Surgical Anatomy Part 3

COMMENTARY ON PLATES 63 & 64

DEFORMITIES OF THE URINARY BLADDER; THE OPERATIONS OF SOUNDING FOR STONE; OF CATHETERISM AND OF PUNCTURING THE BLADDER ABOVE THE p.u.b.eS.

General remarks on the causes of the various deformities, and of the formation of stone. Lithic diathesis--its signification. The sacculated bladder considered in reference to sounding, to catheterism, to puncturation, and to lithotomy. Polypi in the bladder. Dilated ureters.

The operation of catheterism. General rules to be followed. Remarks on the operation of puncturing the bladder above the p.u.b.es.

COMMENTARY ON PLATES 65 & 66.

THE SURGICAL DISSECTION OF THE POPLITEAL s.p.a.cE, AND THE POSTERIOR CRURAL REGION.

Varieties of the popliteal and posterior crural vessels. Remarks on popliteal aneurism, and the operation for tying the popliteal artery, in wounds of this vessel. Wounds of the posterior crural arteries requiring double ligatures. The operations necessary for reaching these vessels.

COMMENTARY ON PLATES 67 & 68.

THE SURGICAL DISSECTION OF THE ANTERIOR CRURAL REGION; THE ANKLES AND THE FOOT.

Varieties of the anterior and posterior tibial and the peronaeal arteries. The operations for tying these vessels in several situations.

Practical observations on wounds of the arteries of the leg and foot.

CONCLUDING COMMENTARY

ON THE FORM AND DISTRIBUTION OF THE VASCULAR SYSTEM AS A WHOLE; ANOMALIES; RAMIFICATION; ANASTOMOSIS.

The double heart. Universal systemic capillary anastomosis. Its division, by the median line, into two great lateral fields--those subdivided into two systems or provinces--viz., pulmonary and systemic.

Relation of pulmonary and systemic circulating vessels. Motions of the heart. Circulation of the blood through the lungs and system. Symmetry of the hearts and their vessels. Development of the heart and primary vessels. Their stages of metamorphosis simulating the permanent conditions of the parts in lower animals. The primitive branchial arches undergoing metamorphosis. Completion of these changes. Interpretation of the varieties of form in the heart and primary vessels. Signification of their normal condition. The portal system no exception to the law of vascular symmetry. Signification of the portal system. The liver and spleen as h.o.m.ologous organs,--as parts of the same whole quant.i.ty.

Cardiac anastomosing vessels. Vasa vasorum. Anastomosing branches of the systemic aorta considered in reference to the operations of arresting by ligature the direct circulation through the arteries of the head, neck, upper limbs, pelvis, and lower limbs. The collateral circulation.

Practical observations on the most eligible situations for tying each of the princ.i.p.al vessels, as determined by the greatest number of their anastomosing branches on either side of the ligature, and the largest amount of the collateral circulation that may be thereby carried on for the support of distal parts.

[End Table of Contents]

COMMENTARY ON PLATES 1 & 2.

THE FORM OF THE THORACIC CAVITY, AND THE POSITION OF THE LUNGS, HEART, AND LARGER BLOODVESSELS.

In the human body there does not exist any such s.p.a.ce as cavity, properly so called. Every s.p.a.ce is occupied by its contents. The thoracic s.p.a.ce is completely filled by its viscera, which, in ma.s.s, take a perfect cast or model of its interior. The thoracic viscera lie so closely to one another, that they respectively influence the form and dimensions of each other. That s.p.a.ce which the lungs do not occupy is filled by the heart, &c., and vice versa. The thoracic apparatus causes no vacuum by the acts of either contraction or dilatation. Neither do the lungs or the heart. When any organ, by its process of growth, or by its own functional act, forces a s.p.a.ce for itself, it immediately inhabits that s.p.a.ce entirely at the expense of neighbouring organs. When the heart dilates, the pulmonary s.p.a.ce contracts; and when the thoracic s.p.a.ce increases, general s.p.a.ce diminishes in the same ratio.

The mechanism of the functions of respiration and circulation consists, during the life of the animal, in a constant oscillatory nisus to produce a vacuum which it never establishes. These vital forces of the respiratory and circulatory organs, so characteristic of the higher cla.s.ses of animals, are opposed to the general forces of surrounding nature. The former vainly strive to make exception to the irrevocable law, that "nature abhors a vacuum." This act of opposition between both forces const.i.tutes the respiratory act, and thus the respiratory thoracic being (like a vibrating pendulum) manifests respiratory motion, not as an effort of volition originating solely with itself, but according to the measure of the force of either law; as ent.i.ty is relationary, so is functionality likewise. The being is functional by relations.h.i.+p; and just as a pendulum is functional, by reason of the counteraction of two opposing forces,--viz., the force of motion and the force of gravity,--so is a thoracic cavity (considering it as a mechanical apparatus) functional by two opposing forces--the vital force and the surrounding physical force. The inspiration of thoracic s.p.a.ce is the expiration of general s.p.a.ce, and reciprocally.

The thoracic s.p.a.ce is a symmetrical enclosure originally, which aftercoming necessities modify and distort in some degree. The s.p.a.ces occupied by the opposite lungs in the adult body do not exactly correspond as to capacity, O O, Plate 1. Neither is the cardiac s.p.a.ce, A E G D, Plate 1, which is traversed by the common median line, symmetrical. The asymmetry of the lungs is mainly owing to the form and position of the heart; for this organ inclines towards the left thoracic side. The left lung is less in capacity than the right, by so much s.p.a.ce as the heart occupies in the left pulmonary side. The general form of the thorax is that of a cone, I I N N, Plate 1, bicleft through its perpendicular axis, H M. The line of bicleavage is exactly median, and pa.s.ses through the centre of the sternum in front, and the centres of the dorsal vertebral behind. Between the dorsal vertebral and the sternum, the line of median cleavage is maintained and sketched out in membrane. This membranous middle is formed by the adjacent sides of the opposite pleural or enveloping bags in which the lungs are enclosed. The heart, A, Plate 1, is developed between these two pleural sacs, F F, and separates them from each other to a distance corresponding to its own size. The adjacent sides of the two pleural sacs are central to the thorax, and form that s.p.a.ce which is called mediastinum; the heart is located in this mediastinum, U E, Plate 1. The extent of the thoracic region ranges perpendicularly from the root of the neck, Q, Plate 1, to the roof of the abdomen--viz., the diaphragm, P, transversely from the ribs of one side, I N, Plate 1, to those of the other, and antero-posteriorly from the sternum, H M, to the vertebral column. All this s.p.a.ce is pulmonary, except the cardiac or median s.p.a.ce, which, in addition to the heart, A, Plate 1, and great bloodvessels, G C B, contains the oesophagus, bronchi, &c. The ribs are the true enclosures of thoracic s.p.a.ce, and, generally, in mammalian forms, they fail or degenerate at that region of the trunk which is not pulmonary or respiratory. In human anatomy, a teleological reason is given for this--namely, that of the ribs being mechanically subservient to the function of respiration alone. But the transcendental anatomists interpret this fact otherwise, and refer it to the operation of a higher law of formation.

The capacity of the thorax is influenced by the capacity of the abdomen and its contents. In order to admit of full inspiration and pulmonary expansion, the abdominal viscera recede in the same ratio as the lungs dilate. The diaphragm, P P, Plate 1, or transverse musculo-membranous part.i.tion which divides the pulmonary and alimentary cavities, is, by virtue of its situation, as mechanically subservient to the abdomen as to the thorax. And under general notice, it will appear that even the abdominal muscles are as directly related to the respiratory act as those of the thorax. The connexion between functions is as intimate and indissoluble as the connexion between organs in the same body. There can be no more striking proof of the divinity of design than by such revelations as anatomical science everywhere manifests in facts such as this--viz., that each organ serves in most cases a double, and in many a triple purpose, in the animal economy.

The apex of the lung projects into the root of the neck, even to a higher level, Q, Plate 1, than that occupied by the sternal end of the clavicle, K. If the point of a sword were pushed through the neck above the clavicle, at K, Plate 1, it would penetrate the apex of the right lung, where the subclavian artery, Q, Plate 1, arches over it. In connexion with this fact, I may mention it as very probable that the bruit, or continuous murmur which we hear through the stethoscope, in chlorotic females, is caused by the pulsation of the subclavian artery against the top of the lung. The stays or girdle which braces the loins of most women prevents the expansion of the thoracic apparatus, naturally attained by the descent of the diaphragm; and hence, no doubt, the lung will distend inordinately above towards the neck. It is an interesting fact for those anatomists who study the higher generalizations of their science, that at those very localities--viz., the neck and loins, where the lungs by their own natural effort are p.r.o.ne to extend themselves in forced inspiration--happen the "anomalous"

creations of cervical and lumbar ribs. The subclavian artery is occasionally complicated by the presence of these costal appendages.

If the body be transfixed through any one of the intercostal s.p.a.ces, the instrument will surely wound some part of the lung. If the thorax be pierced from any point whatever, provided the instrument be directed towards a common centre, A, Plate 1, the lung will suffer lesion; for the heart is, almost completely, in the healthy living body, enveloped in the lungs. So true is it that all the costal region (the asternal as well as the sternal) is a pulmonary enclosure, that any instrument which pierces intercostal s.p.a.ce must wound the lung.

As the sternal ribs degenerate into the "false" asternal or incomplete ribs from before, obliquely backward down to the last dorsal vertebra, so the thoracic s.p.a.ce takes form. The lungs range through a much larger s.p.a.ce, therefore, posteriorly than they do anteriorly.

The form of the thorax, in relation to that of the abdomen, may be learned from the fact that a gunshot, which shall enter a little below N, Plate 1, and, after traversing the body transversely, shall pa.s.s out at a corresponding point at the opposite side, would open the thorax and the abdomen into a common cavity; for it would pierce the thorax at N, the arching diaphragm at the level of M, and thereat enter the belly; then it would enter the thorax again at P, and make exit below N, opposite. If a cutting instrument were pa.s.sed horizontally from before backward, a little below M, it would first open the abdomen, then pierce the arching diaphragm, and pa.s.s into the thorax, opposite the ninth or eighth dorsal vertebra.

The outward form or superficies masks in some degree the form of the interior. The width of the thorax above does not exceed the diameter between the points I I, of Plate 1, or the points W W, of Plate 2. If we make percussion directly from before backwards at any place external to I, Plate 1, we do not render the lung vibrative. The diameters between I I and N N, Plate 1, are not equal; and these measures will indicate the form of the thorax in the living body, between the shoulders above and the loins below.

The position of the heart in the thorax varies somewhat with several bodies. The size of the heart, even in a state of perfect health, varies also in subjects of corresponding ages, a condition which is often mistaken for pathological. For the most part, its form occupies a s.p.a.ce ranging from two or three lines right of the right side of the sternum to the middle of the shafts of the fifth and sixth ribs of the left side. In general, the length of the osseous sternum gives the exact perpendicular range of the heart, together with its great vessels.

The aorta, C, Plates 1 and 2, is behind the upper half of the sternum, from which it is separated by the pericardium, D, Plate 1, the thin edge of the lung, and the mediastinal pleurae, U E, Plate 1, &c. If the heart be injected from the abdominal aorta, the aortal arch will flatten against the sternum. Pulmonary s.p.a.ce would not be opened by a penetrating instrument pa.s.sed into the root of the neck in the median line above the sternum, at L, Plate 1. But the apices of both lungs would be wounded if the same instrument entered deeply on either side of this median line at K K. An instrument which would pierce the sternum opposite the insertion of the second, third, or fourth costal cartilage, from H downwards, would transfix some part of the arch of the aorta, C, Plate 1. The same instrument, if pushed horizontally backward through the second, third, or fourth inters.p.a.ces of the costal cartilages close to the sternum, would wound, on the right of the sternal line, the vena cava superior, G, Plate 1; on the left, the pulmonary artery, B, and the descending thoracic aorta. In the healthy living body, the thoracic sounds heard in percussion, or by means of the stethoscope, will vary according to the locality operated upon, in consequence of the variable thickness of those structures (muscular and osseous, &c.,) which invest the thoracic walls. Uniformity of sound must, owing to these facts, be as materially interrupted, as it certainly is, in consequence of the variable contents of the cavity. The variability of the healthy thoracic sounds will, therefore, be too often likely to be mistaken for that of disease, if we forget to admit these facts, as instanced in the former state. Considering the form of the thoracic s.p.a.ce in reference to the general form of the trunk of the living body, I see reason to doubt whether the pract.i.tioner can by any boasted delicacy of manipulation, detect an abnormal state of the pulmonary organs by percussion, or the use of the stethoscope, applied at those regions which he terms coracoid, scapulary, subclavian, &c., if the line of his examination be directed from before backwards. The scapula, covered by thick carneous ma.s.ses, does not lie in the living body directly upon the osseous-thorax, neither does the clavicle. As all antero-posterior examination in reference to the lungs external to the points, I I, between the shoulders cannot, in fact, concern the pulmonary organs, so it cannot be diagnostic of their state either in health or disease. The difficulties which oppose the pract.i.tioner's examination of the state of the thoracic contents are already numerous enough, independent of those which may arise from unanatomical investigation.

DESCRIPTION OF PLATES 1 & 2.

PLATE 1.

A. Right ventricle of the heart.

B. Origin of pulmonary artery.

C. Commencement of the systemic aorta, ascending part of aortic arch.

D. Pericardium investing the heart and the origins of the great bloodvessels.

E. Mediastinal pleura, forming a second investment for the heart, bloodvessels, &c.

F. Costal pleura, seen to be continuous above with that which forms the mediastinum.

G. Vena cava superior, entering pericardium to join V, the right auricle.

H. Upper third of sternum.

I I. First ribs.

K K. Sternal ends of the clavicles.

L. Upper end of sternum.

M. Lower end of sternum.

N N. Fifth ribs.

O O. Collapsed lungs.

P P. Arching diaphragm.