Page images
PDF
EPUB

former meet at the crest of the ilium and Poupart's ligament, the latter is confined to the cavity of the true pelvis.

The FASCIA TRANSVERSALIS (Fascia Cooperi)' is a thin fibrous membrane, which lines the inner surface of the transversalis muscle, and is interposed between that muscle and the peritoneum. It is thick and dense below, near the lower part of the abdomen; but becomes thinner as it ascends, and is gradually lost in the subserous areolar tissue. It is attached inferiorly to the reflected margin of Poupart's ligament and to the crest of the ilium; internally, to the pectineal line and border of the rectus muscle; and, at the inner part of the femoral arch [see p. 279] is continued beneath Poupart's ligament, and forms the anterior segment of the crural canal, or sheath of the femoral vessels.

The internal abdominal ring (annulus inguinalis internus, vel posterior) is situated in this fascia, at about midway between the symphysis pubis and anterior superior spine of the ilium, and half an inch above Poupart's ligament; it is oval in form, and bounded on its inner side by a well-marked falciform border, but is ill-defined around its outer margin. From the circumference of this ring is given off an infundibuliform process which surrounds the testicle and spermatic cord, constituting the fascia propria of the spermatic cord, and forms the first investment to the sac of oblique inguinal hernia. It is the strength of the transversalis fascia, in the interval between the tendon of the rectus and the internal abdominal ring, that defends the parietes against the frequent occurrence of direct inguinal hernia.

INGUINAL HERNIA.

Inguinal hernia is of two kinds, oblique and direct.

In OBLIQUE INGUINAL HERNIA the intestine escapes from the cavity of the abdomen into the spermatic canal (canalis inguinalis) through the internal abdominal ring, pressing before it a pouch of peritoneum, which constitutes the hernial sac, and distending the infundibuliform process of the transversalis fascia. After emerging through the internal abdominal ring it passes firstly beneath the lower and arched border of the transversalis muscle; then beneath the lower border of the internal oblique muscle; and finally through the external abdomi nal ring (annulus inguinalis externus, vel anterior) in the aponeurosis of the external oblique. From the transversalis muscle it receives no investment; while passing beneath the lower border of the internal oblique it obtains the cremaster muscle; and on escaping at the external abdominal ring, receives the intercolumnar fascia. So that the coverings of an oblique inguinal hernia, after it has emerged through the external abdominal ring, are, from the surface to the intestine, the

Integument,
Superficial fascia,

Intercolumnar fascia,

Cremaster muscle,
Transversalis, or infundibuliform fascia,
Peritoneal sac.

The Spermatic Canal, which in the normal condition of the abdominal parietes serves for the passage of the spermatic cord in the male, and the round ligament with its vessels in the female, is about one inch and a half in length. It is bounded in front by the aponeurosis of the external oblique muscle; behind by the transversalis fascia, and the conjoined tendon of the internal oblique and transversalis; above by the arched border of the internal oblique and transversalis; below by the grooved border of Poupart's ligament: and at each extremity. by one of the abdominal rings, the internal ring at the inner, the external ring Sir Astley Cooper first described this fascia in its important relation to inguinal hernia.

[merged small][graphic]
[ocr errors]

ANATOMY OF THE SPERMATIC CANAL. After the removal of the lower part of the external oblique (with the exception of a small slip including Poupart's ligament), the lower portion of the internal oblique was raised, and thereby the transversalis muscle and fascia have been brought into view. The femoral artery and vein are seen to a small extent, the iliac portion of the fascia lata having been turned aside and the sheath of the blood vessels laid open.. 1. External oblique muscle. 2. Internal oblique muscle. 2'. Part of same turned up. 3. Transversalis muscle. Upon the last-named muscle is seen a branch of the circumflexa ilii artery, with its companion veins; and some ascending tendinous fibres are seen over the conjoined tendon of the two last-named muscles. 4. Transversalis fascia. 5. Spermatic cord covered with the infundibuliform fascia from preceding. 6. Upper angle of the iliac part of fascia lata. 7. The sheath of the femoral vessels. 8. Femoral artery. 9. Femoral vein. 10. Internal saphenous vein. 11. A vein joining it.]

at the outer extremity. These relations may be more distinctly illustrated by the following plan:

Above.

[blocks in formation]

There are three varieties of oblique inguinal hernia: common, congenital, and encysted.

Common oblique hernia is that which has been described above.

Congenital hernia results from the non-closure of the pouch of peritoneum carried downwards into the scrotum by the testicle, during its descent in the Velpeau describes a fourth, in which the protrusion takes place between the edge of the rectus and the umbilical ligament, and then takes the course of the spermatic canal.

footus. In consequence of this defect, the intestine at some period of life is forced into the peritoneal canal, and descends through it into the tunica vaginalis, where it lies in contact with the testicle; so that congenital hernia has no proper sac, but is contained within the tunica vaginalis. The other coverings are the same as those of common inguinal hernia.

Encysted hernia (hernia infantilis of Hey) is that form of protrusion in which the pouch of peritoneum forming the tunica vaginalis, being only partially closed, and remaining open externally to the abdomen, admits of the hernia passing into the scrotum, behind the tunica vaginalis. So that the surgeon, in operating upon this variety, requires to divide three layers of serous membrane; the first and second layer being those of the tunica vaginalis; the third the true sac of the hernia.

DIRECT INGUINAL HERNIA [ventro-inguinal] has received its name from passing directly through the external abdominal ring, and forcing before it the opposing parietes. This portion of the wall of the abdomen is strengthened by the conjoined tendon of the internal oblique and transversalis, which is pressed before the hernia, and forms one of its investments. Its coverings therefore are, the

[blocks in formation]

Direct inguinal hernia differs from oblique, firstly, in never attaining the same bulk, in consequence of the resisting nature of the conjoined tendon of the internal oblique and transversalis and transversalis fascia; secondly, in its direction, having a tendency to protrude from the middle line rather than towards it; thirdly, in making for itself a new passage through the abdominal parietes. instead of following a natural channel; and fourthly, in the relation of the neck of its sac to the epigastric artery; that vessel lying to the outer side of the opening of the sac of direct hernia, and to the inner side of that of oblique hernia. All the forms of inguinal hernia are designated scrotal, when they have descended into the cavity of the scrotum.

The FASCIA ILIACA (lumbo-iliaca) is the aponeurotic investment of the psoas and iliacus muscle; and like the fascia transversalis, is thick below, and becomes gradually thinner as it ascends. It is attached superiorly, along the edge of the psoas, to the anterior lamella of the aponeurosis of the transversalis muscle, to the ligamentum arcuatum internum, and to the bodies of the lumbar vertebræ, leaving arches, corresponding with the constricted part of the vertebræ, for the transit of the lumbar vessels. Lower down it passes beneath the external iliac vessels, and is attached along the margin of the true pelvis; externally it is connected to the crest of the ilium; and, inferiorly, to the outer two-thirds of Poupart's ligament, where it is continuous with the fascia transversalis. Passing beneath Poupart's ligament, it surrounds the psoas and iliacus muscle to its termination, and beneath the inner part of the femoral arch forms the posterior segment of the crural canal or sheath of the femoral vessels.

The FASCIA PELVICA is an aponeurotic layer situated beneath the peritoneum, forming a covering to the walls of the pelvis, and reflected from its walls upon the viscera. The pelvic fascia is attached to the internal surface of the ossa pubis near the symphysis, to the body of the pubes above the origin of the obturator internus muscle, to the ilio-pectineal line of the brim of the pelvis as far back as the sacro-iliac articulation, and to the margin of the great sacro-ischiatic foramen. Having descended upon the wall of the pelvis as low as the pubic arch in front, and the spine of the ischium behind, it divides in the direction of a line drawn between those points, into two layers, internal and external.

The internal layer (recto-vesical) is continued downwards to the prostate gland, neck of the bladder, (vagina), and rectum, to which it is closely attached;

[merged small][graphic][subsumed]

TRANSVERSE VERTICAL SECTION OF THE PELVIS, SHOWING THE DISTRIBUTION OF THE PELVIC FASCIA. 1. Bladder. 2. Vesicula seminalis of one side, divided. 3. Rectum. 4. Iliac fascia, covering in the iliacus and psoas (5); and forming a sheath for the external iliac vessels (6). 7. Anterior crural nerve excluded from the sheath. 8. Pelvic fascia. 9. Its ascending layer, forming the lateral ligament of the bladder of one side, and a sheath to the vesical plexus of veins. 10. A layer of fascia passing between the bladder and rectum. 11. A layer passing around the rectum. 12. Levator ani. 13. Obturator internus, covered in by the obturator fascia, which also forms a sheath for the internal pudic vessels and nerves (14). 15. Perineal fascia investing the under surface of the levator ani. Figures 14, 15, are placed in the ischio-rectal fossa.

and is reflected for a short distance upwards and downwards on those viscera This layer is in contact, by its external surface, with the levator ani muscle and

[merged small][graphic][subsumed][ocr errors][subsumed]

SIDE VIEW OF THE VISCERA OF THE PELVIS, SHOWING THE DISTRIBUTION OF THE PELVIC

FASCIA. 1. Symphysis pubis. 2. Bladder. 3. Recto-vesical fold of peritoneum, passing from the anterior surface of the rectum to the posterior part of the bladder; and from the upper part of the bladder to the abdominal parietes. 4. Ureter. 5. Vas deferens crossing behind the ureter. 6. Vesicula seminalis. 7, 7, 8, 8. Prostate gland divided longitudinally. 9. Prostatic portion of the urethra. 10. Membranous portion embraced by the compressor urethræ muscle. 11. Commencement of the corpus spongiosum penis; the bulb. 12. Anterior ligaments of the bladder. 13. The pelvic fascia reflected on the rectum. 14. An interval between the pelvic fascia and triangular ligament occupied by a plexus of veins. 15. The triangular ligament. 16. Cowper's gland. 17. Superficial perineal fascia ascending in front of the root of the penis to become continuous with the dartos of the scrotum (18). 19. The fascia prolonged to the rectum. 20. Lower part of the levator ani. 21. A layer of fascia situated between the bladder and rectum.

coccygeus; and is prolonged backwards over the sacral nerves to the lower part of the sacrum and the coccyx, to which it is attached, meeting at the middle line the layer of the opposite side.

The external layer is the obturator fascia; it covers in the obturator muscle, and is attached to the ramus of the pubes and ischium in front, and to the tuberosity of the ischium and falciform border of the great sacro-ischiatic ligament below. The levator ani arises from the line of division of the two layers of the pelvic fascia.

The anterior border of the pelvic fascia is separated from its fellow of the opposite side by a narrow interval, and the fascia passing from the side of the symphysis to the upper part of the prostate gland and front of the neck of the bladder, constitutes the anterior true ligament of the bladder (pubio-vesicale); a little further outwards, the fascia passing to the side of the neck of the bladder constitutes its lateral true ligament; and reflected forwards from the neck of the bladder upon the prostate, it forms a sheath for that gland which incloses the prostatic plexus of veins. Upon the rectum and vagina it also forms a sheath. The posterior boundary of the pelvic fascia forms a free semilunar border in front of the pyriformis muscle.

PERINEAL FASCIÆ. The fascia of the perineum are the superficial and the

deep.

The Superficial fascia consists as in other situations of two layers, one lying next the skin and containing an abundance of fat, the other more condensed, lying in contact with the muscles.

The superficial layer in the perineum is connected with the raphé at the middle line and with the external border of the sphincter ani, and is continuous by its circumference with the dartos of the scrotum, or cellular tissue of the labia majora, in front, with the superficial fascia of the thighs at each side, and with the superficial fascia covering the glutei maximi and coccyx behind.

The deep layer or proper perineal fascia (fascia perinei superficialis) is divisible into two portions, anterior and posterior, the former investing the muscles of the perineum, the other the ischio-rectal fossa. The anterior portion (fascia ischio-pubica, Velpeau) is a thin aponeurotic layer which covers in the muscles of the genital region of the perineum and the root of the penis. It is firmly attached at each side to the ramus of the pubes and ischium; posteriorly it is reflected upwards behind the transversi perinei muscles to become continuous with the deep perineal fascia or triangular ligament; while, in front it is continuous with the dartos in the male, and is lost in the labia majora and nymphæ in the female. The continuation of the perineal fascia into the triangular ligament along the posterior border of the transversi perinei muscles, is a barrier to the extension of extravasation of urine backwards, and the chief cause of its advance into the scrotum and lower part of the abdomen.

The posterior portion of the perineal fascia (fascia analis; ischio-rectalis, Velpeau) lines the deep fossa (excavatio perinei) which surrounds the anus and levator ani muscles, and is bounded externally by the ischia and internal obturatot muscles, and behind by the glutei maximi, the ischio-rectal fossa.' The ischiorectal fascia is continuous with the anterior portion of the fascia perinei in front; invests the levatores ani as high as their origin, and the obturator fascia at each side, and is attached to the tuberosities of the ischia and great sacro-ischiatic ligaments. In the ischio-rectal fossa the two layers of the superficial fascia are separated by the masses of fat which fill that cavity.

The Deep perineal fascia (ligamentum triangulare; perineale; Camper's ligament) is a thin layer of aponeurosis stretched across the anterior portion of the outlet of the pelvis; it is attached at each side to the pelvic border of the ramus of the pubes and ischium, as far back as the origin of the erector penis muscle. [There are, properly, two ischio-rectal fosse, one on either side of the rectum.]

« PreviousContinue »