
 ment 83 " * ne cor P us spongiosum of the urethra presents, 
 
 when an incision is made into its substance, and 
 
 the blood removed with a sponge. 
 
159 
 ON PASSING THE CATHETER. 
 
 This has long been considered as one of the JSJj" 
 most delicate and uncertain operations which the ration, 
 surgeon is called on to perform. It is, therefore, 
 incumbent on him to make himself perfect master 
 of the anatomy of the urethra and adjacent parts — 
 to revolve frequently in his mind the connections 
 of this canal, the course which it takes, the ine- 
 qualities in its dimensions, and irregularities in its 
 surface: without an intimate acquaintance with all 
 these, he cannot be supposed to know what may 
 be termed, the natural difficulties of this operation. 
 To this study he should add an inquiry into those 
 alterations in the dimensions or directions of this 
 canal, which may be induced either by the disease 
 of the urethra or of the neighbouring parts. 
 
 Let us now take a review of all these points, 
 for the purpose of ascertaining the manner in 
 which each may affect the introduction of instru- 
 ments into the bladder. 
 
 That portion of the urethra then, which lies curvature 
 anteriorly to the angle of the pubis makes, with the of uretbr9 - 
 portion immediately in this angle, an arch, the con- 
 cavity of which looks towards the perineum. From 
 this point, the canal begins to take a direction 
 exactly the reverse of the former, for now it runs 
 from the angle of the pubis upwards, behind the 
 symphysis until it terminates in the neck of the 
 bladder. 
 
 That curvature of the urethra then, which is 
 formed anteriorly to the pubis when the penis lies 
 flaccid on the scrotum, can be destroyed, and the 
 course of this portion of the canal be reduced to a 
 straight line by raising up the penis towards the 
 abdomen. In other words, that part of the ure- 
 
160 ON PASSING 
 
 thra which lies immediately under the arch of 
 pubis is fixed, while all anterior to it is perfectly 
 moveable: so that there is no difficulty in bringing 
 the anterior moveable portion on a line with that 
 which is fixed. In short, by holding the anterior 
 part of the penis in a line perpendicular to the 
 abdomen, we reduce the deviation of the urethra 
 to a single curve, which commencing at the arch 
 of the pubis terminates in the bladder, and has its 
 concavity directed upwards. 
 
 You should now inquire how far the different 
 connections of the urethra and bladder will admit 
 of any alteration in this curve. The membranous 
 portion, then, immediately behind the bulb of the 
 urethra, is secured in a fixed position, by passing 
 through the triangular ligament of the urethra. — 
 The prostate gland also admits but of slight alte- 
 ration of place, except at its base or posterior part. 
 Hence it follows, that the instrument can be passed 
 through the membranous and prostatic portions of 
 the urethra only by giving to it a direction corres- 
 ponding to that of the canal. 
 
 What are the inequalities in the dimensions and 
 irregularities in the surface of this canal, which 
 can influence the method of passing the catheter? 
 Natural The mucous lacuna? of the urethra are said to 
 obstacles. j iave occasionally presented such large openings, 
 Mucous that the point of the catheter has passed into .some 
 acunae. Q £ fa em jf g^^ an occurrence had taken place, 
 
 I presume it could have happened only when a 
 
 very small instrument had been used. — The canal 
 
 Dilatations as it passes through the bulb, is somewhat dilated, 
 
 at the bulb an( j at ^jg S p £ \\ ie instrument often is stopped. 
 
 For if the point of the instrument be allowed to 
 glide along the lower surface of the canal, it will 
 enter into this dilated part, and cause great em- 
 barrassment to a surgeon unacquainted with the 
 condition of this portion of the canal. For here 
 the canal is not only more wide, but its course is 
 
THE CATHETER. 161 
 
 such, that a straight instrument entered into it, 
 will if pushed on, pass into the perinaeum, while 
 that part of the canal which lies in the triangular 
 ligament of the urethra, is situated much above it; 
 or, in other words, the canal of the urethra, where 
 it is covered by the bulb, forms a recess, or species 
 of cul de sac, which is situated below, and even a 
 little further back than the outer extremity of the 
 membranous part of the urethra. — If then, a ca- 
 theter with the ordinary curve, be passed into this 
 cul de sac, the surgeon cannot make it enter into HowfaJw- 
 the bladder without using very considerable force, catheter 
 and inflicting very unwarrantable violence. For, if affected by 
 he attempt, by raising the point, to push onwards 
 the instrument, he must break through the inter- 
 posed fold or projection of the urethra before he 
 can enter the membranous part of this canal; and 
 if he push on the instrument without elevating its 
 point, he will force the instrument through the 
 urethra at the end of this recess, and plunge it into 
 the perinaeum, or even into the space between the 
 rectum and bladder. 
 
 When the catheter has been unfortunately forc- 
 ed through the posterior part of the bulb, or begin- That the 
 ning of the membranous portion of the urethra, j^™™^ 
 it may be pushed on until it has sunk so deeply as between 
 to give to the bye-stander an idea that it has pass- SaE"* 4 
 ed fully into the bladder. A surgeon conversant how ascer- 
 with this branch of practice, will be sensible that tained ' 
 the instrument has taken a false route by the feel 
 of resistances successively recurring, and by the 
 absence of that sensation which he experiences 
 when the instrument is passing along the smooth 
 membrane of the urethra. Should he not be 
 aware of the real state of the case, he will be 
 convinced of his error, by the two following tests: 
 — One is, the exquisite pain of which the patient 
 complains whenever the surgeon attempts to de- 
 press the handle, and elevate the point of the in- 
 
 x 
 
162 ON PASSING 
 
 strument. This probably arises from the point 
 pressing against the vesiculae seminales. — The 
 other means of detecting this error is, by introduc- 
 ing the finger in ano. For, when the catheter is 
 lodged between the rectum and bladder, the pros- 
 tate gland cannot be felt, except very obscurely; at 
 the same time, the instrument is found to lie im- 
 mediately upon the coats of the rectum. Should 
 any opportunity occur to you in the course of 
 practice of examining by the finger in ano, you 
 will be surprised at the freedom with which the 
 instrument can be moved in this newly-formed 
 cavity. 
 How tbis This natural difficulty at the bulb of the ure- 
 s^ddent thra, may possibly be in some degree surmounted, 
 avoided, by drawing the penis forward, at the same time that 
 the handle of the catheter is depressed. But from 
 the fixed state of the membranous part of the ure- 
 thra it cannot by such means be entirely removed. 
 The only mode of effectually guarding against 
 the disadvantage of such a form of the canal is to 
 keep the point of the instrument slightly elevated, 
 even before it has arrived at the bulb. By doing 
 so, you may possibly enter into the membranous 
 part of the urethra, without encountering any other 
 Greatdi ffi. obstacle; but this does not generally happen — for 
 cuity to this is the most critical step of the operation, viz. 
 membra"- to pass the instrument from the bulbous into the 
 nous part membranous portion of the urethra. The trian- 
 ' gular ligament of the urethra is of such firmness, 
 that if the point of the instrument deviate even in 
 a small degree, from the axis of the canal, it will 
 be felt to rub against the edge of the opening in 
 this ligament, and then to pass on quickly. The 
 sensation which this obstacle communicates to the 
 surgeon, is similar to that experienced in passing 
 obstacle through a stricture, and I fear that some mistakes 
 taken for have been committed in practice, owing to this 
 stricture, sensation. — This point, which is six and a half or 
 
THE CATHETER. 163 
 
 seven inches distant from the orifice of the ure- 
 thra, has been represented by Mr. Home, to be the 
 most frequent seat of this disease. This circum- 
 stance must have contributed to the number of 
 those mistakes. I think it not improbable that the 
 edge of the opening in the ligament might even 
 make an impression on the point of a soft bougie, 
 and thus render the mistake almost inevitable. 
 
 Let us return to the operation of passing the 
 catheter. The obstacles then, which we have to 
 encounter in this part of our course are the direc- oleics 
 tion of the canal, and occasionally a contraction branous" 
 produced by the spasmodic action of the levatores P ort i° n of 
 am. The former of these may be obviated by de- 
 pressing the handle of the instrument, as much as 
 will give to its point a direction corresponding with 
 the direction of this portion of the urethra. The 
 spasmodic contraction will best be overcome by 
 keeping the instrument steadily in that spot where 
 it is stopped by the spasm. 
 
 In compliance with the generality of writers, 
 who speak of spasm as one cause of difficulty in f^p 3 ™^. 
 passing the catheter, I have mentioned it; and from 
 seeing that this is the only part of the urethra 
 where muscles can have any influence, I have sup- 
 posed it to occur here. But I must candidly avow v 
 that I have not, in a single instance, felt that sort 
 of obstacle which I could safely ascribe to spasm 
 of any part of the urethra. 
 
 That enlarged part of the canal which runs in 
 the prostate gland, or the prostatic sinus, as some i n prosta- 
 term it, is next to be considered; and here more ,ic P ortioii - 
 sources of difficulty are to be encountered than 
 you might expect. For the point of the catheter, 
 if small, may pass into that sinus described by Morgans 
 Morgagni, as seated at the posterior end of the s " 
 caput gallinaginis, and this, although the instru- 
 ment should move on in the direction of the canal. 
 This may be avoided by keeping the point of the 
 
164 ON PASSING 
 
 instrument elevated, and this rule will enable you 
 to avoid another difficulty to which the form of 
 the canal here exposes you. For at each side of 
 the caput gallinaginis, the urethra grows wider and 
 deeper, until you arrive at the neck of the bladder. 
 This, the most posterior part of the canal, ap- 
 pears still more deep in consequence of the neck 
 Ridge °f tne bladder forming a sharp and pretty high 
 formed by ridge, interposed between the canal and the blad- 
 foTi eC of ng der. Should the instrument then be moved on 
 neck of either side of the caput gallinaginis along this 
 er ' deepest part, until it reached the furthest extremity 
 of the canal, you must observe, that it could not 
 be pushed into the bladder even by then raising its 
 point, without forcibly tearing through this ridge 
 at the neck of the bladder. The pain produced 
 by such violence, is extremely severe on the in- 
 stant, and its consequences may prove very dan- 
 How obvi- gerous to a patient of irritable habit. You can 
 ated ' then pass the instrument along this last portion of 
 the canal with facility, by depressing the handle so 
 as to elevate the point in such a degree as will 
 enable you to surmount the ridge, formed by the 
 neck of the bladder. 
 summary On a review of the various obstacles, and the 
 st ftl ies 0b means °f surmounting them, you will observe, 
 that you should keep the urethra gently elongated, 
 and should begin to depress the handle, and ele- 
 vate the point of the instrument before you arrive 
 at the bulb of the urethra, that you should from 
 this point continue to increase the depression of 
 the handle, and elevation of the point as you ad- 
 vance along the canal, and therefore we might 
 simplify all these directions by saying, that you 
 should begin to describe a semicircle with the in- 
 strument, from the time the point approaches to 
 the bulb until it enters into the bladder; and should 
 the instrument at any time be stopped, you must 
 not push it on forcibly, but withdrawing it for a 
 
THE CATHETER. 
 
 165 
 
 quarter or half an inch, elevate the point, and then 
 attempt to push it onwards. 
 
 What position of the patient is most favourable 
 for this operation, or should the form of instrument, 
 or the direction of its course be varied, according 
 to the different posture of the patient? 
 
 When you turn to the plates of surgical instru- 
 ments, it must strike you as an extraordinary fact, 
 that different authors represent their catheters of 
 different forms, and with very different degrees of 
 curvature. 
 
 The form of the catheter, which will probably Form of 
 answer best for general use, is that, in which the jj r g e enera i 
 curvature beginning at the middle of the instru- use. 
 ment, describes an arch of a circle of six inches 
 in diameter, and terminates at the point. Some 
 have their catheters formed with a beak, extending 
 two inches or two inches and a half, between the 
 termination of the curvature and the point of the 
 instrument. But to such a form these objections ^ e a c t [j°" e s r 
 apply. First, it is more difficult to make it enter, with a 
 next, that when entered, as the water escapes, the lon s beak - 
 bladder collapsing, falls in upon the point of the 
 catheter, by which, much pain is produced, espe- 
 cially if the handle of the instrument be moved; 
 and even the end of the catheter may be so wrap- 
 ped about by the lax portion of the bladder, as to 
 prevent any more urine entering through the open- 
 ings or eyes of the tube. The suggestions of 
 Camper relative to the eyes of the catheter, have 
 been unaccountably overlooked. He proposed that 
 the sides of the instrument should be perforated 
 to a much greater distance from the point, by 
 which means a considerable quantity of urine 
 might still be discharged, after the openings near 
 the point had been closed up, by the bladder falling 
 in on them. 
 
 The catheter should not be formed with a greater objections 
 
 , , . . . . ° , to much 
 
 <furve than what is requisite to secure its introduc- curvature. 
 
16*6 ON PASSING 
 
 tion into the bladder, because if much curved, the 
 convexity of the instrument, when introduced, lies 
 towards the inferior part or base of that viscus, 
 while the apex is raised up near to the point from 
 which the urachus ascends, hence a considerable 
 quantity of urine will remain in the bladder, after 
 each introduction of the instrument, and this more 
 particularly, when the bladder is in a state of 
 paralysis. 
 
 To draw off then, the entire quantity of urine 
 with an inflexible catheter, we must use one with 
 a slight degree of curvature, and with a short beak 
 — and this we must, before withdrawing it, endea- 
 vour to sink into the fundus of the bladder — not 
 by lowering the point only, for by this movement, 
 the handle would be proportionably elevated, and 
 the flow of urine impeded, but we must press the 
 whole of the instrument downwards towards the 
 perinaeum; by this means, we sink the anterior part 
 into the fundus, as low as the attachments of the 
 membranous part of the urethra will admit, and 
 remove that obstacle which the elevation of the 
 handle would occasion. 
 
 The gum-elastic catheter accommodating itself 
 to the form of the bladder, must have a decided 
 preference for drawing off the urine, especially 
 from paralytic bladders. 
 
 In cases of paraplegia, you will find it necessary 
 off urirxTin to make considerable pressure over the pubis, for 
 paralytic fl ie purpose of discharging the last portions of 
 urine; for without this expedient, you could not 
 possibly draw off more than two-thirds of the urine 
 with an inflexible instrument. 
 .such cases By the way, we may observe, that there is a pe- 
 theter ca ~ cunar facility of introducing the catheter in cases 
 most easily of paraplegia, whether arising spontaneously, or 
 excited by injury. And, therefore, the student 
 should select such cases for his first attempts on 
 the living body. 
 
THE CATHETER. 
 
 167 
 
 There is a case in which a catheter of consider- where a 
 able length may be used with advantage — should 2 u S t 
 a quantity of coagulated blood and urine be con- is to be 
 tained in the bladder of a patient, seized with re- preerre ' 
 tention of urine, it is plain, that the blood will lie 
 in the fundus, while the urine occupies the upper 
 part. If in such a case, a catheter of ordinary 
 length were used, it could not pass through the 
 coagulum, whereas if a very long instrument were 
 introduced, it might pass through the blood, and 
 come into the region occupied by the urine. The 
 idea of such an instrument was first suggested to 
 me, by observing in the case of an old gentleman, 
 that the catheter which easily entered the bladder, 
 was always withdrawn plugged up by clots of blood, 
 and yet, in a few minutes, a very large quantity of 
 urine and blood was discharged, by puncturing the 
 bladder above the pubis. If the end of the stilet 
 be surrounded with sponge, so as to fill up the eyes 
 of the instrument, then these cannot be clogged as 
 the catheter is passing through the coagulum; and 
 the stilet being withdrawn, when the catheter has 
 reached to the collection of urine, this fluid may 
 be evacuated. I have not yet had an opportunity 
 of putting this instrument to the test of experi- 
 ment. 
 
 It must be admitted that the form of the instru- Position of 
 ment is not so material to facilitate its introduction, more" 
 as the recollection of the course of the urethra, essential. 
 and the manner in which it is altered by the dif- 
 ferent positions of the pelvis. Now as the mem- 
 branous portion of the urethra is closely connected 
 with the arch of the pubis, it is obvious that it must 
 follow the motions of these bones. Hence a more Effects of 
 acute angle is formed between the commencement the erect 
 of the membranous portion of the urethra, and posl 
 that immediately anterior to it, whenever the lower 
 edge of the arch of the pubis is turned backwards. 
 Now as the arch is thrown into this position, by 
 
168 ON PASSING THE CATHETER. 
 
 the erect posture of the body, it is plain that in this 
 posture a more curved instrument will pass with 
 greater facility, than one of a more straight form. 
 If we use an instrument with the ordinary degree 
 of curvature, we must take care to lower the 
 handle very quickly, as we approach the bulb of 
 Effects of the urethra. When the patient is laid horizontally 
 h "™ tal with the pelvis raised, the axis of the pelvis is 
 with pelvis made almost to coincide with that of the trunk. 
 raised. j n ^j s p OS ition, the pubis is placed nearly horizon- 
 tally, and consequently the curve of the urethra is 
 considerably diminished, and the course of this 
 canal is brought as near to a straight line as can 
 be effected by posture. In such a position, the in- 
 strument of the ordinary curve should not be turn- 
 ed quickly under the arch, by a sudden depression 
 of the handle. Such a position admits with pecu- 
 liar facility, the introduction of a more straight in- 
 strument. When the patient is placed horizon- 
 tally, the instrument of the form above described, 
 will pass with the greatest facility, and will require 
 only a moderate and gradual depression of the 
 handle. " 
 
169 
 ON THE OPERATION OF LITHOTOMY. 
 
 In no other operation in surgery is a knowledge 
 of anatomy of more essential service to the sur- 
 geon, than in that of lithotomy. Let us now con- 
 sider how it will guide him through the different 
 steps of this hazardous operation. 
 
 The patient should be laid on a higher table p os iti n f 
 than that ordinarily used for the purpose: as this patient, 
 will allow greater freedom of motion to the sur- 
 geon's hand, and lessen the dangers attendant on 
 some of the most difficult steps in the operation. 
 The staff should be of as full a size as the urethra Staffi 
 can well admit — should have the handle made 
 rough, which will enable the operator to hold it 
 firmly without much difficulty. Having introduc- 
 ed the staff, now hold the handle of it firmly with How to be 
 the thumb and two forefingers of your left hand ; ,e 
 this hold will enable you more sensibly to feel the 
 point of the knife when it first enters the groove 
 of the staff, and (which is of much consequence) 
 will facilitate one of the most difficult and import- 
 ant steps of the operation, the lowering the handle 
 of the staff. The staff thus held , is to be drawn 
 into the arch of the pubis, and then is to be made 
 prominent in the perinasum. You are not, observe, 
 to hold the handle of the instrument inclined over 
 the right groin of the patient, as is generally di- 
 rected. Let the staff be perpendicular to the 
 horizon, let it at the same time be drawn up as 
 closely as possible into the arch of the pubis, with 
 its convexity bulging out in the perinasum. 
 
 If you take care to keep the staff well up into Advanta- 
 ge pubis, you will be secured against its slipping p sof J hl,s 
 out of the bladder; you will thereby save the rectum staff' ng 
 from being wounded; and you will avoid all risk 
 
 y 
 
170 ON THE OPERATION 
 
 of injuring the pudic artery. In a word, you will, 
 by attending to this simple direction, render the 
 different steps of the operation, easy and certain. 
 Posture of Then kneeling on your left knee, hold the staff in 
 surgeon, this position; and if you wish to render the right 
 hand more steady, rest your right elbow upon the 
 corresponding knee. 
 
 The staff being thus held, you now feel for the 
 arch of the pubis with the forefinger of the right 
 hand, and a little below this spot you commence 
 External your external incision, close to the left side of the 
 incision. ra ph ej anc [ continue it obliquely, so as to pass 
 midway between the tuberosity of the ischium and 
 the anus. This first incision you will make, not 
 with the point, but by laying the bellying edge of 
 your knife fairly to the perinaeum. The integu- 
 ments will then fly asunder; their natural elasticity 
 being aided by the divarication of the perinasum. 
 In the same line with this, you are to make your 
 second second incision, commencing it half an inch below 
 incision, ^g U pp er en( j f t ne first, carry it deeply into the 
 perinagum, by it you will divide the transversalis 
 perinei, a few fibres of the spinchter ani, a few 
 fibres also of the transversalis perinei alter (if 
 present,) a portion of the levator ani, and a portion 
 of the ligamentus septum of the perineum; taking 
 care that your second shall be nearly equal in 
 length to your first incision. Now enter your knife 
 into the groove of the staff, which you will readily 
 accomplish, if you recollect that your incision is 
 to open the membranous part of the urethra, — 
 How to ex that thi s part of the canal passes through the liga- 
 poim at mentous septum of the perinaeum, at the distance 
 which you f one mc h below the arch of the pubis, and two 
 
 Should . . r» i • 1 • /v 
 
 enter the inches above the tuberosity oi the ischium. Atten- 
 fkTsTaff ti° n to tnese points will direct you to the height in 
 the perinasum, at which you are to enter into the 
 groove of the staff. The depth at which this liga- 
 ment lies from the surface, may be ascertained by 
 
OP LITHOTOMY . 171 
 
 attending to the fullness of the perinaeum in each 
 individual, and recollecting that it is attached to 
 the rami of the pubis behind the crura of the 
 penis. 
 
 It is the more necessary for you to bear these why so 
 anatomical facts in your recollection, because the l^tl- 
 deeper parts of the perinaeum do not recede when certain 
 divided. On the contrary, in corpulent subjects, 
 even the knife is concealed from your view, by the 
 edges of the wound falling together, as soon as it 
 has passed through them. 
 
 Therefore, holding the knife horizontally, you 
 will push it forwards, and a little towards the right 
 side of your patient, taking care to enter it, not at, 
 but a little below the upper extremity of your ex- 
 ternal incision. As you perceive the point of the 
 knife grating on the staff, move it from side to 
 side, that you may be sure of its being in the groove, 
 as you might be deceived, were you to rely merely Divide 
 on the rubbing of the knife against the staff; when "o*™ pot" 
 thus assured that your knife is fairly lodged in the tioQ of 
 groove, you are to bare it for about a quarter of me 
 an inch; this is to be done while the staff continues 
 to be held perpendicular, by moving the knife in 
 the same perpendicular direction. If you do not Necessity 
 lay bare so much of the staff before you attempt for lhis 
 the division of the prostate gland, you will have 
 to encounter many and most insuperable difficul- 
 ties, of which we shall speak when we come to 
 describe the division of the prostate — one however, 
 may here be noticed, viz. the resistance given to 
 the knife by the levator ani and the triangular 
 ligament, and by that ligamentous structure which 
 envelops the membranous part of the urethra. 
 Having thus divided a portion of the membranous 
 part of the urethra, you now proceed to the most 
 difficult part of the operation, viz. the division of 
 the prostate gland and the neck of the bladder on 
 its left side. To effect this, you must alter the 
 
172 ON THE OPERATION 
 
 Division position of your instruments; because you know 
 
 p,ostae that the direction of the parts now to be divided 3 
 
 is very different from the direction of those through 
 
 S be C gi°ven wmcn vou have already cut. For you are now to 
 
 to the in- divide parts which lie behind the arch and sym- 
 
 strument. physis pubis. Wherefore, while you hold your 
 
 knife horizontally in the lower part of the incision 
 
 in the urethra, you should now bring the handle of 
 
 the staff down towards yourself, by making it move 
 
 on the point of your knife as on a pivot, and at 
 
 the same time keeping its concavity close up to the 
 
 arch of the pubis; by this movement, the back of 
 
 the knife, instead of the point, comes to be lodged 
 
 in the groove of the staff, and the beak of the 
 
 t° *nn latter is directed upwards. You will experience 
 
 the knife , . ..,., ,.«, ., r . . , . ■, n 
 
 along the but little difficulty in running the back ol your 
 82n eof knife along the groove of the staff; if you but re- 
 collect the direction into which this last movement 
 has thrown the staff, viz. that it has lodged it im- 
 mediately behind the arch of the pubis, and there- 
 fore, in order to give a corresponding direction to 
 your knife, you must depress the handle of it, low- 
 ering your right wrist by throwing back your hand, 
 and then pushing the knife on in the groove, tak- 
 ing especial care that you lower the wrist as you 
 push on the knife. 
 Lateraiize I should have observed, that before you begin 
 the kmfe. j. Q p^ your k m f e on along the groove, you should 
 incline its edge a little towards the left ischium, 
 that you may divide the prostate gland on the left 
 side. You will be sensible that your knife has 
 entered the bladder, by all resistance being removed 
 and by the sudden flow of the urine. 
 
 I have said that it is a matter of the greatest 
 importance to the successful, and indeed to the 
 safe performance of this operation, that a conside- 
 rable portion of the membranous part of the ure- 
 thra should be divided before the staff is depressed, 
 or that incision commenced, by which the prostate 
 
OP LITHOTOMY 
 
 173 
 
 and neck of the bladder are to be divided. For, if 
 you have entered your knife into the urethra, high 
 up in the perinaeum; and while the point of the 
 knife is lodged there, should depress the staff, and 
 attempt the division of the prostate, you will have 
 to make it describe a portion of a circle, at the 
 time that it is dividing very resisting parts. 
 
 Nothing can be more unsatisfactory to the ope- 
 rator, than the feel, when he attempts the division 
 of the prostate, where he has entered the knife too 
 high in the urethra. He feels as if the parts had 
 not fully yielded or indeed as if they had not 
 yielded at all; and yet he is conscious that the de- 
 gree of force which he uses, cannot be continued 
 without the danger of throwing the knife altogether 
 out of the groove of the staff, and plunging it far 
 forwards into the cellular substance, between the 
 bladder and rectum, or of sinking it into the rectum 
 if the point should be at all depressed, so that the 
 knife used in this manner, is productive of all the 
 dangers, and liable to many of those objections 
 which apply to the gorget. — Should the knife, on 
 the contrary, be used in the manner here directed, 
 you will not experience any resistance to the pro- 
 gress of it, except what you may naturally expect 
 from the texture of the parts to be cut; and you 
 have, in the complete absence of all resistance, the 
 most satisfactory proof of the division being fully 
 effected. 
 
 You may remark here, that I have advised you 
 to run the back of the knife slightly lateralized, 
 along the groove of the staff, and would wish you 
 to have no other object in view, when performing 
 this movement. For if you accomplish this, the 
 prostate and neck of the bladder must at the same 
 time be divided. 
 
 The breadth of your knife may, in every instance, shape of 
 be determined by this rule; use one of such breadth, kmfe - 
 that when lodged in the groove of the staff, it shall 
 
1 74 ON THE OPERATION 
 
 be nearly equal to the diameter of the canal of the 
 urethra, and thickness of the prostate gland: a 
 knife of this breadth, and with its cutting edge, not 
 above one inch long, will freely divide all those 
 deep seated parts, which are to be divided, and 
 from its dimensions and form, cannot possibly di- 
 vide the other parts in the neighbourhood if used 
 in the manner here directed. 
 How to Let us suppose the incision to be made into the 
 the Eft. neck of the bladder, the knife is now to be with- 
 drawn, by drawing its back a little way along the 
 groove of the staff; and then by lowering the knife 
 as you come out, such of the external parts as have 
 not been sufficiently divided, can now be cut to the 
 necessary extent. Here your knowledge of the 
 How to wide flat pouch, formed by the rectum at this part, 
 avoid w jh prevent you from carrying your knife too low 
 the rectum down, before you have withdrawn it a little, lest 
 you wound this intestine. Now examine the state 
 of the incision with the index finger of your right 
 hand, and if any bands of undivided cellular sub- 
 stance lie across the wound, break them down 
 with your finger. You now take the forceps with 
 introduce the handles lying on the same plane, and by intro- 
 tbe forceps ducing them, inclined from below upwards and 
 forwards, in the direction of the axis of the pelvis, 
 you push them into the bladder, guiding them by 
 the staff which you still hold, with its handle de- 
 pressed. 
 Cautions This step of the operation requires a good deal 
 ste tb of the °^ care 5 f° r > we re you to enter the forceps hori- 
 operation. zontally, you run the risk, or rather you will 
 scarcely avoid the danger of pushing the instru- 
 ment into the cellular substance between the rec- 
 tum and bladder, however complete your division 
 of the neck of the bladder may have been. For 
 the edges of the wounded levator ani contracting, 
 expose this interspace, which now feels as a cavity, 
 in consequence of the retraction of all that cellular 
 
OP LITHOTOMY- 
 
 175 
 
 substance which lies between these parts. The 
 forceps being introduced, you now withdraw the 
 staff, and standing up, you search for the stone. 
 When you have laid hold on the stone, proceed to P'™^ 
 extract it, by withdrawing your instrument in the stone is to 
 direction of the axis of the pelvis, viz. from above ^extract- 
 downward. If you attempt to withdraw the forceps 
 in a horizontal direction, the stone, if large, must 
 injure the urethra, by pressing it against the pubic 
 ligament, and the arch of the pubis, nor can room 
 be gained in this direction; a slight pressure to- 
 wards the right side of the patient, may gain some 
 little room, but it is only in the direction above- 
 mentioned, that you can gain any material room, 
 and this too, without inducing any contusion of the 
 soft parts. 
 
 When you introduce the finger to try for a se- 
 cond stone, be careful not to mistake, for the cavity 
 of the bladder, the space interposed between it 
 and the rectum. 
 
 If the stone has been unfortunately broken into ]J^ is 
 small pieces by the forceps, you should endeavour broken 
 to wash them out, by throwing tepid water into the ^° nts frag 
 bladder, with a large syringe, armed with a pipe 
 three or four inches long. In performing this, you 
 must also be careful to pass the pipe completely 
 into the bladder, and not to mistake for its cavity, 
 the space between it and the rectum, to which we 
 have so often alluded. Some leave these fragments 
 to be discharged with the urine; but this is objec- 
 tionable, because although they may have fallen 
 down towards the fundus of the bladder, yet they 
 may be prevented from escaping, by the inflamma- 
 tion and swelling of the lips of the wound; and 
 while those fragments are allowed to remain, the 
 patient suffers to a considerable degree, that series 
 of distress, for the removal of which, he had sub- 
 mitted to the operation. 
 
176 
 
 ON THE OPERATION 
 
 This, in point of the number of instruments 
 employed, is the most simple mode of performing 
 the lateral operation for lithotomy. It is the only 
 mode that should be practised on children under 
 six or eight years of age; because in them the 
 urethra is too small to admit of the introduction of 
 the instruments hereafter to be described, without 
 danger of lacerating this canal. At the sanje time 
 we must admit, that a more accurate knowledge of 
 the anatomy of the parts, more dexterity in the use 
 of the instruments, and more constant practice in 
 this particular operation, than fall to the lot of sur- 
 geons in general, will be required, to enable the 
 operator to execute it with confidence in himself, 
 and security to his patient. 
 The late- By using two more instruments, this operation 
 
 nil oDcrs." * 
 
 tion with can be performed with much greater facility, and 
 
 hf s r tru- ile s w * tn sucn secur ty, that few accidents have occur- 
 
 ments. red during the operation, and still fewer instances 
 
 of a fatal event, since this mode of operating has 
 
 been generally adopted by the surgeons of this 
 
 city. 
 
 meat"" re- ^he additional instruments required are, a 
 
 quired, straight conductor and a knife, which is called the 
 
 lithotome. These instruments had originally been 
 
 invented by Mr. Daunt, an eminent surgeon in this 
 
 city; they were improved by the late Mr. Dease, 
 
 and owe their present perfect form to the ingenuity 
 
 of Mr. Peile. 
 
 The first steps of the operation are the same as 
 those above described. The position of the patient, 
 the mode of holding the staff, of making the ex- 
 ternal incision, and of laying bare the groove of 
 the staff, correspond in every particular, and there- 
 fore it is unnecessary to describe them here. The 
 rules to be observed in the part of the operation to 
 Directions ^ e performed by Mr. Peile's instruments are as 
 for this follow: — The staff being laid bare, and the surgeon 
 
OF LITHOTOMY. 
 
 177 
 
 being assured, by moving the knife from side to ™° e d r * ti ° n f 
 side, that its point is lodged in the groove, must 
 now bring down the handle of the staff towards 
 himself, making it move on the point of the knife 
 as on a pivot; by this motion the back of the knife 
 is sunk into the groove. You now divide the mem- 
 branous part of the urethra, and the anterior point 
 of the prostate gland. This you effect by lower- 
 ing the wrist while you move the knife onwards, 
 taking especial care to make the back of the knife 
 run in the groove, which can only be done by 
 lowering the wrist in proportion as the knife is 
 pushed forwards. The knife you now withdraw, 
 retaining the staff in the present position. Nextro intro- 
 take up the conductor, catching a firm hold of it, duc ? * e 
 
 i ■> o » conductor. 
 
 by applying your fore-finger along its stem, while 
 the remaining fingers embrace its handle; enter its 
 beak, into the groove of the staff, you ascertain 
 that it is fairly lodged by moving it from side to 
 side; and then lowering the right wrist, run it along 
 the staff, taking care to lower the wrist as you 
 push the director forwards, until you have intro- 
 duced it fairly into the bladder. The urine now 
 flows along the groove of the conductor, assuring 
 you of your success in this step. You now with- withdraw 
 draw the staff by moving up the handle towards tbe staff - 
 the abdomen of the patient, at the same time that 
 you are drawing it out of the urethra, the conduc- 
 tor during this time being held immoveable. Now 
 rising off your knee, stand between the legs of the 
 patient, and passing the two first fingers of your 
 left hand into the ring, while your thumb is pushed 
 against the handle of the instrument, raise it up as How to 
 high as possible into the arch of the pubis. In ho!d the 
 this position you carefully hold it, as by this alone 
 can a wound of the rectum be avoided. ISowLnhotome 
 holding the lithotome between the thumb and two how . tobe 
 fingers of the right hand, lay its beak on the lower 
 
 z 
 
178 
 
 ON THE OPERATION 
 
 edge of the groove, and pushing it on, until its point 
 has got to the external incision, give it the neces- 
 sary degree of obliquity or lateralization, as it is 
 termed; by turning the groove of the conductor 
 more or less towards the arch of the pubis. Hav- 
 ing determined on the degree of lateralization 
 which you judge necessary, now push on the knife, 
 running it close and parallel to the conductor until it 
 is stopped at the point of the conductor. Withdraw 
 it cautiously, by bringing it back again along the 
 groove. By this means, the division of the prostate 
 is effected with the slightest possible force, for the 
 operator is scarcely sensible of any resistance from 
 prostate, and judges that it has been divided — not 
 so much by his having overcome a certain degree 
 of resistance, as by the knife having reached to the 
 end of the groove. 
 A e d s V o? This The great advantages of this mode of operating 
 mode of are, that any man who can lay open the urethra on 
 operating. tne g ro0 ved staff, and has dexterity enough to in- 
 troduce along it the straight conductor into the 
 bladder, will certainly guard against dividing the 
 rectum, will be enabled to give his knife the requir- 
 ed lateralization, which is secured without any 
 further dexterity in making the incision, and there- 
 fore, he will be able to avoid in every instance, the 
 division of the internal pudic artery. 
 
 Having withdrawn your lithotome, run your 
 
 finger along the conductor into the bladder, to 
 
 satisfy yourself of the extent of the incision; but 
 
 How to should you find that the prostate is not sufficiently 
 
 wound?.? 6 divided, introduce the same lithotome again, now 
 
 prostate, keeping the handle depressed below the stem of 
 
 the conductor. The division of the gland will be 
 
 increased in proportion as the handle of the knife 
 
 is depressed, and therefore you can regulate the 
 
 movement of the cutting part of the knife, merely 
 
 by observing the direction of its handle. Now in- 
 
OF LITHOTOMY. 179 
 
 troduce the forceps guided by the conductor, but 
 passed from below upwards, or in a line correspond- 
 ing with the axis of the pelvis, and conduct the re- 
 mainder of the operation as already described. 
 
 END 
 
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