 |
[Footnote 1: The situation of this vessel, its close relation to the pleura, the aorta, the large venous trunks, the vagus and phrenic nerves, and the uncertainty as to its length, or as to whether or not a thyroid or vertebral branch arises from it, are circumstances which render the operation of tying the vessel in cases of aneurism very doubtful as to a successful issue. The operation (so far as I know) has hitherto failed. Anatomical relations, nearly similar to these, prevent, in like manner, an easy access to the iliac arteries, and cause the operator much anxiety as to the issue.]
[Footnote 2: The effusion of fluid into the pleural sac (from whatever cause it may arise) sometimes takes place to a very remarkable extent. I have had opportunities of examining patients, in whom the heart appeared to be completely dislocated, from the left to the right side, owing to the large collection of serous fluid in the left pleural sac. The heart's pulsations could be felt distinctly under the right nipple. Paracentesis thoracis was performed at the point indicated in PLATE 26. In these cases, and another observed at the Hotel Dieu, the heart and lung, in consequence of the extensive adhesions which they contracted in their abnormal position, did not immediately resume their proper situation when the fluid was withdrawn from the chest. Nor is it to be expected that they should ever return to their normal character and position, when the disease which caused their displacement has been of long standing.]
DESCRIPTION OF PLATE 26.
A. The systemic aorta. Owing to the body being inclined forwards, the root of the aorta appears to approach too near the lower boundary (N) of the thorax.
B. The left brachio-cephalic vein.
C. Left subclavian vein.
D. Right brachia-cephalic vein.
E. Left common carotid artery.
F. Brachio-cephalic artery.
G G*. The first pair of ribs.
H. Superior vena cava.
I. Left bronchus.
K K*. Fourth pair of ribs.
L. Descending thoracic aorta.
M. Oesophagus.
N. Epigastrium.
O. Left kidney.
P. Umbilicus.
Q. Abdominal aorta, at its bifurcation.
R R*. Right and left iliac fossae.
S. Left common iliac vein.
T. Inferior vena cava.
U. Psoas muscle, supporting the right spermatic vessels.
V. Left external iliac artery crossed by the left ureter.
W. Right external iliac artery crossed by the right ureter.
X. The rectum.
Y. The urinary bladder, which being fully distended, and viewed from above, gives it the appearance of being higher than usual above the pubic symphysis.
Z. Pubic symphysis.
2. The left internal abdominal ring complicated with the epigastric vessels, the vas deferens, and the spermatic vessels.
3. The right internal abdominal ring in connection with the like vessels and duct as that of left side.
4. Superior mesenteric artery.
5, 6. Right and left external iliac veins.
7, 8. Situations of the anterior superior iliac spinous processes.
9, 10. Situations of the coracoid processes.
11, 12. Right and left hypochondriac regions.
Plate 26
COMMENTARY ON PLATE 27.
THE SURGICAL DISSECTION OF THE SUPERFICIAL BLOODVESSELS ETC. OF THE INGUINO-FEMORAL REGION.
Hernial protrusions are very liable to occur at the inguino-femoral region; and this fact has led the surgeon to study the anatomical relations of this part with more than ordinary care and patience. So minutely has he dissected every structure proper to this locality, and so closely has he investigated every possible condition of it as being the seat of hernial, that the only novelty which now remains to be sought for is that of a simplification of the facts, already known to be far too much obscured by an unwieldy nomenclature, and a useless detail of trifling evidence. And it would seem that nothing can more directly tend to this simplification, than that of viewing the inguinal and femoral regions, not separately, but as a relationary whole. For as both regions are blended together by structures which are common to both, so do the herniae which are described as being proper to either region, occur in such close connexion as at times to render it very difficult to distinguish between them.
The human species is, of all others, most subject to hernial in the groin. The erect attitude of the human form, and the fact that many of its more powerful muscular efforts are performed in this posture, cause its more frequent liability to the accidents called abdominal herniae or ruptures.
The viscera of the abdomen occupy this cavity completely, and indeed they naturally, at all times, subject the abdominal parietes to a state of constant pressure, as may be proved by their escape from the abdomen in cases of large wounds of this region. In the erect posture of the body this pressure is increased, for the viscera now gravitate and force downwards and forwards against the abdominal parietes. In addition to this gravitating force, another power impels the viscera from above downwards—namely, that of the muscles of the trunk, and the principal agent amongst these is the diaphragm. The lungs, again, expanding above the diaphragm, add also to the gravitation of the abdominal contents, and these, under the pressure thus accumulated, occasionally make an exit for themselves at the groins, which are the weakest and most depending parts of the abdomen.
Herniae are variously named in accordance with the following circumstances—viz., the precise locality at which they occur—the size and form of the tumour—the time of life at which they happen. Sexual peculiarities do not serve to distinguish herniae, though it is true that the inguinal form, at the part D F, occurs more commonly in the male, whilst the crural form, at the opening E, happens more frequently in the female.
The most common forms of herniae happen at those localities where the abdominal walls are traversed by the bloodvessels on their way to the outstanding organs, and where, in consequence, the walls of the abdomen have become weakened. It also happens, that at these very situations the visceral pressure is greatest whilst the body stands erect. These localities are, A, the umbilicus, a point characterized as having given passage (in the foetal state) to the umbilical vessels; D, the place where the spermatic vessels and duct pass from the abdomen to the testicle; and immediately beneath this, the crural arch, which gives exit to the crural vessels. Herniae may happen at other localities, such as at the thyroid aperture, which transmits the thyroid vessels; and at the greater sacrosciatic notch, through which the gluteal vessels pass; and all regions of the abdominal walls may give exit to intestinal protrusion in consequence of malformations, disease, or injury. But as the more frequent varieties of herniae are those which traverse the localities, A, D, E, and as these, fortunately, are the most manageable under the care of the surgical anatomist, we proceed to examine the structures concerned in their occurrence.
A direct opening from within outwards does not exist in the walls of the abdomen; and anatomy demonstrates to us the fact, that where the spermatic cord, D F, and the femoral vessels, pass from the abdomen to the external parts, they carry with them a covering of the several layers of structures, both muscular and membranous, which they encounter in their passage. The inguinal and crural forms of herniae which follow the passages made by the spermatic cord, and the crural vessels, must necessarily carry with them the like investments, and these are what constitute the coverings of the herniae themselves.
The groin in its undissected state is marked by certain elevations and depressions which indicate the general relations of the subcutaneous parts. The abdomen is separated from the thigh by an undulating grooved line, extending from C*, the point of the iliac bone, to B, the symphysis pubis This line or fold of the groin coincides exactly with the situation of that fibrous band of the external oblique muscle named Poupart's ligament. From below the middle of this abdomino-femoral groove, C B, another curved line, D, b, springs, and courses obliquely, inwards and downwards, between the upper part of the thigh and the pubis, to terminate in the scrotum. The external border of this line indicates the course of the spermatic cord, D F, which can be readily felt beneath the skin. In all subjects, however gross or emaciated they may happen to be, these two lines are readily distinguishable, and as they bear relations to the several kinds of rupture taking place in these parts, the surgeon should consider them with keen regard. A comparison of the two sides of the figure, PLATE 27, will show that the spermatic cord, D F, and Poupart's ligament, C B, determine the shape of the inguino-femoral region. When the integument with the subcutaneous adipose tissue is removed from the inguino-femoral region, we expose that common investing membrane called the superficial fascia. This fascia, a a a, stretches over the lower part of the abdomen and the upper part of the thigh. It becomes intimately attached to Poupart's ligament along the ilio-pubic line, C B; it invests the spermatic cord, as shown at b, and descends into the scrotum, so as to encase this part. Where this superficial fascia overlies the saphenous opening, E, of the fascia lata, it assumes a "cribriform" character, owing to its being pierced by numerous lymphatic vessels and some veins. As this superficial fascia invests all parts of the inguino-femoral region, as it forms an envelope for the spermatic cord, D F, and sheathes over the saphenous opening, E, it must follow of course that wherever the hernial protrusion takes place in this region, whether at D, or F, or E, or adjacent parts, this membrane forms the external subcutaneous covering of the bowel.
There is another circumstance respecting the form and attachments of the superficial fascia, which, in a pathological point of view, is worthy of notice—viz., that owing to the fact of its enveloping the scrotum, penis, spermatic cord, and abdominal parietes, whilst it becomes firmly attached to Poupart's ligament along the abdomino-femoral fold, B C, it isolates these parts, in some degree, from the thigh; and when urine happens to be from any cause extravasated through this abdominal-scrotal bag of the superficial fascia, the thighs do not in general participate in the inflammation superinduced upon such accident.
The spermatic cord, D, emerges from the abdomen and becomes definable through the fibres of the sheathing tendon of the external oblique muscle, H, at a point midway between the extremities of the ilio-pubic line or fold. In some cases, this place, whereat the cord first manifests itself in the groin, lies nearer the pubic symphysis; but however much it may vary in this particular, we may safely regard the femoro-pubic fold, D, b, as containing the cord, and also that the place where this fold meets the iliopubic line, C B, at the point D, marks the exit of the cord from the abdomen.
The spermatic cord does not actually pierce the sheathing tendon of the external oblique muscle at the point D, and there does not, in fact, exist naturally such an opening as the "external abdominal ring," for the cord carries with it a production of the tendon of the external oblique muscle, and this has been named by surgical anatomists the "intercolumnar fascia," [Footnote] the "spermatic fascia." The fibres of this spermatic fascia are seen at D F, crossing the cord obliquely, and encasing it. This covering of the cord lies beneath the spermatic envelope formed by, a b, the superficial fascia; and when a hernial protrusion descends through the cord, both these investing membranes form the two outermost envelopes for the intestine in its new and abnormal situation.
[Footnote: On referring to the works of Sir Astley Cooper, Hesselbach, Scarpa, and, others, I find attempts made to establish a distinction between what is called the "intercolumnar fascia" and the "spermatic fascia," and just as if these were structures separable from each other or from the aponeurotic sheath of the external oblique muscle. I find, in like manner, in these and other works, a tediously-laboured account of the superficial fascia, as being divisible into two layers of membrane, and that this has given rise to considerable difference of opinion as to whether or not we should regard the deeper layer as being a production of the fascia lata, ascending from the thigh to the abdomen, or rather of the membrane of the abdomen descending to the thigh, &c. These and such like considerations I omit to discuss here; for, with all proper deference to the high authority of the authors cited, I dare to maintain, that, in a practical point of view, they arc absolutely of no moment, and in a purely scientific view, they are, so far as regards the substance of the truth which they would reveal, wholly beneath the notice of the rational mind. The practitioner who would arm his judgment with the knowledge of a broad fact or principle, should not allow his serious attention to be diverted by a pursuit after any such useless and trifling details, for not only are they unallied to the stern requirements of surgical skill, but they serve to degrade it from the rank and roll of the sciences. Whilst operating for the reduction of inguinal hernia by the "taxis" or the bistoury, who is there that feels anxiety concerning the origin or the distinctiveness of the "spermatic fascia?" Or, knowing it to be present, who concerns himself about the better propriety of naming it "tunica vaginalis communis," "tunique fibreuse du cordon spermatique," "fascia cremasterica," or "tunica aponeurotica?"]
The close relations which the cord, D F, bears to the saphenous opening, E, of the fascia lata, should be closely considered, forasmuch as when an oblique inguinal hernia descends from D to F, it approaches the situation of the saphenous opening, E, which is the seat of the femoral or crural hernia, and both varieties of hernia may hence be confounded. But with a moderate degree of judgment, based upon the habit of referring the anatomy to the surface, such error may always be avoided. This important subject shall be more fully treated of further on.
The superficial bloodvessels of the inguino-femoral region are, e e, the saphenous vein, which, ascending from the inner side of the leg and thigh, pierces the saphenous opening, E, to unite with the femoral vein. The saphenous vein, previously to entering the saphenous opening, receives the epigastric vein, i, the external circumflex ilii vein, h, and another venous branch, d, coming from the fore part of the thigh. In the living body the course of the distended saphenous vein may be traced beneath the skin, and easily avoided in surgical operations upon the parts contained in this region. Small branches of the femoral artery pierce the fascia lata, and accompany these superficial veins. Both these orders of vessels are generally divided in the operation required for the reduction of either the inguinal or the femoral strangulated hernia; but they are, for the most part, unimportant in size. Some branches of nerves, such as, k, the external cutaneous, which is given off from the lumbar nerves, and, f, the middle cutaneous, which is derived from the crural nerve, pierce the fascia lata, and appear upon the external side and middle of the thigh.
Numerous lymphatic glands occupy the inguino-femoral region; these can be felt, lying subcutaneous, even in the undissected state of the parts. These glands form two principal groups, one of which, c, lies along the middle of the inguinal fold, C B; the other, G g, lies scattered in the neighbourhood of the saphenous opening. The former group receive the lymphatic vessels of the generative organs; and the glands of which it is composed are those which suppurate in, syphilitic or other affections of these parts.
The general relations which the larger vessels of the inguino-femoral region bear to each other and to the superficies, may be referred to in PLATE 27, with practical advantage. The umbilicus, A, indicates pretty generally the level at which the aorta bifurcates on the forepart of the lumbar vertebrae. In the erect, and even in the recumbent posture, the aorta may (especially in emaciated subjects) be felt pulsating under the pressure of the hand; for the vertebrae bear forward the vessel to a level nearly equal with, C C, the anterior superior spinous processes of the iliac bones. If a gunshot were to pass through the abdomen, transversely, from these points, and through B, it would penetrate the aorta at its bifurcation. The line A B coincides with the linea alba. The oblique lines, A D, A D,* indicate the course of the iliac vessels. The point D marks the situation where the spermatic vessels enter the abdomen; and also where the epigastric artery is given off from the external iliac. The most convenient line of incision that can be made for reaching the situation of either of the iliac arteries, is that which ranges from C, the iliac spine, to D, the point where the spermatic cord enters the abdomen. The direct line drawn between D and G marks the course of the femoral artery, and this ranges along the outer border, E, of the saphenous opening.
DESCRIPTION OF PLATE 27.
A. The umbilicus.
B. The upper margin of the pubic symphysis.
C. The anterior superior spine of the left iliac bone. C*, the situation of the corresponding part on the right side.
D. The point where, in this subject, the cord manifested itself beneath the fibres of the external oblique muscle. D*, a corresponding part on the opposite side.
E. The saphenous opening in the fascia lata, receiving e, the saphenous vein.
F. The lax and pendulous cord, which in this case, overlies the upper part of the saphenous opening.
G. Lymphatic glands lying on the fascia lata in the neighbourhood of the saphenous opening.
H. The fleshy part of the external oblique muscle.
a a a. The superficial fascia of the abdomen.
b. The same fascia forming an envelope for the spermatic cord and scrotum.
c. Inguinal glands lying near Poupart's ligament.
d. A common venous trunk, formed by branches from the thigh and abdomen, and joining—
e e. The saphenous vein.
f. The middle cutaneous nerve, derived from the anterior crural nerve.
g. Femoral lymphatic glands.
h. Superficial external iliac vein.
i. Superficial epigastric vein.
k. External cutaneous branches of nerves from the lumbar plexus.
PLATE 27
COMMENTARY ON PLATES 28 & 29.
THE SURGICAL DISSECTION OF THE FIRST, SECOND, THIRD, AND FOURTH LAYERS OF THE INGUINAL REGION IN CONNEXION WITH THOSE OF THE THIGH.
The common integument or first layer of the inguino-femoral region being removed, we expose the superficial fascia constituting the second layer. The connexion of this fascia with Poupart's ligament along the line C D, together with the facts, that corresponding with this line the fascia is devoid of adipous substance, and the integument thin and delicate, whilst above over the abdomen, and below over the upper part of the thigh, the meshes of the fascia are generally loaded with a considerable quantity of adipous tissue, will account for the permanency and distinctness of the fold of the groin. As this fold corresponds with Poupart's ligament, it is taken as a guide to distinguish between the inguinal and femoral forms of herniae.
The general relations of the superficial fascia are well described by Camper in the following sentence: "Musculus obliquus igitur externus abdominis, qua parte carneus est, membrana quadam propria, quali omnes musculi, tegitur, quae sensim in aponeurosin mutata, ac cum tendineis hujus musculi partibus unita, externe ac anteriore parte abdomen tegit; finem vero nullibi habere perspicuum est, ad pubem enim miscet cellulosa membrana, cum ligamento penis in viris ac clitoridis in feminis, involucrum dat musculo cremasteri, ac aponeuroseos speciem musculis anterioribus femoris, qua glandulae inguinales, ac cruris vasa majora obteguntur." (Icones Herniarum.)
Owing to the varied thickness of the adipous tissue contained in the superficial fascia at several regions of the same body, and at some corresponding regions of different individuals, it will be evident that the depth of the incision required to divide it, so as to expose subjacent structures, must vary accordingly. Where the superficial fascia, after encasing the cord, descends into the scrotum, it is also devoid of the fatty tissu.
By the removal of the superficial fascia and glands we expose the aponeurosis of the external oblique muscle, A a, Pl. 28, (constituting the third layer of the groin,) and also the fascia of the thigh, H L. These strong fibrous structures will be observed to hold still in situ the other parts, and to be the chief agents in determining the normal form of this region.
The inguino-femoral region, as being the seat of hernial protrusions, may in this stage of the dissection be conveniently described as a space formed of two triangles—the one inguinal, the other femoral, placed base to base. The inguinal triangle may be drawn between the points, B C D, Pl. 28, while the femoral triangle may be marked by the points, C D N. The conjoined bases of these triangles correspond to Poupart's ligament along the line, C D. The inguinal varieties of herniae occur immediately above the line, C D, while the femoral varieties of herniae take place below this line. The herniae of the inguinal triangle are, therefore, distinguishable from those of the femoral triangle by a reference to the line, C D, or Poupart's ligament.
The aponeurosis of the external oblique muscle occupies the whole of that space which I have marked as the inguinal triangle, B C D, Pl. 28. The fleshy fibres of the muscle, A, after forming the lateral wall of the abdomen, descend to the level of C, the iliac spinous process, and here give off the inguinal part of their broad tendon, a. The fibres of this part of the tendon descend obliquely downwards and forwards to become inserted at the median line of the abdomen into the linea alba, B D, as also into the symphysis and crista of the os pubis. The lower band of the fibres of this tendinous sheath—viz., that which is stretched between C, the iliac spine, and D, the crista pubis, is named Poupart's ligament; and this is strongly connected with H, the iliac portion of the fascia lata of the thigh.
Poupart's ligament is not stretched tensely in a right line, like the string of a bow, between the points, C and D. With regard to these points it is lax, and curves down towards the thigh like the arc of a circle. The degree of tension which it manifests when the thigh is in the extended position is chiefly owing to its connexion with the fascia lata. If in this position of the limb we sever the connexion between the ligament and fascia, the former becomes relaxed in the same degree as it does when we flex the thigh upon the abdomen. The utmost degree of relaxation which can be given to Poupart's ligament is effected by flexing the thigh towards the abdomen, at the same time that we support the body forwards. This fact has its practical application in connexion with the reduction of herniae.
Immediately above the middle of Poupart's ligament, at the point E, Pl. 28, we observe the commencement of a separation taking place among the fibres of the aponeurosis. These divide into two bands, which, gradually widening from each other as they proceed inwards, become inserted, the upper one into the symphysis pubis, the lower into the spine and pectineal ridge of this bone. The lower band identifies itself with Poupart's ligament. The interval which is thus formed by the separation of these fibres assumes the appearance of an acute triangle, the apex of which is at E, and the base at D. But the outer end of this interval is rounded off by certain fibres which cross those of the bands at varying angles. At this place, the aponeurosis, thus constituted of fibres disposed crossways, is elongated into a canal, forming an envelope for the cord, K. This elongation is named the "external spermatic fascia," and is continued over the cord as far as the testicle. In the female, a similar canal encloses the round ligament of the uterus. From the above-mentioned facts, it will appear that the so-called "external abdominal ring" does not exist as an aperture with defined margins formed in the tendon of the external oblique muscle. It is only when we divide the spermatic fascia upon the cord at K, that we form the external ring, and then it must be regarded as an artificial opening, as at D, Pl. 29.
The part of the groin where the spermatic fascia is first derived from the aponeurosis, so as to envelope the cord, varies in several individuals; and thereupon depends, in great measure, the strength or weakness of the groin. In some cases, the cord becomes pendulous as far outwards as the point E, Pl. 28, which corresponds to the internal ring, thereby offering a direct passage for the hernial protrusion. In other instances, the two bands of the aponeurosis, known as the "pillars of the ring," together with the transverse fibres, or "intercolumnar fascia," firmly embrace and support the cord as far inwards as the point K, and by the oblique direction thus given to the cord in traversing the inguinal parietes, these parts are fortified against the occurrence of hernia. In Pl. 28, the cord, K, will be observed to drop over the lower band of fibres, ("external pillar of the ring,") and to have D, the crista pubis, on its inner side. In Pl. 29, the upper band of fibres ("internal pillar of the ring") may be seen proceeding to its insertion into the symphysis pubis. When a hernial tumour protrudes at the situation K, it is invested, in the same manner as the cord, by the spermatic fascia, and holds in respect to the fibrous bands or pillars the same relations also as this part.
After removing the tendon of the external oblique muscle, A a, Pl. 28, together with its spermatic elongation, E, we expose the internal oblique, F E, Pl. 29, and the cremaster, constituting the fourth inguinal layer. The fleshy part of this muscle, F E, occupies a much greater extent of the inguinal region than does that of the external oblique. Whilst the fleshy fibres of the latter terminate on a level with C, the iliac spine, those of the internal oblique are continued down as far as the external abdominal ring, E D h, and even protrude through this place in the form of a cremaster. The muscular fibres of the internal oblique terminate internally at the linea semilunaris, g; while Poupart's ligament, the spinous process and crest of the ilium, give origin to them externally. At the linea semilunaris, the tendon of the internal oblique is described as dividing into two layers, which passing, one before and the other behind the rectus abdominis, thus enclose this muscle in a sheath, after which they are inserted into the linea alba, G. The direction of the fibres of the inguinal portion of the muscle, F E, is obliquely downwards and forwards, and here they are firmly overlaid by the aponeurosis of the external oblique.
The cremaster muscle manifests itself as being a part of the internal oblique, viewing this in its totality. Cloquet (Recherches anatomiques sur les Hernies de l'Abdomen) first demonstrated the correctness of this idea.
The oblique and serial arrangement of the muscular fibres of the internal oblique, F, Pl. 29, is seen to be continued upon the spermatic cord by the fibres of the cremaster, E e. These fibres, like those of the lower border of the internal oblique, arise from the middle of Poupart's ligament, and after descending over the cord as far as the testicle in the form of a series of inverted loops, e, again ascend to join the tendon of the internal oblique, by which they become inserted into the crest and pectineal ridge of the os pubis. The peculiar looping arrangement exhibited by the cremasteric fibres indicates the fact that the testicle, during its descent from the loins to the scrotum, carried with it a muscular covering, at the expense of the internal oblique muscle. The cremaster, therefore, is to be interpreted as a production of the internal oblique, just as the spermatic fascia is an elongation of the external oblique. The hernia, which follows the course of the spermatic vessels, must therefore necessarily become invested by cremasteric fibres.
The fascia lata, H, Pl. 28, being strongly connected and continuous with Poupart's ligament along its inferior border, the boundary line, which Poupart's ligament is described as drawing between the abdomen and thigh, must be considered as merely an artificial one.
In the upper region of the thigh the fascia lata is divided into two parts—viz., H, the iliac part, and L, the pubic. The iliac part, H, which is external, and occupying a higher plane than the pubic part, is attached to Poupart's ligament along its whole extent, from C to D, Pl. 28; that is, from the anterior iliac spinous process to the crista pubis. From this latter point over the upper and inner part of the thigh, the iliac division of the fascia appears to terminate in an edge of crescentic shape, h; but this appearance is only given to it by our separating the superficial fascia with which it is, in the natural state of the parts, blended. The pubic part of the fascia, L, Pl. 28, which is much thinner than the iliac part, covers the pectineus muscle, and is attached to the crest and pectineal ridge of the os pubis, occupying a plane, therefore, below the iliac part, and in this way passes outwards beneath the sheath of the femoral vessels, K I, Pl. 29. These two divisions of the fascia lata, although separated above, are united and continuous on the same plane below. An interval is thus formed between them for the space of about two inches below the inner third of Poupart's ligament; and this interval is known as the "saphenous opening," L h, Pl. 28. Through this opening, the saphena vein, O, Pl. 29, enters the femoral vein, I.
From the foregoing remarks it will appear that no such aperture as that which is named "saphenous," and described as being shaped in the manner of L h, Pl. 28, with its "upper and lower cornua," and its "falciform process," or edge, h, exists naturally. Nor need we be surprised, therefore, that so accurate an observer as Soemmering (de Corporis Humani Fabrica) appears to have taken no notice of it.
Whilst the pubic part of the fascia lata passes beneath the sheath of the femoral vessels, K I, Pl. 29, the iliac part, H h, blends by its falciform margin with the superficial fascia, and also with N n, the sheath of the femoral vessels. The so-called saphenous opening, therefore, is naturally masked by the superficial fascia; and this membrane being here perforated for the passage of the saphena vein, and its tributary branches, as also the efferent vessels of the lymphatic glands, is termed "cribriform."
The femoral vessels, K I, contained in their proper sheath, lie immediately beneath the iliac part of the fascia lata, in that angle which is expressed by Poupart's ligament, along the line C D above; by the sartorius muscle in the line C M externally; and by a line drawn from D to N, corresponding to the pectineus muscle internally. The femoral vein, I, lies close to the outer margin of the saphenous opening. The artery, K, lies close to the outer side of the vein; and external to the artery is seen, L, the anterior crural nerve, sending off its superficial and deep branches.
When a femoral hernia protrudes at the saphenous space L h, Pl. 28, the dense falciform process, h, embraces its outer side, while the pubic portion of the fascia, L, lies beneath it. The cord, K, is placed on the inner side of the hernia; the cribriform fascia covers it; and the upper end of the saphena vein, M, passes beneath its lower border. The upper cornu, h, Pl. 29, of the falciform process would seem, by its situation, to be one of the parts which constrict a crural hernia. An inguinal hernia, which descends the cord, K, Pl. 28, provided it passes no further than the point indicated at K, and a crural hernia turning upwards from the saphenous interval over the cord at K, are very likely to present some difficulty in distinctive diagnosis.
DESCRIPTION OF THE FIGURES OF PLATES 28 & 29.
PLATE 28.
A. The fleshy part of the external oblique muscle; a, its tendon covering the rectus muscle.
B. The umbilicus.
C. The anterior superior spinous process of the ilium.
D. The spinous process of the os pubis.
E. The point where in this instance the fibres of the aponeurotic tendon of the external oblique muscle begin to separate and form the pillars of the external ring.
F G. See Plate 29.
H. The fascia lata—its iliac portion. The letter indicates the situation of the common femoral artery; h, the falciform edge of the saphenous opening.
I. The sartorius muscle covered by a process of the fascia lata.
K. The spermatic fascia derived from the external oblique tendon.
L. The pubic part of the fascia lata forming the inner and posterior boundary of the saphenous opening.
M. The saphenous vein.
N. A tributary vein coming from the fore part of the thigh.
Plate 28
PLATE 29.
A. The muscular part of the external oblique; a, its tendon.
B. The umbilicus.
C. The anterior superior iliac spine.
D. The spine of the os pubis.
E. The cremasteric fibres, within the external ring, surrounding the cord; e, the cremasteric fibres looping over the cord outside the ring.
F. The muscular part of the internal oblique giving off, E, the cremaster; its tendon sheathing the rectus muscle.
G. The linea alba; f, g, the linea semilunaris.
H. The iliac part of the fascia lata; h, the upper cornu of its falciform process.
I. The femoral vein.
K. The femoral artery.
L. The anterior crural nerve.
M. The sartorius muscle.
N. The sheath of the femoral vessels; n, its upper part.
O. The saphena vein.
P. The pubic part of the fascia lata.
Plate 29
COMMENTARY ON PLATES 30 & 31.
THE SURGICAL DISSECTION OF THE FIFTH, SIXTH, SEVENTH, AND EIGHTH LAYERS OF THE INGUINAL REGION, AND THEIR CONNEXION WITH THOSE OF THE THIGH.
When we remove the internal oblique and cremaster muscles, we expose the transverse muscle, which may be regarded as the fifth inguinal layer, F, Pl. 30. This muscle is similar in shape and dimensions to the internal oblique. The connexions of both are also similar, inasmuch as they arise from the inner edge of the crista ilii, and from the outer half of, V, Poupart's ligament. The fleshy fibres of these two muscles vary but little in direction, and terminate at the same place—viz., the linea semilunaris, which marks the outer border of the rectus muscle. But whilst the fleshy parts of these three abdominal muscles, D E F, form successive strata in the groin, their aponeurotic tendons present the following peculiarities of arrangement in respect to the rectus muscle. The tendon of the external oblique, d, passes altogether in front of the rectus; that of the internal oblique is split opposite the linea semilunaris into two layers, which enclose the rectus between them as they pass to be inserted into the linea alba. But midway between the navel and pubes, at the point marked G, both layers of the tendon are found to pass in front of the rectus. The tendon of the transverse muscle passes behind the rectus; but opposite the point G, it joins both layers of the internal oblique tendon, and with this passes in front of the rectus. The fibrous structure thus constituted by the union of the tendons of the internal oblique and transverse muscles, e f, is named the "conjoined tendon."
The conjoined tendon, f, Plates 30 and 31, appears as a continuation of the linea semilunaris, for this latter is in itself a result of the union of the tendons of the abdominal muscles at the external border of the rectus. As the conjoined tendon curves so far outwards to its insertion into the pectineal ridge of the pubic bone, as to occupy a situation immediately behind the external ring, it thereby fortifies this part against the occurrence of a direct protrusion of the bowel. But the breadth, as well as the density, of this tendon varies in several individuals, and these will accordingly be more or less liable to the occurrence of hernia.
The arched inferior border of the transverse muscle, F, Plate 30, expresses by its abrupt termination that some part is wanting to it; and this appearance, together with the fact that the fibres of this part of the muscle blend with those of the internal oblique and cremaster, and cannot be separated except by severing the connexion, at once suggests the idea that the cremaster is a derivation from both these muscles.
Assuming this to be the case, therefore, it follows that when the dissector removes the cremaster from the space L h, he himself causes this vacancy in the muscular parietes of the groin to occur, and at the same time gives unnatural definition to the lower border of the transverse and oblique muscles. In a dissection so conducted, the cord is made to assume the variable positions which anatomists report it to have in respect to the neighbouring muscles. But when we view nature as she is, and not as fashioned by the scalpel, we never fail to find an easy explanation of her form.
In the foetus, prior to the descent of the testicle, the cremaster muscle does not exist. (Cloquet, op cit.) From this we infer, that those parts of the muscles, E F, Plate 30, which at a subsequent period are converted into a cremaster, entirely occupy the space L h. In the adult body, where one of the testicles has been arrested in the inguinal canal, the muscles, E F, do not present a defined arched margin, above the vacant space L h, but are continued (as in the foetus) as low down as the external abdominal ring. In the adult, where the testicle has descended to the scrotum, the cremaster exists, and is serially continuous with the muscles, E F, covering the space L h; the meaning of which is, that the cremasteric parts of the muscles, E F, cover this space. The name cremaster therefore must not cancel the fact that the fibres so named are parts of the muscles, E F. Again, in the female devoid of a cremaster, the muscles, E F, present of their full quantities, having sustained no diminution of their bulk by the formation of a cremaster. But when an external inguinal hernia occurs in the female body, the bowel during its descent carries before it a cremasteric covering at the expense of the muscles E F, just in the same way as the testicle does in the foetus. (Cloquet.)
From the above-mentioned facts, viewed comparatively, it seems that the following inferences may be legitimately drawn:—1st, that the space L h does not naturally exist devoid of a muscular covering; for, in fact, the cremaster overlies this situation; 2nd, that the name cremaster is one given to the lower fibres of the internal oblique and transverse muscles which cover this space; and 3rd, that to separate the cremasteric elongation of these muscles, and then describe them as presenting a defined arched margin, an inch or two above Poupart's ligament, is an act as arbitrary on the part of the dissector as if he were to subdivide these muscles still more, and, while regarding the subdivisions as different structures, to give them names of different signification. When once we consent to regard the cremaster as constituted of the fibres originally proper to the muscles, E F, we then are led to the discovery of the true relations of the cord in respect to these muscles.
On removing the transverse muscle, we expose the inguinal part of the transversalis fascia—the sixth inguinal layer, L h, Plate 30—K k, Plate 31. This fascia or membrane affords a general lining to the abdominal walls, in some parts of which it presents of a denser and stronger texture than in others. It is stretched over the abdomen between the muscles and the peritonaeum. The fascia iliaca, the fascia pelvica, and the fascia transversalis, are only regional divisions of the one general membrane. On viewing this fascia in its totality, I find it to exhibit many features in common with those other fibrous structures which envelope serous cavities. The transversalis fascia supports externally the peritonaeum, in the same way as the dura mater supports the arachnoid membrane, or as the pleural fascia supports the serous pleura. While the serous membranes form completely shut sacs, the fibrous membranes which lie external to those sacs are pierced by the vessels which course between them and the serous membranes, and afford sheaths or envelopes for these vessels in their passage from the interior to the external parts. The sheath, H h, Plates 30 and 31, which surrounds the spermatic vessels, and the sheath, R, Plate 31, which envelopes the crural vessels, are elongations of the fascia transversalis.
In the groin, the transversalis fascia, K k, Plate 31, presents, in general, so dense a texture as to offer considerable resistance to visceral pressure. Here it is stretched between the transverse muscle, F, Plate 31, and the peritonaeum, I. It adheres to the external surface of the peritonaeum, and to the internal surface of the transverse muscle, by means of an intervening cellular tissue. It is connected below to Poupart's ligament, along the line of which it joins the fascia iliaca. It lines the lower posterior aspect of the rectus muscle, where this is devoid of its sheath; and it is incorporated with f, the conjoined tendon, thereby fencing the external abdominal ring. Immediately above the middle of Poupart's ligament, this membrane, at the point marked h, Plate 30, is pouched into a canal-shaped elongation, which invests the spermatic vessels as far as the testicle in the scrotum; and to this elongation is given the names "fascia spermatica interna" (Cooper), "fascia infundibuliform" (Cloquet). The same part, when it encloses an external oblique hernia, is named "fascia propria." The neck or inlet of this funnel-shaped canal is oval, and named the "internal abdominal ring." As this ring looks towards the interior of the abdomen, and forms the entrance of the funnel-shaped canal, it cannot of course be seen from before until we slit open this canal. Compare the parts marked H h in Plates 30 and 31.
The inguinal and iliac portions of the fascia transversalis join along the line of Poupart's ligament, A C. The iliac vessels, in their passage to the thigh, encounter the fascia at the middle third of the crural arch formed by the ligament, and take an investment (the sheath, R) from the fascia. The fore part of this sheath is mentioned as formed by the fascia transversalis—the back part by the fascia iliaca; but these distinctions are merely nominal, and it is therefore unnecessary to dwell upon them. The sheath of the femoral vessels is also funnel-shaped, and surrounds them on all sides. Its broad entrance lies beneath the middle of Poupart's ligament. Several septa are met with in its interior. These serve to separate the femoral vessels from each other. The femoral vein, O, Plate 30, is separated from the falciform margin, S s, of the saphenous opening by one of these septa. Between this septum and the falx an interval occurs, and through it the crural hernia usually descends. These parts will be more particularly noticed when considering the anatomy of crural hernia.
Beneath the fascia transversalis is found the subserous cellular membrane, which serves as a connecting medium between the fascia and the peritonaeum. This cellular membrane may be considered as the seventh inguinal layer. It is described by Scarpa (sull' Ernie) as forming an investment for the spermatic vessels inside the sheath, where it is copious, especially in old inguinal hernia. It is also sometimes mixed with fatty tissue. In it is found embedded the infantile cord—the remains of the upper part of the peritoneal tunica vaginalis—a structure which will be considered in connexion with congenital herniae.
By removing the subserous cellular tissue, we lay bare the peritonaeum, which forms the eighth layer of the inguinal region. Upon it the epigastric and spermatic vessels are seen to rest. These vessels course between the fascia transversalis and the peritonaeum. The internal ring which is formed in the fascia, K h, may be now seen to be closed by the peritonaeum, I. The inguinal canal, therefore, does not, in the normal state of these parts, communicate with the general serous cavity; and here it must be evident that before the bowel, which is situated immediately behind the peritonaeum, I, can be received into the canal, H h, it must either rupture that membrane, or elongate it in the form of a sac.
The exact position which the epigastric, L, Plate 31, and spermatic vessels, M, bear in respect to the internal ring, is a point of chief importance in the surgical anatomy of the groin; for the various forms of herniae which protrude through this part have an intimate relation to these vessels. The epigastric artery, in general, arises from the external iliac, close above the middle of Poupart's ligament, and ascends the inguinal wall in an oblique course towards the navel. It applies itself to the inner border of the internal ring, and here it is crossed on its outer side by the spermatic vessels, as these are about to enter the inguinal canal.
The inguinal canal is the natural channel through which the spermatic vessels traverse the groin on their way to the testicle in the scrotum. In the remarks which have been already made respecting the several layers of structures found in the groin, I endeavoured to realize the idea of an inguinal canal as consisting of elongations of these layers invaginated the one within the other, the outermost layer being the integument of the groin elongated into the scrotal skin, whilst the innermost layer consisted of the transversalis fascia elongated into the fascia spermatica interna, or sheath. The peritonaeum, which forms the eighth layer of the groin, was seen to be drawn across the internal ring of this canal above in such a way as to close it completely, whilst all the other layers, seven in number, were described as being continued over the spermatic vessels in the form of funnel-shaped investments, as far down as the testicle.
With the ideas of an inguinal canal thus naturally constituted, I need not hesitate to assert that the form, the extent, and the boundaries of the inguinal canal, as given by the descriptive anatomist, are purely conventional, and do not exist until after dissection; for which reason, and also because the form and condition of these parts so described and dissected do not appear absolutely to correspond in any two individuals, I omit to mention the scale of measurements drawn up by some eminent surgeons, with the object of determining the precise relative position of the several parts of the inguinal region.
The existence of an inguinal canal consisting, as I have described it, of funnel-shaped elongations from the several inguinal layers continued over the cord as far as the testicle, renders the adult male especially liable to hernial protrusions at this part. The oblique direction of the canal is, in some measure, a safeguard against these accidents; but this obliquity is not of the same degree in all bodies, and hence some are naturally more prone to herniae than others.
DESCRIPTION OF THE FIGURES OF PLATES 30 & 31.
PLATE 30.
A. The anterior superior iliac spine.
B. The umbilicus.
C. The spine of the pubis.
D. The external oblique muscle; d, its tendon. .
E. The internal oblique muscle; e, its tendon.
F. The transverse muscle; f, its tendon, forming, with e, the conjoined tendon.
G. The rectus muscle enclosed in its sheath.
H. The fascia spermatica interna covering the cord; h, its funnel-shaped extremity.
I, K, L, M. See Plate 31.
N. The femoral artery; n, its profunda branch.
O. The femoral vein.
P. The saphena vein.
Q. The sartorius muscle.
R. The sheath of the femoral vessels.
S. The falciform margin of the saphenous opening.
T. The anterior crural nerve.
U. The pubic portion of the fascia lata.
V. The iliac portion attached to Poupart's ligament.
W. The lower part of the iliacus muscle.
PLATE 30
PLATE 31.
A. The anterior superior iliac spine.
B. The umbilicus.
C. The spine of the pubis.
D. The external oblique muscle; d, its tendon; d*, the external ring.
E. The internal oblique muscle.
F. The transverse muscle; f, its tendon; forming, with e, the conjoined tendon.
G. The rectus muscle laid bare.
H h. The fascia spermatica interna laid open above and below d*, the external ring.
I. The peritonaeum closing the internal ring.
K. The fascia transversalis; k, its pubic part.
L. The epigastric artery and veins.
M. The spermatic artery, veins, and vas deferens bending round the epigastric artery at the internal ring; m, the same vessels below the external ring.
N. The femoral artery; n, its profunda branch.
O. The femoral vein, joined by—
P. The saphena vein.
Q. The sartorius muscle.
R. The sheath of the femoral vessels.
S S. The falciform margin of the saphenous opening,
T. The anterior crural nerve.
U. The pubic part of the fascia lata.
V. The iliac part of the fascia lata.
W. The lower part of the iliacus muscle.
Plate 31
COMMENTARY ON PLATES 32, 33, & 34.
THE DISSECTION OF THE OBLIQUE OR EXTERNAL AND THE DIRECT OR INTERNAL INGUINAL HERNIAE.
The order in which the herniary bowel takes its investments from the eight layers of the inguinal region, is precisely the reverse of that order in which these layers present in the dissection from before backwards. The innermost layer of the inguinal region is the peritonaeum, and from this membrane the intestine, when about to protrude, derives its first covering. This covering constitutes the hernial sac. Almost all varieties of inguinal herniae are said to be enveloped in a sac, or elongation of the peritonaeum. This is accounted as the general rule. The exceptions to the rule are mentioned as occurring in the following modes: 1st, the caecum and sigmoid flexure of the colon, which are devoid of mesenteries, and only partially covered by the peritonaeum, may slip down behind this membrane, and become hernial; 2nd, the inguinal part of the peritonaeum may suffer rupture, and allow the intestine to protrude through the opening. When a hernia occurs under either of these circumstances, it will be found deprived of a sac.
All the blood vessels and nerves of the abdomen lie external to the peritonaeum. Those vessels which traverse the abdomen on their way to the external organs course outside the peritonaeum; and at the places where they enter the abdominal parietes, the membrane is reflected from them. This disposition of the peritonaeum in respect to the spermatic and iliac vessels is exhibited in Plate 32.
The part of the peritonaeum which lines the inguinal parietes does not (in the normal state of the adult body) exhibit any aperture corresponding to that named the internal ring. The membrane is in this place, as elsewhere, continuous throughout, being extended over the ring, as also over other localities, where subjacent structures may be in part wanting. It is in these places, where the membrane happens to be unsupported, that herniae are most liable to occur. And it must be added, that the natural form of the internal surface of the groin is such as to guide the viscera under pressure directly against those parts which are the weakest.
The inner surface of the groin is divided into two pouches or fossae, by an intervening crescentic fold of the peritonaeum, which corresponds with the situation of the epigastric vessels. This fold is formed by the epigastric vessels and the umbilical ligament, which, being tenser and shorter than the peritonaeum, thereby cause this membrane to project. The outer fossa represents a triangular space, the apex of which is below, at P; the base being formed by the fibres of the transverse muscle above; the inner side by the epigastric artery; and the outer side by Poupart's ligament. The apex of this inverted triangle is opposite the internal ring. The inner fossa is bounded by the epigastric artery externally; by the margin of the rectus muscle internally; and by the os pubis and inner end of Poupart's ligament inferiorly. The inner fossa is opposite the external abdominal ring, and is known as the triangle of Hesselbach.
The two peritonaeal fossae being named external and internal, in reference to the situation of the epigastric vessels, we find that the two varieties of inguinal herniae which occur in these fossae are named external and internal also, in reference to the same part.
The external inguinal hernia, so called from its commencing in the outer peritonaeal fossa, on the outer side of the epigastric artery, takes a covering from the peritonaeum of this place, and pushes forward into the internal abdominal ring at the point marked P, Plate 32. In this place, the incipient hernia or bubonocele, covered by its sac, lies on the forepart of the spermatic vessels, and becomes invested by those same coverings which constitute the inguinal canal, through which these vessels pass. In this stage of the hernia, its situation in respect to the epigastric artery is truly external, and in respect to the spermatic vessels, anterior, while the protruded intestine itself is separated from actual contact with either of these vessels by its proper sac. The bubonocele, projecting through the internal ring at the situation marked F, (Plate 33,) midway between A, the anterior iliac spine, and I, the pubic spine, continues to increase in size; but as its further progress from behind directly forwards becomes arrested by the tense resisting aponeurosis of the external oblique muscle, h, it changes its course obliquely inwards along the canal, traversing this canal with the spermatic vessels, which still lie behind it, and, lastly, makes its exit at the external ring, H. The obliquity of this course, pursued by the hernia, from the internal to the external ring, has gained for it the name of oblique hernia. In this stage of the hernial protrusion, the only part of it which may be truly named external is the neck of its sac, F, for the elongated body, G, of the hernia lies now actually in front of the epigastric artery, P, and this vessel is separated from the anterior wall of the canal, H h, by an interval equal to the bulk of the hernia. While the hernia occupies the canal, F H, without projecting through the external ring, H, it is named "incomplete." When it has passed the external ring, H, so as to form a tumour of the size and in the situation of f g, it is named "complete." When, lastly, the hernia has extended itself so far as to occupy the whole length of the cord, and reach the scrotum, it is termed "scrotal hernia." These names, it will be seen, are given only to characterise the several stages of the one kind of hernia—viz., that which commences to form at a situation external to the epigastric artery, and, after following the course of the spermatic vessels through the inguinal canal, at length terminates in the scrotum.
The external inguinal hernia having entered the canal, P, (Plate 32,) at a situation immediately in front of the spermatic vessels, continues, in the several stages of its descent, to hold the same relation to these vessels through the whole length of the canal, even as far as the testicle in the scrotum. This hernia, however, when of long standing and large size, is known to separate the spermatic vessels from each other in such a way, that some are found to lie on its fore part—others to its outer side. However great may be the size of this hernia, even when it becomes scrotal, still the testicle is invariably found below it. This fact is accounted for by the circumstance, that the lower end of the spermatic envelopes is attached so firmly to the coats of the testicle as to prevent the hernia from either distending and elongating them to a level below this organ, or from entering the cavity of the tunica vaginalis.
The external form of inguinal hernia is, comparatively speaking, but rarely seen in the female. When it does occur in this sex, its position, investments, and course through the inguinal canal, where it accompanies the round ligament of the uterus, are the same as in the male. When the hernia escapes through the external abdominal ring of the female groin, it is found to lodge in the labium pudendi. In the male body, the testicle and spermatic cord, which have carried before them investments derived from all the layers of the inguinal region, have, as it were, already marked out the track to be followed by the hernia, and prepared for it its several coverings. The muscular parietes of the male inguinal region, from which the loose cremaster muscle has been derived, have by this circumstance become weakened, and hence the more frequent occurrence of external inguinal hernia in the male. But in the female, where no such process has taken place, and where a cremaster does not exist at the expense of the internal oblique and transverse muscles, the inguinal parietes remain more compact, and are less liable to suffer distention in the course of the uterine ligament.
The internal inguinal hernia takes its peritonaeal covering (the sac) from the inner fossa, Q R, Plate 32, internal to the epigastric artery, and forces directly forwards through the external abdominal ring, carrying investments from each of such structures as it meets with in this locality of the groin. As the external ring, H, Plate 34, is opposite the inner peritonaeal fossa, Q R, Plate 32, this hernia, which protrudes thus immediately from behind forwards, is also named direct. In this way these two varieties of hernia, (the external, Plate 33, and the internal, Plate 34,) though commencing in different situations, P and R, Plate 32, within the abdomen, arrive at the same place—viz., the external ring, H, Plates 33 and 34. The coverings of the internal hernia, Plate 34, though not derived exactly from the same locality as those which invest the cord and the external variety, are, nevertheless, but different parts of the same structures; these are, 1st, the peritonaeum, G, which forms its sac; 2nd, the pubic part of the fascia transversalis; 3rd, the conjoined tendon itself, or (according as the hernia may occur further from the mesial line) the cremaster, which, in common with the internal oblique and transverse muscles, terminates in this tendon; 4th, the external spermatic fascia, derived from the margins of the external ring; 5th, the superficial fascia and integuments.
The coverings of the internal inguinal hernia are (as to number) variously described by authors. Thus with respect to the conjoined tendon, the hernia is said, in some instances, to take an investment of this structure; in others, to pass through a cleft in its fibres; in others, to escape by its outer margin. Again, the cremaster muscle is stated by some to cover this hernia; by others, to be rarely met with, as forming one of its coverings; and by others, never. Lastly, it is doubted by some whether this hernia is even covered by a protrusion of the fascia transversalis in all instances. [Footnote]
[Footnote: Mr. Lawrence (Treatise on Ruptures) remarks, "How often it may be invested by a protrusion of the fascia transversalis, I cannot hitherto determine." Mr. Stanley has presented to St. Bartholomew's Hospital several specimens of this hernia invested by the fascia. Hesselbach speaks of the fascia as being always present. Cloquet mentions it as being present always, except in such cases as where, by being ruptured, the sac protrudes through it. Langenbeck states that the fascia is constantly protruded as a covering to this hernia: "Quia hernia inguinalis interna non in canalis abdominalis aperturam internam transit, tunicam vaginalem communem intrare nequit; parietem autem canalis abdominalis internum aponeuroticum, in quo fovea inguinalis interna, et qui ex adverso annulo abdominali est, ante se per annulum trudit." (Comment, ad illust. Herniarum, &c.) Perhaps the readiest and surest explanation which can be given to these differences of opinion may be had from the following remark:—"Culter enim semper has partes extricat, quae involucro adeo inhaerent, ut pro lubitu musculum (membranam) efformare queas unde magnam illam inter anatomicos discrepantiam ortam conjicio." (Camper. Icones Herniarum.)]
The variety in the number of investments of the internal inguinal hernia (especially as regards the presence or absence of the conjoined tendon and cremaster) appears to me to be dependent, 1st, upon the position whereat this hernia occurs; 2nd, upon the state of the parts through which it passes; and 3rd, upon the manner in which the dissection happens to be conducted.
The precise relations which the internal hernia holds in respect to the epigastric and spermatic vessels are also mainly dependent (as in the external variety) upon the situation where it traverses the groin. The epigastric artery courses outside the neck of its sac, sometimes in close connexion with this part—at other times, at some distance from it, according as the neck may happen to be wide and near the vessel, or narrow, and removed from it nearer to the median line. At the external ring, H, (Plate 34,) the sac of this hernia, g, protrudes on the inner side of the spermatic vessels, f; and the size of the hernia distending the ring, removes these vessels at a considerable interval from, I, the crista pubis. At the ring, H, (Plate 34,) the investments, g f, of the direct hernia are not always distinct from those of the oblique hernia, g f, (Plate 33); for whilst in both varieties the intestine and the spermatic vessels are separated from actual contact by the sac, yet it is true that the direct hernia, as well as the oblique, may occupy the inguinal canal. It is in relation to the epigastric artery alone that the direct hernia differs essentially from the oblique variety; for I find that both may be enclosed in the same structures as invest the spermatic vessels.
The external ring of the male groin is larger than that of the female; and this circumstance, with others of a like nature, may account for the fact, that the female is very rarely the subject of the direct hernia. In the male, the direct hernia is found to occur much less frequently than the oblique, and this we might, a priori, expect, from the anatomical disposition of the parts. But it is true, nevertheless, that the part where the direct hernia occurs is not defended so completely in some male bodies as it is in others. The conjoined tendon, which is described as shielding the external ring, is in some cases very weak, and in others so narrow, as to offer but little support to this part of the groin.
DESCRIPTION OF THE FIGURES OF PLATES 32, 33, & 34.
PLATE 32.
A. That part of the ilium which abuts against the sacrum.
B. The spine of the ischium.
C. The tuberosity of the ischium.
D. The symphysis pubis.
E. Situation of the anterior superior iliac spine.
F. Crest of the ilium.
G. Iliacus muscle.
H. Psoas magnus muscle supporting the spermatic vessels.
I. Transversalis muscle.
K. Termination of the sheath of the rectus muscle.
L1 L2 L3. The iliac, transverse and pelvic portions of the transversalis fascia.
M M. The peritonaeum lining the groin.
N. The epigastric vessels lying between the peritonaeum, M, and the transversalis fascia, L2. O. The umbilical ligament.
P. The neck of the sac of an external inguinal hernia formed before the spermatic vessels.
Q. An interval which occasionally occurs between the umbilical ligament and the epigastric artery.
R and Q. Situations where the direct inguinal hernia occurs when, as in this case, the umbilical ligament crosses the space named the internal fossa—the triangle of Hesselbach.
S. Lower part of the right spermatic cord.
T. The bulb of the urethra.
U. External iliac vein covered by the peritonaeum.
V. External iliac artery covered by the peritonaeum.
W. Internal iliac artery.
X. Common iliac artery.
Plate 32
PLATE 33.—The External Inguinal Hernia.
A. Anterior iliac spinous process.
B. The umbilicus.
C. Fleshy part of the external oblique muscle; c, its tendon.
D. Fleshy part of the internal oblique muscle; d, its tendon.
E. Transversalis muscle; e, the conjoined tendon.
F f. The funnel-shaped sheath of the spermatic vessels covering the external hernia; upon it are seen the cremasteric fibres.
G g. The peritonaeal covering or sac of the external hernia within the sheath.
H. The external abdominal ring.
I. The crista pubis.
K k. The saphenous opening.
L. The saphena vein.
M. The femoral vein.
N. The femoral artery; n, its profunda branch.
O. The anterior crural nerve.
P. The epigastric vessels overlaid by the neck of the hernia.
Q Q. The sheath of the femoral vessels.
R. The sartorius muscle.
S. The iliacus muscle.
Plate 33
PLATE 34.—The Internal Inguinal Hernia.
The letters indicate the same parts as in Plate 33
Plate 34
COMMENTARY ON PLATES 35, 36, 37, & 38.
THE DISTINCTIVE DIAGNOSIS BETWEEN EXTERNAL AND INTERNAL INGUINAL HERNIAE, THE TAXIS, THE SEAT OF STRICTURE, AND THE OPERATION.
A comparison of the relative position of these two varieties of herniae is in ordinary cases the chief means by which we can determine their distinctive diagnosis; but oftentimes they are found to exhibit such an interchange of characters, that the name direct or oblique can no longer serve to distinguish between them. The nearer the one approaches the usual place of the other, the more likely are they to be mistaken the one for the other. An internal hernia may enter the inguinal canal, and become oblique; while an external hernia, though occupying the canal, may become direct. It is only when these herniae occur at the situations commonly described, and where they manifest their broadest contrast, that the following diagnostic signs can be observed.
The external bubonocele, H, Plate 37, G, Plate 38, when recently formed, may be detected at a situation midway between the iliac and pubic spinous processes, where it has entered the internal ring. When the hernia extends itself from this part, its course will be obliquely inwards, corresponding with the direction of the inguinal canal. While it still occupies the canal without passing through the external ring, it is rendered obscure by the restraint of the external oblique tendon; but yet a degree of fulness may be felt in this situation. When the hernia has passed the external ring, T, Plate 36, it dilates considerably, and assumes the form of an oblong swelling, H, Plate 36, behind which the spermatic vessels are situated. When it has become scrotal, the cord will be found still on its posterior aspect, while the testicle itself occupies a situation directly below the swelling.
The internal hernia, H, Plate 38, also traverses the external ring, T, where it assumes a globular shape, and sometimes projects so far inwards, over the pubes, C, as to conceal the crista of this bone. As the direction of this hernia is immediately from behind forwards, the inguinal canal near the internal ring is found empty, unswollen. The cord, Q, lies external to and somewhat over the fore part of this hernia; and the testicle does not occupy a situation exactly beneath the fundus of the sac, (as it does in the external hernia,) but is found to be placed either at its fore part or its outer side. This difference as to the relative position of the cord and testicle in both these forms of herniae, is accounted for under the supposition that whilst the external variety descends inside the sheaths of the inguinal canal, the internal variety does not. But this statement cannot apply to all cases of internal hernia, for this also occasionally enters the canal. Both forms of inguinal herniae may exist at the same time on the same side: the external, G, Plate 38, being a bubonocele, still occupying the inguinal canal; while the internal, H, protrudes through the external ring, T, in the usual way. In this form of hernia—a compound of the oblique and direct—while the parts remain still covered by the integuments, it must be difficult to tell its nature, or to distinguish any mark by which to diagnose the case from one of the external variety, H, Plate 36, which, on entering the canal at the internal ring, protrudes at the external ring. In both cases, the swelling produced in the groin must be exactly of the same size and shape. The epigastric artery in the case where the two herniae co-exist lies between them, holding in its usual position with respect to each when occurring separately—that is, on the outer side of the internal hernia, H, and on the inner side of the external one, G; and the external hernia, G, not having descended the canal as far as the external ring, T, allows the internal hernia, H, to assume its usual position with respect to the cord, Q. [Footnote]
[Footnote: Cases of this double hernia (external and internal) have been met with by Wilmer, Arnaud, Sandifort, Richter, and others. A plurality of the same variety of hernia may also occur on the same side. A complete and incomplete external inguinal hernia existing in the one groin, is recorded by Mr. Aston Key in his edition of Sir Astley Cooper's work on Hernia. Sir Astley Cooper states his having met with three internal inguinal herniae in each inguinal region. (Ing. et Congenit. Hernire.) ]
Returning, however, to the more frequent conditions of inguinal hernia—viz., those in which either the direct or the oblique variety occurs alone—it should be remembered that a hernia originally oblique, H, Plates 35 and 37, may, when of long standing, and having attained a large size, destroy, by its gravitation, the obliquity of the inguinal canal to such a degree as to bring the internal, H, Plate 35, opposite to the external ring, as at I, and thereby exhibit all the appearance of a hernia originally direct, I, Plate 37. In such a case, the epigastric artery, F, which lies on the outer side of the neck of a truly direct hernia, I, Plate 37, will be found to course on the inner side, G, of the neck of this false-seeming direct hernia, I, Plate 35.
In the trial made for replacing the protruded bowel by the taxis, two circumstances should be remembered in order to facilitate this object: 1st, the abdominal parietes should be relaxed by supporting the trunk forward, and at the same time flexing the thigh on the trunk; 2nd, as every complete hernial protrusion becomes distended more or less beyond the seat of stricture—wherever this may happen to be—its reduction by the taxis should be attempted, with gradual, gentle, equable pressure, so that the sac may be first emptied of its fluid. That part of the hernia which protruded last should be replaced first. The direction in which the hernia protrudes must always determine the direction in which it is to be reduced. If it be the external or oblique variety, the viscus is to be pushed upwards, outwards, and backwards; if it be the internal or direct variety, it is to be reduced by pressure, made upwards and backwards. Pressure made in this latter direction will serve for the reduction of that hernia which, from being originally external and oblique, has assumed the usual position of the internal or direct variety.
The seat of the stricture in an external inguinal hernia is found to be situated either at the internal ring, corresponding to the neck of the sac, or at the external ring. Between these two points, which "bound the canal," and which are to be regarded merely as passive agents in causing stricture of the protruding bowel, the lower parts of the transversalis and internal oblique muscles embrace the herniary sac, and are known at times to be the cause of its active strangulation or spasm.
The seat of stricture in an internal hernia may be either at the neck of its sac, I, Plate 37, or at the external ring, T, Plate 38; and according to the locality where this hernia enters the inguinal wall, the nature of its stricture will vary. If the hernia pass through a cleft in the conjoined tendon, f, Plate 38, this structure will constrict its neck all around. If it pass on the outer margin of this tendon, then the neck of the sac, bending inwards in order to gain the external ring, will be constricted against the sharp resisting edge of the tendon. Again, if the hernia enter the inguinal wall close to the epigastric artery, it will find its way into the inguinal canal, become invested by the structures forming this part, and here it may suffer active constriction from the muscular fibres of the transverse and internal oblique or their cremasteric parts. The external ring may be considered as always causing some degree of pressure on the hernia which passes through it.
In both kinds of inguinal herniae, the neck of the sac is described as being occasionally the seat of stricture, and it certainly is so; but never from a cause originating in itself per se, or independently of adjacent structures. The form of the sac of a hernia is influenced by the parts through which it passes, or which it pushes and elongates before itself. Its neck, H, Plate 37, is narrow at the internal ring of the fascia transversalis, because this ring is itself narrowed; it is again narrowed at the external ring, T, Plate 36, from the same cause. The neck of the sac of a direct hernia, I, Plate 37, being formed in the space of the separated fibres of the conjoined tendon, or the pubic part of the transversalis fascia, while the sac itself passes through the resisting tendinous external ring, is equal to the capacities of these outlets. But if these constricting outlets did not exist, the neck of the sac would be also wanting. When, however, the neck of the sac has existed in the embrace of these constricting parts for a considerable period—when it suffers inflammation and undergoes chronic thickening—then, even though we liberate the stricture of the internal ring or the external, the neck of the sac will be found to maintain its narrow diameter, and to have become itself a real seat of stricture. It is in cases of this latter kind of stricture that experience has demonstrated the necessity of opening the sac (a proceeding otherwise not only needless, but objectionable) and dividing its constricted neck.
The fact that the stricture may be seated in the neck of the sac independent of the internal ring, and also that the duplicature of the contained bowel may be adherent to the neck or other part of the interior, or that firm bands of false membrane may exist so as to constrict the bowel within the sac, are circumstances which require that this should be opened, and the state of its contained parts examined, prior to the replacement of the bowel in the abdomen. If the bowel were adherent to the neck of the sac, we might, when trying to reduce it by the taxis, produce visceral invagination; or while the stricture is in the neck of the sac, if we were to return this and its contents en masse (the "reduction en bloc") into the abdomen, it is obvious that the bowel would be still in a state of strangulation, though free of the internal ring or other opening in the inguinal wall.
The operation for the division of the stricture by the knife is conducted in the following way: an incision is to be made through the integuments, adipous membrane, and superficial fascia, of a length and depth sufficient to expose the tendon of the external oblique muscle for an inch or so above the external ring; and the hernia for the same extent below the ring. The length of the incision will require to be varied according to circumstances, but its direction should be oblique with that of the hernia itself, and also over the centre of its longitudinal axis, so as to avoid injuring the spermatic vessels. If the constriction of the hernia be caused by the external ring, a director is to be inserted beneath this part, and a few of its fibres divided. But when the stricture is produced by either of the muscles which lie beneath the aponeurosis of the external oblique, it will be necessary to divide this part in order to expose and incise them.
When the thickened and indurated neck of the sac is felt to be the cause of the strangulation, or when the bowel cannot be replaced, in consequence of adhesions which it may have contracted with some part of the sac, it then becomes necessary to open this envelope. And now the position of the epigastric artery is to be remembered, so as to avoid wounding it in the incision about to be made through the constricted neck of the sac. The artery being situated on the inner side of the neck of the sac of an oblique hernia, requires the incision to be made outwards from the external side of the neck; whereas in the direct hernia, the artery being on its outer side, the incision should be conducted inwards from the inner side of the neck. But as the external or oblique hernia may by its weight, in process of time, gravitate so far inwards as to assume the position and appearance of a hernia originally direct and internal, and as by this change of place the oblique hernia, becoming direct as to position, does not at the same time become internal in respect to the epigastric artery,—for this vessel, F, Plate 35, has been borne inwards to the place, G, where it still lies, internal to the neck of the sac, and since, moreover, it is very difficult to diagnose a case of this kind with positive certainty, it is therefore recommended to incise the stricture at the neck of the sac in a line carried directly upwards. (Sir Astley Cooper.) It will be seen, however, on referring to Plates 32, 33, 34, 35, 36, 37, & 38, that an incision carried obliquely upwards towards the umbilicus would be much more likely to avoid the epigastric artery through all its varying relations.
DESCRIPTION OF THE FIGURES OF PLATES 35, 36, 37, & 38.
PLATE 35.
A. Anterior superior spine of the ilium; a, indicates the situation of the middle of Poupart's ligament.
B. Symphysis pubis.
C. Rectus abdominis muscle covered by the fascia transversalis.
D. The peritonaeum lining the groin.
E. The situation of the conjoined tendon resisting the further progress of the external hernia gravitating inwards.
F. A dotted line indicating the original situation of the epigastric artery in the external hernia.
G. The new position assumed by the epigastric artery borne inwards by the weight of the old external hernia.
H. The original situation of the neck of the sac of the external hernia.
I. The new situation assumed by the neck of the sac of an old external hernia which has gravitated inwards from its original place at H.
K. The external iliac vein covered by the peritonaeum.
L. The external iliac artery covered by the peritonaeum and crossed by the spermatic vessels.
M. The psoas muscle supporting the spermatic vessels and the genito-crural nerve.
N. The iliacus muscle.
O. The transversalis fascia lining the transverse muscle.
Plate 35
PLATE 36.—AN ANTERIOR VIEW OF PLATE 35.
A. Anterior superior iliac spinous process.
B. The navel.
C. The situation of the crista pubis.
D. The external oblique muscle; d, its tendon.
E. Internal oblique muscle; e, its tendon, covering the rectus muscle.
F. Lower part of the transverse muscle; f, the conjoined tendon.
G. The transversalis fascia investing the upper part of the hernial sac; g, the original situation of the epigastric artery internal to this hernia; g*, the new situation of the artery pushed inwards.
H. The hernial sac, invested by h, the elongation of the fascia transversalis, or funnel-shaped sheath.
I. The femoral artery.
K. The femoral vein.
L. The sartorius muscle.
M. Iliac part of the fascia lata joining Poupart's ligament.
N. Pubic part of the fascia lata.
O. Saphena vein.
P P. Falciform margin of the saphenous opening.
Q. See Plate 38.
R. Sheath of the femoral vessels.
S. Anterior crural nerve.
T. The external ring.
Plate 36
PLATE 37.
All the letters except the following indicate the same parts as in Plate 35.
F. The epigastric artery passing between the two hernial sacs
G. The umbilical ligament.
H. The neck of the sac of the external hernia.
I. The neck of the sac of the internal hernia.
Plate 37
PLATE 38.—AN ANTERIOR VIEW OF PLATE 37.
All the letters, with the exception of the following, refer to the same parts as in Plate 36.
G. The funnel-shaped elongation of the fascia transversalis receiving g, the sac of the external bubonocele.
H. The sac of the internal inguinal hernia invested by h, the transversalis fascia.
Q. The spermatic vessels lying on the outer side of H, the direct inguinal hernia.
Plate 38
COMMENTARY ON PLATES 39 & 40.
DEMONSTRATIONS OF THE NATURE OF CONGENITAL AND INFANTILE INGUINAL HERNIAE, AND OF HYDROCELE.
PLATE 39. Fig. 1—The descent of the testicle from the loins to the scrotum.—The foetal abdomen and scrotum form one general cavity, and are composed of parts which are structurally identical. The cutaneous, fascial, muscular, and membranous layers of the abdominal parietes are continued into those of the scrotum. At the fifth month of foetal life, the testicle, 3, is situated in the loins beneath the kidney, 2. The testicle is then numbered amongst the abdominal viscera, and, like these, it is developed external to the peritonaeal membrane, which forms an envelope for it. At the back and sides of the testicle, where the peritonaeum is reflected from it, a small membranous fold or mesentery (mesorchium, Seiler) is formed, and between the layers of this the nerves and vessels enter the organ, the nerves being derived from the neighbouring sympathetic ganglia (aortic plexus), while the arteries and veins spring directly from the main abdominal bloodvessels. It being predetermined that the testicle, 3, should migrate from the loins to the scrotum, 6 a, 7, at a period included between the sixth and ninth month, certain structural changes are at this time already effected for its sure and easy passage. By the time that the testis, 5, is about to enter the internal inguinal ring, 6 a, (seventh or eighth month,) a process or pouch of the peritonaeal membrane (processus vaginalis) has already descended through this aperture into the scrotum, and the testicle follows it. |
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