No. 172. LONDON, SATURDAY, DECEMBER 16. [1826-7.

MR. ABERNETHY’S

PHYSIOLOGICAL, PATHOLOGICAL, AND

SURGICAL OBSERVATIONS;

DELIVERED IN THE

ANATOMICAL COURSE OF LECTURES,At St. Bartholomew’s Hospital.

On the Muscles of the Abdomen.

ENOUGH was said, in the IntroductoryLectures relative to the structure and officeof muscles, to enable a person who pretendsto teach anatomy, to go on showing themuscles that are found in the different partsof the body : and I shall begin with thosemuscles which are the most apt to decay,namely, those in contiguity with the viscera.It might be said, take the simple musclesat first, and these are unquestionably notthe most simple in the body ; but I alwayslike to begin with the most difficult partsfirst, because if you once master them, allthe rest is easy. And as to talking of diffi-culty, why therio, is absolutely no such thingas difficulty about anatomy ; at least all thatwe know of it is easy, and not difficult.

Well, in describing the muscles, we makeuse of the words-origin and insertion : now,these are not good words to be used; we, !ought rather to say, the attachment of themuscles. But people will make use of theseexpressions, sometimes applying the namesto the actions of the parts. Muscles, how-ever, in acting, are not conscious of whatthey do ; they simply contract at one part,and bring the more moveable part to whichthey are attached towards that part at whichthey do contract. Now, notwithstandingthese terms are inaccurate, yet, really, weshould boggle very much in the descriptionof the muscles, if we were not to use them ;and therefore they,maybe,for the sake ofconvenience, continued. Now the musclesof the abdomen are ranged in strata at thesides of the belly; there are three strata,

and the fleshy portion of those terminates insheets of tendons-sheets of sinews, which’are technically called aponeuroses and theseaponeuroses separating, enclose others in asort of sheet. Well, then, we shall beginwith the external stratum ; and when yousee it exposed to you, you will find that themuscle runs obliquely. It has been called

obliquus descendens abdominis; but that de-

pends upon which part you take the attach-ment to be at. However, there is no ob-jection to the term, and it is described asfollows :-Mr. Abernethy went over the description

of the muscle, and then said :-IVell, there’s the description of the

muscle. You’ may get the descriptionsmuch more accurately than I teach them ;but I would have you to learn them first asI teach them, and then you may learn themmore minutely afterwards, if you please.But now, after this general description, Icome to certain particulars that it is im-

portant for surgeons to attend to ; and oneof those particulars is, the formation of anaperture through which the spermatic chordpasses in the male, and the 7,oitnd ligamentof the womb in the female subject. Now,to know how this opening is formed, it isnecessary that you should understand howthe aponeurosis is formed.Mr. Abernethy described the aponeurosis,

and continued :-Now, a knowledge of this opening, I hold

to be a very important point : ruptures areoften taking place there ; and what wouldyou think of a surgeon who would take holdof a rupture in this place, and who woulduse all his might to push it in through thevery walls of the belly, to the belly itself.Then it is important to know how to findthat aperture ; and you may always know.that, if you recollect these anatomical facts.I will venture to say, there is no subject sofat, that you cannot distinguish the angles.of the pubes, and the jutting parts to befound there ; then, knowing that, by pokingyour finger along the bones, near to theangle, push it a little upwards, and then itgoes into the abdominal ring. Let the skinbe off or on, and I do the same thing withmy finger. Now here I besin to say. what

338

I shall often repeat, I dare say, that it is which you do, till you have cut away the

really necessary, as far as I am capable of eight slips ; then you turn it back, and you’

determining, for gentlemen to come to Lon- expose beneath it another stratum of abdo-don, or some large school, where they may minal muscles, another stratum, anotherhave opportunities of dissecting and under- steak of fleshy matter, (laughter,) as I maystanding the structure of the body : but call it. Here that muscle is, the fibres ofthere is a great deal of anatomy, and the which are oblique, but in an opposite di-very best part of anatomy, for practical pur- rection to the others-obliquus internus abdo.poses, that you may always remember with- minis, that’s the name of it.out a subject, by recollecting that you con- Mr. Abernethy described the muscle.tinually carry about with you a subject in So far for the general description of theyour own persons ; and, egad, I hope you muscle; and then, as to what I call thewill all put your fingers into your abdo- most important point to surgeons. Attendminal rings, and learn for yourselves. And to the lower margin, half way up, belowif you reduce a hernia by piecemeal, poking Poupart’s ligament. A surgeon operatesit in bit by bit in this aperture, then that is for an incarcerated hernia he slits the ringthe mode of proceeding. - up; he frees the stricture; he pokes backMr. Abernethy gave a further description the hernia, and, egad, he feels a strong

of the aponeurosis, as being connected transverse portion of flesh running athwprtfirmly to Poupart’s ligament. the belly, running under the margin of that

Well, now I have described the muscle, muscle. It is often necessary to pass theand dwelt most upon those parts which seem finger freely into the abdomen, becauseto me to be of most importance, and now there’s often stricture higher up than thethen for the use of it :- external. It is at all times advisable to put

What’s the use of the external oblique your finger freely into the abdomen, to seemuscle ? 1 Why, no one can tell what use it that the bowels you are to return have nois of, but upon the supposition, that one attachment, no adhesion to other parts,part of it is fixed and the other moveable. which from inflammation they may have.Now grant that the pelvis is the fixed, and Now I say, that is important in an opera-the ribs the moveable parts, why it will tion for hernia ; but you are further to

unquestionably draw down the eight ribs understand, that where the spermatic chordto which it is attached, and by so doing it passes under the edge of the internal ob-will be an expiratory power : but having lique muscle, it does pass through anotherdrawn them down, it will bring the ribs to sinewy aperture,-it does pass throughthe pelvis, and it will bow forward the another sinewy aperture ; there is a fasciawhole front of the body. But granting that extended up from Poupart’s ligament thatone muscle acts with superior power, or lines the lower surface of the abdominalwithout the power of the other, then it must muscles ; it is a firm fascia, and hasbe evident that this, the external oblique, an aperture in it for the transmission ofwill draw the ribs towards the front of the the spermatic chord, just half way up Pou-body, behind the trunk indeed, but behind part’s ligament. This is called the externalit with an inclination to the opposite side. ring; that you will understand; and thereNow all this is upon the presumption of is sometimes stricture there. But what Ithe pelvis being the fixed part. You have want you to consider the subject for nowseen a little tumbler throw himself on his more, with respect to the physiology, isback, and cant his pelvis over his head ; this : you see the spermatic chord, a largeand no doubt he used the abdominal muscles chord, is not made to pass right out of thein doing that. I say theeffect of the actions belly through any one aperture. If it had,will be various, but it is utterly-utterly what would have been the consequences 1impossible for any one to understand the A weakness in the walls of the belly aboutaction of the abdominal muscles, until he that part, and in the straining actions wehas seen the actions of the diaphragm. I are perpetually undergoing,—g, some ofnever attempt to speak of the use of the the contents would have burst out. Butabdominal muscles at this first demonstra- not so ; the spermatic chord goes through antion, and therefore you must postpone the oblique canal from the internal to the ex-

full knowledge of that subject till you have ternal ; it is called the inguinal canal. Youseen the diaphragm. have sometimes hernia in the aperture,

Well, now, so much for the external ob- which never comes out of the ring, and thatlique muscle ; and then having examined is called incomplete. Again, you may havethis, the next thing you do in dissection is, hernia coming out of the external ring,to raise it. What’s meant by raising a which is not strangulated by the canal.muscle! 1 0, you cut away the different Moreover you maybe called upon to tietheslips from tlie different ribs to which they e:;:ternal iliac artery, before it passes dovnare attached: here’s a slip, here’s a slip, under Poupart’s ligament. Well, but do nothere’a a slip, which you cut away, and think you can get at it while this muscle

339

remains stiff and firm ; and it is necessary testicle by any will. There are people intherefore to divide it, that you may he able ill health, where the testicle hangs danglingto pass your finger down, and clearly ascer- half way down the thighs. (Much laughter.)tain it. The testicles seem to be very importantNow, having dwelt on this, what is the parts, and this muscle does seem to act in-

use of the internal oblique muscle ? It being voluntarily. It’s curious that in an ancientfixed to the ribs, and as it draws the ribs statue, this action of the cremaster has beendown to that part to which it is attacked, so expressed by the statuary, which onlyfar it is an expiratory muscle ; but as the shows what observing fellows those Greeksfibres go obliquely in a contrary direction to were. It is a muscle which acts at the timethose of the external oblique, so the left of copulation, and under the excitement ofinternal oblique, and the right external the venereal desire. It draws the testiclesoblique, will join in twisting the body to the up towards the abdominal ring, and com-right side. presses them, as it were,,to urge forward

I have no more to say about that muscle, the fluids. I say it is a muscle, however,and therefore raising it, we bring into view over which the will has no influence. Ianother stratum of muscle, the fibres of have known it act involuntarily and spas-which are not oblique, but transverse ; and modically, to the great annoyance of theso it is called the transversalis abdominis. patient. I remember one patient who hadThe transversalis and the internal oblique hernia humoralis, and, egad, this cremaster,are so connected together as to make it every now and then, drew up the testicle,very difficult to separate them, and to say squeezed it, and kept the fellow bellowingwhat portion you should leave to the in- out for an immense length of time. (Laugh-ternal oblique and what portion you should ter.) It is a suspensory muscle, and it actsleave to the transversalis. in compressing. Now, I never tried to

[Mr. Abernethy described the muscle make any minute examination of the nervesmore particularly. that supplied this cremaster muscle, for IWell, here’s a muscle that won’t move did not think it necessary : I am perfectlythe pelvis to the trunk, or the trunk to the well satisfied, they are filaments of the lum-pelvis, and what can it do ? 1 0, simply- bar nerves which supply the muscles in thesimply embrace and support the abdominal neighbourhood ; but these very same nervesviscera. It does that which the other supply muscles over which the will has themuscles do, but this is its especial office, to most perfect command, and yet they supplysupport, and occasionally to compress the those over which it has no command. Ifabdominal viscera. you prove to the contrary, you will show usNow there would be no use in raising something that may be done, I suppose.

this muscle, for if we attempted’to do it, For my own part, I don’t know, but I be-we should find no flesh beneath it. What lieve it is supplied by the branches of theshould we find, then 1 A membranous bag, lumbar nerves, passing between the stratawhich seems to hold the bowels-the bag of of the abdominal muscles.the pe7·itnneum, that’s what we should find Now then I have done with the three-the bag of the peritoneum, with cellular strata found at the sides of the belly. ’

substance on the outside of it; and if I look (Mr. Abernethy then described the rectuswhere the spermatic chord passes out, I muscle.]shall find at that part that there is a sinewy Besides, there are three muscles aboutsubstance lying upon Poupart’s ligament. this part in a sheath, attached to the symphy-Now, then, there was one muscle which I sis pubis, and going up to be connected to the

omitted to mention; where the spermatic linea alba. They are called pyramidales;chord goes under the edge of the internal there are, however, no such things in theoblique, muscular fibres are sent off from it, subject before us, and as they are sometimesto cover the spermatic chord, which run wanting, they must only be coadjutors to thedown in front of the spermatic chord, and as other muscles, and are not of much im-they descend gradually separate round the portance, or they would not be wanting,spermatic chord ; but when they come to the you may depend upon it.testicle, they separate and encompass the Well, now, what is the action of the rec-testicle, as in a bag : you will see that tus 1 It supports and compresses the ab-when you come to examine -the testicle. dominal viscera..Well, and what’s the useThis is called the cremaster, or suspensory of those transverse bands 1 Probably tomuscle of the testicle. That it can have allow the different portions of this musclethis effect, no one can doubt. Every one to act separately, for I think you may putwill admit that Poupart’s ligament is the the upper part of the muscle into actionattachment of the muscle, and that the tes- without engaging the whole of the muscle ;ticle is the moveable part. But then it is a for instance, you can bend your body for-muscle not under the command of the will. wards and take in part of the muscle, butIt certainly cannot be said to support the the whole of it does not seem to act at the

340

same time, which probably it would do if I will turn down the rectus muscle, andit were not for these transversed bands; that will show you what seems to be im-and I have perceived myself, a man put the portant with regard to this sheath, whichoperation of the muscles, on both sides, is, that it will show you the front of theinto action, and exhibit an appearance which sheath is very thick, and the back part ofwas perfectly astonishing to all his medical it not near so thick ; it will show you alsoattendants. The man was a madman, and, that the back of the sheath is very thickwhich is no uncommon thing with such above and very thin below. I say that’s

persons, he thought he had got some mon- important. They may make wlmtjuss theyster in the inside of him ; and when a man please about the suppuration of the aponeu.has once got that notion into his noddle, the rosis, but this is important, that the sur-very growling of his guts is as a tremen- ge.on should remember the sheath is muchdous rumbling to him. (Laughter.) But thicker in front than behind ; but it is thickthis man could not only hear his guts rum- above behind, yet as you go down there isble. but he could, see them move. He put very little sinewy matter, so that you seehis hands upon this part of his body; some through it. The different degrees of thick-thought he had an aneurism; what he might ness of the surface is what every body shouldhave done I don’t know, but I am convinced remember; but I have turned down thisthat this was the only rational solution of muscle for another purpose still. If youthe phenomena. wish to see the situation of the epigastric

Well, now, this rectus muscle goes down artery, you will never see it so well as now;in a sheath, and it is connected to the sheath if you wish to have ss distinct view of that,by nothing more than cellular substance, you must not look at an injected subject,save, and except where those transverse but you must dissect a subject for the pur-bands join the cellular part; so loose is it, pose. It is to be met with at about two-that I can put my finger behfnd it and strip thirds from the inner edge, and about one-it up. third from the outer edge of the muscle ;

Well, now, wherever matter forms be- this is the main branch of the epigastricneath an aponeurosis, it is a case that artery. Well, these vessels you should veryshould, and that does call for the surgeon’s carefully avoid in tapping a patient. I 11 illattention ; because an aponeurosis, a sinewy venture to say that I have known wounds ofexpansion, is by nature indolent, and it forms this artery in tapping thirteen times in thea sort of separation between the matter and course of my life.the skin, and if the skin don’t break, the People, when I was young, always usedmatter will go on separating the cellular to tap where they were likely to wound thesubstance by which it is confined to the epigastric artery. What was the rule forsheath,’to an enormous extent. Now I am tapping 1 Some said, wishing to tap in theperfectly convinced that I once saw a case linea alba, you are to tap between the itm-of this kind in an hospital in this town. A bilicl/s, and the superior anterior spine ofwoman had been a physician’s patient ; she the ilium; accordingly they used to tap therehad had great pain about the stomach ; the frequently, and hence came those wounds.symptoms were rather abated, but she could It happened that a surgeon in this town,not be prevailed upon to get up and move going on in the old practice ; he, an anato-about ; what was the nature of the disease mist too ! did wound the epigastric artery;the physician could not very well make up he drew off the water, and knew nothing ofan opinion; she still lingered, as it were, in what he had done. The woman died of in-bed, though she acknowledged that she had ternal haemorrhage into the abdomen. Theno violent pain, but only was unable to surgeon afterwards had the manliness to tellmove. A considerable lapse of time took the case, and every body after that timeplace, and then the lower part of her belly tapped in the linea alba, where they couldgrew bigger on one side ; she remarked it, have no chance of injuring this artery. Butspoke of it to the physician, and the phy- you cannot always tap in the linea alba:sician said, y ou must let the surgeon see you have to tap in dropsy, in the Ol’a1’ia;this. The surgeon came, saw it, and said, you must tap where the fluid is ; you mustthere’s afluctuation-a fluctuation ! What tap at the side, but if you do, take care towill you do with it 1 Why, put a lancet keep fairly on the outside of the rectus

into it. The lancet was put into it, and out muscle. How shall I know where that is!came an enormous quantity of matter. The Why it’s a very difficult thing to say, for

surgeon made a good gap, put his finger into the .rectus muscle yields in a most micnu-it, shut up the wound, put the patient to mon manner over any accumulation in the-rest in bed, and said you must keep yourself abdomen. Water accumulates in the abdo-

very quiet, for he,-tliought there was some men, and the rectus muscle spreads itselfhorrible mischief likely to ensue from his over that water. It is really a very curiousoperation ; but the woman got well, and thing to see this muscle spreading itself overthere was an end to it. some tumour below it. I have seen the

341

sartoritis muscle spread out to a most uncom-mon breadth, in the case of a tumour in thethigh. The rectus muscle also does it in amost extraordinary manner, and we makeample allowances for it. You must notsuppose, if you go on tapping at the side ofthe linea alba, that that will be sufficient.What I tell you is a fact, which I am sureyou will all see and feel at once, that therectus muscle yields in a particular manner.All parts don’t yield in the same manner:you don’t see fat peoples’ parts yielding inthis way ; you have seen Punch’s belly prettyfat, I am inclined to think ; and what is itthat yields there Why, the muscles arekept in,,but the front of the belly yields,so that Punch could lay his belly on the Itable. And, therefore, I cannot tell youexactly where you are to tap at the side ;but, I say, make ample allowance for theyielding of the rectus muscle.

Linea sentilitnaris (Mr. Abernethy de-scribed this). Well, what is the linea semi-lunaris’! What is it but the three sinews

appearing together without muscles inter-vening on the outside of the rectus’! Nowthe rectus muscle going down, reaches thelower end of the symphysis pubis, and theouter edge gradually tucks in ; so that it isthe tucking in, as I have called it, whichoccasions this semilunar sweep, in the white

appearance. Semilunar it ought not to becalled; it is but one horn, one half moon,or horn.There are, sometimes, ventral herniæ

sometimes, from great exertion, those sinewychords are rent, and, at the gap made inthem, the bowels come out. There was onewoman brought into the Hospital, who,from the straining of parturition, tore bothher linea alba and linea semilunaris ; thebowels came out en musse, as the French-man said. I never saw such a thing in mylife ; an immense quantity of her bowels.She got sent to this Hospital; where theplague she came from, nobody could tell,and it was not till after a great deal of la-bour and attention that we got a great por-tibn of her gut back through the linea alba.When that part was restored, some one puthis fingers into another gap, and so thewhole was reduced. Of course bandageswere applied ; and it ’was a case that couldnot be expected to have been got well in asudden ; but the woman did get well, andshe went out of the Hospital, as she thought,pretty comfortable.

11’ell, so much for the importance ofthese parts; and what I have said with re-gard to ventral hernia, is only said for thisreason : to show how every fact of anatomyought to be attended to, because they areapplicable to every step in surgery.

LECTURES

ON THE

Diseases of the Nervous System,BY

DR, CLUTTERBUCK,

B LECTURE IV.

On the Varieties of Inflammation uf the Brain.

I AM now to treat of the various forms ofencephalitis, or inflammation of the brain,both acute and chronic; these we shall findto include a great number of diseases towhich different names have been given,but which are all of the same general nature,however different in their external charac-ters. I shall first present you with a theo-retical outline of the subject without regardto names ; for these have in general served little other purpose than to render thematter more obscure.

Inflammation of the brain is to be studiedlike that of any other organ ; taking carenot to give undue importance to symptomsmerely, but to look always to the diseaseitself, out of which the symptoms arise.This is the more necessary here, becausethe attention of practitioners has beengenerally otherwise directed ; the names

employed to designate brain affections,having ’a reference for the most part to

symptoms only ; at the same time thatthese have been made the chief object ofattention in practice. Thus, if a patient issuffering acute pain, without any obvioustopical inflammation ; or is affected with con-vulsive action of muscles ; or watchful or de-lirious; or is the subject of any anomalousaffection; he is supposed to labour undernervous irritation, as it is called; and stimulantsand opiates are probably prescribed, withlittle if any reference to the primary causeof such affections, and which is frequentlyan inflammatory state of some part of theencephalurt.Now, ds in the case of other organs, in-

flammation of the brain may affect its mem-branes or coverings merely ; or it may beseated in the cerebral substance : and it can-not be doubted, that the symptoms will dif-

:’ fer in the two cases. The membranes, notbeing essential _to the performance of the

! functions, will give rise, when inflamed, tobut few and simple, symptoms; as in the; analogous case of pleurisy: while, if thesubstance of the brain be the seat of thedisease, it will be seen principally in the di-