Surgical Anatomy Part 21

13. Left kidney.

[Ill.u.s.tration: Chest and abdomen, showing bones, blood vessels, muscles and other internal organs.]

Plate 24

COMMENTARY ON PLATE 25.

THE RELATION OF THE PRINc.i.p.aL BLOODVESSELS OF THE THORAX AND ABDOMEN TO THE OSSEOUS SKELETON, ETC.

The arterial system of vessels a.s.sumes, in all cases, somewhat of the character of the forms upon which they are distributed, or of the organs which they supply. This mode of distribution becomes the more apparent, according as we rise from particulars to take a view of the whole. With the same ease that any piece of the osseous fabric, taken separately, may be known, so may any one artery, taken apart from the rest, be distinguished as to the place which it occupied, and the organs which it supplied in the economy. The vascular skeleton, whether taken as a whole or in parts, exhibits characteristics as apparent as are those of the osseous skeleton itself. The main bloodvessel, A B C, of the trunk of the body, possesses character, sui generis, just as the vertebral column itself manifests. The main arteries of the head or limbs are as readily distinguishable, the one from the other, as are the osseous fabrics of the head and limbs. The visceral arteries are likewise moulded upon the forms which they supply. But evidently the arterial system of vessels conforms most strictly with the general design of the osseous skeleton.

In Plate 25, viewed as a whole, we find that as the vertebral column stands central to the osseous skeleton, so does the aorta, A B C, take the centre of the arterial skeleton. As the ribs jut symmetrically from either side of the vertebral column, so do the intercostal arteries follow them from their own points of origin in the aorta. The one side of the osseous system is not more like the other than is the system of vessels on one side like that of the other. And in addition to this fact of a similarity of sides in the vascular as in the osseous skeleton, I also remark that both extremities of the aorta divide into branches which are similar to one another above and below, thereby conforming exactly with the upper and lower limbs, which manifest unmistakable points of a.n.a.logy.

The branches which spring from the aortic arch above are destined to supply the head and upper limbs. They are, H, the innominate artery, and I K, the left common carotid and subclavian arteries. The branches which spring from the other extremity of the aorta are disposed for the support of the pelvis and lower limbs; they are the right and left common iliac arteries, L M. These vessels exhibit, at both ends of the main aortic trunk, a remarkable a.n.a.logy; and as the knowledge of this fact may serve to lighten the dry and weary detail of descriptive anatomy, at the same time that it points directly to views of practical import, I may be allowed briefly to remark upon it as follows:--

The vessels which spring from both ends of the aorta, as seen in Plate 25, are represented in what is called their normal character--that is, while three vessels, H I K, spring separately from the aortic arch above, only two vessels, L and M, arise from the aorta below. Let the anatomist now recall to mind the "peculiarities" which at times appear amongst the vessels, H I K, above, and he will find that some of them absolutely correspond to the normal arrangement of the vessels, L M, below. And if he will consider the "peculiarities" which occur to the normal order of the vessels, L M, below, he will find that some of these correspond exactly to the normal order of the vessels above. Thus, when I K of the left side join into a common trunk, this resembles the innominate artery, H, of the right side, and then both these vessels perfectly correspond with the two common iliac arteries below. When, on the other hand, L and M, the common iliac arteries, divide, immediately after leaving the aortic trunk, into two pairs of branches, they correspond to the abnormal condition of the vessels, H I K, above; where H, immediately after leaving the aortic arch, divides into two branches, like I K. With this generalization upon the normal and abnormal facts of arrangement, exhibited among the vessels arising from both ends of the aorta, I furnish to the reader the idea that the vessels, H I K, above may present of the same figure as the vessels, L M, below, and these latter may a.s.sume the character of H I K, above.

Whenever, therefore, either set of vessels becomes the subject of operation, such as having a ligature applied to them, we must be prepared to meet the "varieties."

The veins a.s.sume an arrangement similar to that of the arteries, and the above remarks will therefore equally apply to the veins. In the same way as the arteries, H I K, may present in the condition of two common or brachio-cephalic trunks, and thereby simulate the condition of the common iliac arteries, so we find that the normal forms of the veins above and below actually and permanently exhibit this very type. The brachio-cephalic veins, D B, Plate 26, exactly correspond to each other, and to the common iliac veins, S T; and as these latter correspond precisely with the common iliac arteries, so may we infer that the original or typical condition of the vessels I K, Plate 25, is a brachia-cephalic or common-trunk union corresponding with its brachio-cephalic vein. When the vessels, I K, therefore present of the brachio-cephalic form as the vessel H, we have a perfect correspondence between the two extremes of the aorta, both as regards the arteries arising from it, and the veins which accompany these arteries; and this condition of the vascular skeleton I regard as the typical uniformity.

The separate condition of the vessels I K, notwithstanding the frequency of the occurrence of such, may be considered as a special variation from the original type.

The length of the aorta is variable in two or more bodies; and so, likewise, is the length of the trunk of each of those great branches which springs from its arch above, and of those into which it divides below, The modes in which these variations as to length occur, are numerous. The top of the arch of the aorta is described as being in general on a level with the cartilages of the second ribs, from which point it descends on the left side of the spinal column; and after having wound gradually forwards to the forepart of the lumbar spine at C, divides opposite to the fourth lumbar vertebra into the right and left common iliac arteries. The length of that portion of the aorta which is called thoracic, is determined by the position of the pillars of the diaphragm F, which span the vessel; and from this point to where the aorta divides into the two common iliac arteries, the main vessel is named abdominal. The aorta, from its arch to its point of division on the lumbar vertebrae, gradually diminishes in caliber, according to the number and succession of the branches derived from it.

The varieties as to length exhibited by the aorta itself, and by the princ.i.p.al branches which spring from it, occur under the following mentioned conditions:--When the arch of the aorta rises above or sinks below its ordinary position or level,--namely, the cartilages of the second ribs, as seen in Plate 25,--it varies not only its own length, but also that of the vessels H I K; for if the arch of the aorta rises above this level, the vessels H I K become shortened; and as the arch sinks below this level, these vessels become lengthened. Even when the aortic arch holds its proper level in the thorax, still the vessels H I K may vary as to length, according to the height to which they rise in the neck previously to their division. When the aorta sinks below its proper level at the same time that the vessels H I K rise considerably above that point at which they usually arch or divide in the neck, then of course their length becomes greatly increased. When, on the other hand, the aortic arch rises above its usual level, whilst the vessels H I K arch and divide at a low position in the neck, then their length becomes very much diminished. The length of the artery H may be increased even though the arch of the aorta holds its proper level, and though the vessels H I K occupy their usual position in the neck; for it is true that the vessel H may spring from a point of the aortic arch A nearer to the origin of this from the ventricle of the heart, whilst the vessel I may be shortened, owing to the fact of its arising from some part of H, the innominate vessel. All these circ.u.mstances are so obvious, that they need no comment, were it not for the necessity of impressing the surgeon with the fact that uncertainty as to a successful result must always attach to his operation of including in a ligature either of the vessels H I K, so as to affect an aneurismal tumour.

Now whilst the length of the aorta and that of the princ.i.p.al branches springing from its arch may be varied according to the above-mentioned conditions, so may the length of the aorta itself, and of the two common iliac vessels, vary according to the place whereat the aorta, C, bifurcates. Or, even when this point of division is opposite the usual vertebra,--viz., the fourth lumbar,--still the common iliac vessels may be short or long, according to the place where they divide into external and internal iliac branches. The aorta may bifurcate almost as high up as where the pillars of the diaphragm overarch it, or as low down as the fifth lumbar vertebra. The occasional existence of a sixth lumbar vertebra also causes a variety in the length, not only of the aorta, but of the two common iliac vessels and their branches.[Footnote]

[Footnote: Whatever may be the number of variations to which the branches arising from both extremes of the aorta are liable, all anatomists admit that the arrangement of these vessels, as exhibited in Plate 25, is by far the most frequent. The surgical anatomist, therefore, when planning his operation, takes this arrangement as the standard type. Haller a.s.serts this order of the vessels to be so constant, that in four hundred bodies which he examined, he found only one variety--namely, that in which the left vertebral artery arose from the aorta. Of other varieties described by authors, he observes--"Rara vero haec omnia esse si dixero c.u.m quadringenta nunc cadavera humana dissecuerim, fidem forte inveniam." (Iconum Anatom.) This variety is also stated by J. F. Meckel (Handbuch der Mensch Anat.), Soemmerring (De Corp. Hum Fabrica), Boyer (Tr. d'Anat.), and Mr. Harrison (Surg. a.n.a.l.

of Art.), to be the most frequent. Tiedemann figures this variety amongst others (Tabulae Arteriarum). Mr. Quain regards as the most frequent change which occurs in the number of the branches of the aortic arch, "that in which the left carotid is derived from the innominate."

(Anatomy of the Arteries, &c.) A case is recorded by Petsche (quoted in Haller), in which he states the bifurcation of the aorta to have taken place at the origin of the renal arteries: (query) are we to suppose that the renal arteries occupied their usual position? Cruveilhier records a case (a.n.a.l. Descript.) in which the right common iliac was wanting, in consequence of having divided at the aorta into the internal and external iliac branches. Whether the knowledge of these and numerous other varieties of the arterial system be of much practical import to the surgeon, he will determine for himself. To the scientific anatomist, it must appear that the main object in regard to them is to submit them to a strict a.n.a.logical reasoning, so as to demonstrate the operation of that law which has produced them. To this end I have pointed to that a.n.a.logy which exists between the vessels arising from both extremities of the aorta. "Itaque convertenda plane est opera ad inquirendas et notandas rerum similitudines et a.n.a.loga tam integralibus quam partibus; illae enim sunt, quae naturam uniunt, et const.i.tuere scientias incipiunt." "Natura enim non nisi parendo vincitur; et quod in contemplatione instar causae est; id in operatione instar regulae est."

(Novum Organum Scientiarum, Aph. xxvii-iii, lib. i.)]

The difference between the perpendicular range of the anterior and posterior walls of the thoracic cavity may be estimated on a reference to Plate 25, in which the xyphoid cartilage, E, joined to the seventh pair of ribs, bounds its anterior wall below, while F, the pillars of the diaphragm, bound its posterior wall. The thoracic cavity is therefore considerably deeper in its posterior than in its anterior wall; and this occasions a difference of an opposite kind in the anterior and posterior walls of the abdomen; for while the abdomen ranges perpendicularly from E to W, its posterior range measures only from F to the ventra of the iliac bones, R. The arching form of the diaphragm, and the lower level which the pubic symphysis occupies compared with that of the cristae of the iliac bones, occasion this difference in the measure of both the thorax and abdomen.

The usual position of the kidneys, G G*, is on either side of the lumbar spine, between the last ribs and the cristae of the iliac bones. The kidneys lie on the fore part of the quadratus lumborum and psoae muscles. They are sometimes found to have descended as low as the iliac fossae, R, in consequence of pressure, occasioned by an enlarged liver on the right, or by an enlarged spleen on the left. The length of the abdominal part of the aorta may be estimated as being a third of the entire vessel, measured from the top of its arch to its point of bifurcation. So many and such large vessels arise from the abdominal part of the aorta, and these are set so closely to each other, that it must in all cases be very difficult to choose a proper locality whereat to apply a ligature on this region of the vessel. If other circ.u.mstances could fairly justify such an operation, the anatomist believes that the circulation might be maintained through the anastomosis of the internal mammary and intercostal arteries with the epigastric; the branches of the superior mesenteric with those of the inferior; and the branches of this latter with the perineal branches of the pubic. The lumbar, the gluteal, and the circ.u.mflex ilii arteries, also communicate around the hip-bone. The same vessels would serve to carryon the circulation if either L, the common iliac, V, the external iliac, or the internal iliac vessel, were the subject of the operation by ligature.

DESCRIPTION OF PLATE 25.

A. The arch of the aorta.

B B. The descending thoracic part of the aorta, giving off b b, the intercostal arteries.

C. The abdominal part of the aorta.

D D. First pair of ribs.

E. The xyphoid cartilage.

G G*. The right and left kidneys.

H. The brachio-cephalic artery.

I. Left common carotid artery.

K. Left subclavian artery.

L. Right common iliac artery at its place of division.

M. Left common iliac artery, seen through the meso-r.e.c.t.u.m.

N. Inferior vena cava.

O O. The sigmoid flexure of the colon.

P. The r.e.c.t.u.m.

Q. The urinary bladder.

R. The right iliac fossa.

S S. The right and left ureters.

T. The left common iliac vein, joining the right under the right common iliac artery to form the inferior vena cava.

U. Fifth lumbar vertebra.

V. The external iliac artery of right side.

W. The symphysis pubis.

X. An incision made over the locality of the femoral artery.

b b. The dorsal intercostal arteries.

c. The coeliac axis

d. The superior mesenteric artery.

f f. The renal arteries.

g. The inferior mesenteric artery.

h. The vas deferens bending over the epigastric artery and the os pubis, after having pa.s.sed through the internal abdominal ring.

[Ill.u.s.tration: Chest and abdomen, showing bones, blood vessels, muscles and other internal organs.]