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MANUALS

FOR

STUDENTS OF MEDICINE.

SURGICAL

APPLIED ANATOMY"

FREDERICK TREVES, F.R.C.S.,

ASSISTANT SURGEON TO AND SENIOR DEMONSTRATOR OF ANATOMY AT

THE LONDON HOSPITAL; EXAMINER IN ANATOMY AT THE UNIVERSITY

OF ABERDEEN J WILSON PROFESSOR OF PATHOLOGY, ROYAL

COLLEGE OF SURGEONS OF ENGLAND, 1881.

ILLUSTRATED WITH 61 ENGRAVINGS.

HENKY 0. LEA'S SON & CO,:

PHILADELPHIA, PA.
rt

T8I

WILLIAM KNIGHT TREVES, F.R.C.S.,

SUEGEON TO TUB NATIONAL HOSPITAL FOB SCROFULA,
MARGATE.

fcl

1683

PREFACE.

APPLIED ANATOMY has, I imagine, a twofold function.
On the one hand it serves to give a precise basis to
those incidents and procedures in practice that more
especially involve anatomical knowledge ; on the
other hand it endues the dull items of that knowledge
with meaning and interest by the aid of illustrations
drawn from common medical and surgical experience.
In this latter aspect it bears somewhat the same
relation to Systematic Anatomy that a series of ex-
periments in Physics bears to a treatise dealing with
the bare data of that science.

The student of Human Anatomy has often a
nebulous notion that what he is learning will some-
time prove of service to him ; and may be conscious
also that the study is a valuable, if somewhat unex-
citing, mental exercise. Beyond these impressions he
must regard his efforts as concerned merely in the
accumulation of a number of hard nnasshmlable facts.

61

viii SURGICAL APPLIED ANATOMY.

It should be one object of Applied Anatomy to invest
these facts with the interest derived from an associa-
tion with the circumstances of daily life ; it should
make the dry bones live.

It must be owned also that all details in Anatomy
have not the same practical value, and that the memory
of many of them may fade without loss to the compe-
tency of the practitioner in medicine or surgery. It
should be one other object, therefore, of a book,
having such a purpose as the present, to assist the
student in judging of the comparative value of the
matter he has learnt; and should help him, when
his recollection of anatomical facts grows dim, to
encourage the survival of the fittest.

In writing this manual I have endeavoured, so
far as the space at my command would permit, to
carry out the objects above described ; and while I
believe that the chief matters usually dealt with in
works on Surgical Anatomy have not been neglected,
I have nevertheless tried to make the principle of the
book the principle that underlies Mr. Hilton's familiar
lectures on " Hest and Pain."

I have assumed that the reader has some know-
ledge of Human Anatomy, and have not entered,
except in a few instances, into any detailed anatomical

PREFACE. ix

descriptions. The bare accounts, for example, of the
regions concerned in Hernia I have left to the syste-
matic treatises, and have dealt only with the bearings
of the anatomy of the parts upon the circumstances of
practice. The limits of space have compelled me to
omit all those parts of the " Surgery of the Arteries "
that deal with ligature, collateral circulation, abnor-
malities, and the like. This omission I do not regret,
since those subjects are fully treated not only in
works on operative surgery but also in the manuals
of general anatomy.

The book is intended mainly for the use of
students preparing for their final examination in
surgery. I hope, however, that it will be of use also
to practitioners whose memory of their dissecting
room work is growing a little gray, and who would
wish to recall such anatomical matters as have the
most direct bearing upon the details of practice.
Moreover, it is possible that junior students may find
some interest in the volume, and may have their
studies rendered more intelligent, by learning how
anatomy is concerned in actual dealings with disease.

The illustrations have been executed by Mr.
Charles BerjeaU, F.L.S., to whose skilful pencil I am
much indebted. The majority of them have been

x SURGICAL APPLIED ANATOMY.

copied from familiar sources, from the works of
Riidinger, Tillaux, Braime, Agatz, and others.

My best thanks are due to Mr. J. Macdoiiald
Brown, F.R.C.S., late Demonstrator of Anatomy at
the Owens College, and to Dr. James Anderson, one
of the Demonstrators of Anatomy at the London
Hospital, for kindly assisting me in revising the
proofs, and for many valuable suggestions.

FREDERICK TREVES.

18, Gordon Square,

September > 1883.

CONTENTS.

PART I.-THE HEAD AND NECK.

CHAPTER *AGE

I.— THE SCALP .1

II.— THE BONY VAULT OF THE CRANIUM .... 12

III.- THE CRANIAL CONTENTS 25

IV.— THE ORBIT AND EYE ....... 33

V.— THE EAR 59

VI.— f HE NOSE AND NASAL CAVITIES 70

VII.— THE FACE 82

VIII.— THE MOUTH, TONGUE, PALATE, AND PHARYNX . 100

IX.-THE NECK . . 118

PART tt.
X.— THE THORAX * ... 147

PART III.-THE UPPER EXTREMITY.

XI. —THE REGION OF THE SHOULDER 1C2

XII.— THE ARM . 202

xii SURGICAL APPLIED ANATOMY.

CHAPTER PAGE

XIII.— THE REGION OF THE ELBOW 210

XIV.— THE FORE-ARM 227

XV.— THE WRIST AND HAND . . 235

PART IV.-THE ABDOMEN AND PELVIS.

XVI.— THE ABDOMEN . . .262

XVII.-^THE ABDOMINAL VISCERA 295

XVIIL— THE PELVIS AND PERINEUM * . 334

PART V.-THE LOWER EXTREMITY.

XIX.— THE REGION OF THE HIP 380

XX.— THE THIGH 417

XXL— THE REGION OF THE KNEE 424

XXII. —THE LEG 450

XXIIL— THE ANKLE AND FOOT 461

PART VI.

XXIV.— THE SJPINE 497

INDEX ..**.. , . 616

61

SURGICAL APPLIED ANATOMY.

lart Jh

THE HEAD AND NECK.

CHAPTEE I.

THE SCALP.

THE soft parts covering the vault of the
skull may be divided into five layers : (1) the skin,
(2) the subcutaneous fatty tissue, (3) the occipito-
frontalis muscle and its aponeurosis, (4) the sub-
aponeurotic connective tissue, and (5) the pericranium.
It is convenient to consider the term " scalp " as
limited to the structure formed by the union of the
first three layers above named (Fig. 1).

The skin of the scalp is thicker than it is in any
other part of the body. It is in all parts intimately

Fig. 1.— Diagram of a Vertical Section of the Scalp.

a, Skin ; b, subcutaneous tissue, with vessels ; c, aponeurosis ; d, sub-aponeuro-
tic tissue ; e, pericranium ; /, bone ; g, dura mater.

adherent, by means of the subcutaneous tissue, to the
aponeurosis and muscle beneath it, and, from this

B

2 SURGICAL APPLIED ANATOMY. [Chap. i.

adhesion, it follows that the skin moves in all move-
ments of that muscle. The subcutaneous tissue is, like
a similar tissue in the palm, admirably constructed to
resist pressure, being composed of a multitude of fibrous
bands enclosing fat lobules in more or less isolated
spaces. The density of the scalp is such, that in
surface inflammations, such as cutaneous erysipelas, it
is unable to present (except in a very slight degree)
two conspicuous features of such inflammations, viz.,
redness and swelling. The skin is provided with a
great number of sebaceous glands, which may develop
into cystic tumours or wens, such cysts being more
common upon the scalp than in any other 'part of the
body. Being skin growths, these cysts, even when
large, remain, except in rare instances, entirely out-
side the aponeurosis, and can therefore be removed
without risk of opening up the area of loose con-
nective tissue between the aponeurosis and the peri-
cranium.

There being no fatty tissue in any of the layers
that cover the bony vault, save in the subcutaneous
layer, it happens that in cases of obesity the scalp
undergoes but little change, the fat in the subcu-
taneous tissue being limited by the dense fibrous
structures that enclose it. The attachment of the
hairs collectively to the scalp is so strong that there
are many cases, since the days of Absalom, where
the entire weight of the body has been supported by
the hair of the scalp. Agnew reports the case of a
woman whose hair became entangled in the revolving
shaft of a machine. The hair did not give way, but
the entire scalp was torn off from the skull. The
patient recovered.

The dangerous area of the scalp. — Between
the aponeurosis and the pericranium is an extensive
layer of loose connective tissue, that may, for reasons
to be presently given, be fairly called the dangerous

Chap, i.] THE SCALP. 3

area of the scalp (Fig. 1, d). The mobility of the
scalp depends entirely upon the laxity of this layer of
tissue. In extensive scalp-wounds, when a part of
the scalp is separated in the form of a large flap, a
flap that may hang down and cover half the face, it
is the very looseness of this tissue that permits such
separation. In the Indian process of scalping, a
taste that is becoming one of the past, the much-
prized piece of skin is torn from the skull through
this lax area of connective tissue, and, were there no
such area, scalping would be an operation requiring
some time and art.

Wounds of the scalp never gape, unless
the wound has involved the scalp muscle or its
aponeurosis. When this structure has been divided,
the lax layer beyond permits of great separation of
the edges of even the simplest wound. In uncompli-
cated incised wounds, the amount of gaping of the
cut depends upon the action of the occipito-frontalis
muscle. Those wounds gape the most that are made
across the muscle itself, and that are transverse to the
direction of its fibres, while those show the least
separation that involve the aponeurosis and are made
in an antero-posterior direction. The mobility of the
scalp is more marked in the young than in the old.
A case recorded by Agnew serves in a strange degree
to illustrate this fact in the person of an infant. A
midwife attending a woman in labour mistook the
scalp of the infant for the membranes, and gashed it
with a pair of scissors. Labour pains came on and the
head was protruded through the scalp wound, so that
the whole vault of the skull was peeled like an orange.
The scalp being firmly stretched over the hard
cranium beneath, it follows that contused wounds
often appear as clearly cut as are those that have
been made by an incision. Such wounds may be
compared to the clean cut that may be made in a kid

4 SURGICAL APPLIED ANATOMY. [Chap. i.

glove when it is tightly stretched over the knuckles,
and those parts are sharply rapped.

The scalp is extremely vascular, and presents there-
fore a great resistance to sloughing and gangrenous
conditions. Large flaps of a lacerated scalp, even
when extensively separated and almost cut off from
the rest of the head, are more prone to live than to
die. A like flap of skin, separated from other parts of
the surface, would most probably perish ; but the
scalp has this advantage, that the vessels run practi-
cally in the skin itself, or are, at least, in the tissue
beyond the aponeurosis (Fig. 1). Thus, when a scalp
flap is torn up, it still carries with it a very copious
blood-supply. Bleeding from these wounds is usually
very free, and often difficult to arrest. This depends, not
so much upon the number of vessels in the part, as
upon the density of the tissue through which these
vessels run, the adherence of the outer arterial wall to
the scalp structure, and the inability, therefore, of the
artery to properly retract when divided.

In all parts of the body where a dense bone is
covered by a comparatively thin layer of soft tissues,
sloughing of those tissues is apt to be induced by
long and severe pressure. The scalp, by its vascu-
larity, is saved to a great extent from this evil, and is
much less liable to slough than are the soft parts
covering such bones as the condyles of the humerus or
the sacrum. But such an effect is sometimes pro-
duced, as in a case I saw, where the tissues over the
frontal and occipital regions sloughed from the con-
tinued application of a tight bandage put on to arrest
bleeding from a frontal wound.

The pericranium is but slightly adherent to
the bone, except at the sutures, where it is intimately
united. In lacerated wounds this membrane can be
readily stripped from the skull, and often, in these
injuries, extensive tracts of bone are laid bare. The

Chap, i.] THE SCALP. 5

pericranium differs somewhat in its functions from the
periosteum that covers other bones. If the periosteum
be removed to any extent from a bone, the part from
whence it is removed will very probably perish, and
necrosis from deficient blood-supply result. But the
pericranium may be stripped off a considerable part of
the skull vault without any necrosis, save perhaps a
little superficial exfoliation, following in consequence.
This is explained by the fact that the cranial bones
derive their blood supply mainly from the dura mater,
and are therefore to a considerable extent independent
of the pericranium. A like independence cannot be
claimed for the periosteum covering other bones, since
that membrane brings to the part it covers a very
copious and essential contribution to its blood supply.
This disposition of the pericranium is also well illus-
trated by its action in cases of necrosis of the cranial
bones. In necrosis of a long bone, the separation of
the sequestrum is attended with a vigorous periosteal
growth of new bone, which repairs the gap left after
the removal of such sequestra. In necrosis of the
vault of the skull, however, no new bone is, as a
rule, formed, and the gap remains unrepaired. The
general indisposition of the pericranium to form
new bone in other circumstances is frequently illus-
trated.

Abscess in the scalp region may be situated
(1) above the aponeurosis, (2) between the aponeurosis
and the pericranium, and (3) beneath the pericranium.
Abscesses in the first situation must always be small
and comparatively insignificant, since the density of
the scalp tissue here is such that suppuration can
only extend with the greatest difficulty. Suppuration,
however, in the second situation (in the loose tissue
beneath the aponeurosis) may prove very serious.
The laxity of this tissue offers every inducement to
the abscess to extend when once pus has found its

6 SURGICAL APPLIED ANATOMY. [Chap. i.

way between the aponeurosis and the pericranium.
Suppuration in this area may undermine the entire
scalp, which, in severe and unrelieved cases, may rest
upon the abscess beneath as upon a kind of water-
bed. As in scalp wounds the aponeurosis is often
divided, and as suppuration may follow the injury, it
will be seen that the chief danger of those lesions
depends upon the spreading of such suppuration to
the area of lax connective tissue now under notice.
The significance of a small amount of bare bone in a
scalp wound is not so much that evils will happen to
the bone, but that the aponeurosis has been certainly
divided, and the dangerous area of the scalp opened
up. Suppuration, when it occurs in this area, is only
limited by the attachments of the occipito-frontalis
muscle and its aponeurosis, and therefore the most
dependent places through which pus can be evacuated
are along a line drawn round the head, commencing
in front, above the eyebrow, passing at the side a
little above the zygoma, and ending behind at the
superior curved line of the occipital bone. The
scalp, even when extensively dissected up by such
abscesses does not perish, since it carries, as above
explained, its blood supply with it. The abscess is
often very slow to close, since its walls are prevented
from obtaining perfect rest by the frequent movement
of the epicranial muscle. To mitigate this evil, and
to ensure closing of the sinuses in obstinate cases,
Mr. Hilton advises that the whole scalp be firmly
secured by strapping, so that the movement of the
muscle is arrested.

Abscess beneath the pericranium must be limited
to one bone, since the dipping-in of the membrane at
the sutures prevents a more extensive spreading of
the suppuration.

Ileematomata, or blood tumours of the
scalp region, occur in the same localities as abscess.

Chap, i.] THE SCALP. ' 7

The extravasation of blood above the aponeurosis
must be of a limited character, while that beneath it
may be very extensive. It fortunately happens, how-
ever, that the cellular tissue between the aponeurosis
and the pericranium contains but very few vessels,
and hence large extravasations in this tissue are un-
common.

Extravasations of blood beneath the pericranium
are generally termed cephalhsematomata, and are of
necessity limited to one bone. They are usually con-
genital, are due to pressure upon the head at birth,
and are thus most commonly found over one parietal
bone, that bone being probably the one most exposed
to pressure. Their greater frequency in male children
may depend upon the larger size of the head in the
male foetus. Such extravasations in early life are
encouraged by the laxity of the pericranium, and by
the softness and vascularity of the subjacent bone.

In the temporal region, or the region corre-
sponding to the temporal muscle, the layers of soft
parts between the skin and the bone are somewhat
different from those that have been already described
as common to the chief part of the scalp. There is a
good deal of fat in the temporal fossa, and when this
is absorbed it leads to more or less prominence of the
zygoma and malar bone, and so produces the project-
ing " cheek bones " of the emaciated. The temporal
muscle above the zygoma is covered in by a very
dense fascia, the temporal fascia, which is attached
above to the temporal ridge 011 the frontal and pari-
etal bones, and below to the zygomatic arch. The
unyielding nature of this fascia is well illustrated by
a case recorded by Denonvilliers. It concerned a
woman who had fallen in the street, and who was
admitted into hospital with a deep wound in the
temporal region. A piece of bone several lines in
length was found loose at the bottom of the wound.

8 SURGICAL APPLIED ANATOMY. [Chap. i.

and was removed. After its removal the finger could
be passed through an opening with an unyielding
border, and came in contact with some soft substance
beyond. The case was considered to be one of com-
pound fracture of the squamous bone, with separation
of a fragment and exposure of the brain. A by-
stander, however, noticed that the bone removed was
dry and white, and a more complete examination of
the wound revealed the fact that the skull was un-
injured, that the supposed hole in the skull was
merely a laceration of the temporal fascia, that the
soft matter beyond was muscle and not brain, and that
the fragment removed was simply a piece of bone
which, lying on the ground, had been driven into the
soft parts when the woman fell.

Abscesses in the temporal fossa are prevented
by the fascia from opening anywhere above the
zygoma, and are encouraged rather to spread into
the pterygoid and maxillary regions, and into the
neck.

The pericranium in the temporal region is much
more adherent to the bone than it is over the rest of
the vault, and subpericranial extravasations of blood
are therefore practically unknown- in this part of the
cranial wall.

Trephining1.— This operation is frequently per-
formed in the temporal region, its object being to
reach extravasations of blood from the middle menin-
geal artery. This artery crosses the anterior inferior
angle of the parietal bone at a point 1| inches behind
the external angular process of the frontal bone, and
1| inches above the zygoma.

In cutting down to the bone in the temporal
region the following structures are met with in order :
(1) The skin ; (2) branches of the superficial temporal
vessels and nerves; (3) the fascia continued down
from the epicranial aponeurosis ; (4) the temporal

chap, i.j THE SCALP. 9

fascia ; (5) the temporal muscle ; (6) the deep temporal
vessels ; and (7) the pericranium. In trephining the
skull generally, the comparative thickness of the
cranial wall in various parts should be borne in mind
(page 24), and the large arteries of the scalp should
be avoided if possible. The trephine should not be
applied over the frontal sinuses, which are often of
large size in the aged, and should, when possible, keep
clear of the sutures, owing to the frequent exit of
emissary veins at or about suture lines. Especially
must the superior longitudinal sinus be avoided, which
runs backwards in the middle line, and the lateral
sinus, whose course is represented by a line drawn
horizontally from the occipital protuberance to a
point about one inch behind the external nieatus of
the ear, where it turns downwards to groove the mas-
toid process.

The zygoma may be broken by direct or in-
direct violence. In the latter case the violence is such
as tends to thrust the upper jaw or malar bone back-
wards. When due to direct violence, a fragment may
be driven into the temporal muscle, and much pain
caused in moving the jaw. In ordinary cases there is
little or no displacement, since to both fragments the
temporal fascia is attached above and the masseter
below.

The vessels and nerves of the scalp. — The
supraorbital artery and nerve pass vertically upwards
from the supraorbital notch, which is situate at the
junction of the middle with the inner third of the
upper orbital margin. Nearer the middle line the
frontal artery and supratrochlear nerve ascend. This
artery gives life to the flap that in rhinoplasty is
taken from the forehead to form a new nose. The tem-
poral artery, with the auriculo-temporal nerve behind
it, crosses the base of the zygoma just in front of
the ear. The branches of this artery, especially the

io SURGICAL APPLIED ANATOMY. [Chap, i

anterior branch, are often very tortuous in the aged,
and afford early evidence of arterial degeneration.
Arteriotomy is sometimes practised on the anterior
branch of this vessel. The superficial temporal vessels
are very liable to be the seat of cirsoid aneurism, as,
to a less extent, are the other scalp arteries. Cirsoid
aneurism is more often met with in the superficial
temporal arteries than in any other artery in the
body. The posterior auricular artery and nerve
run in the groove between the mastoid process and
the ear, and the occipital artery and great occipital
nerve reach the scalp just internal to a point midway
between the occipital protuberance arid the mastoid
process.

Certain of the emissary veins are of great im-
portance in surgery. These veins pass through aper-
tures in the cranial wall, and establish communications
between the venous circulation (the sinuses) within
the skull and the superficial veins external to it.
The principal emissary veins are the following : 1.
A vein passing through the mastoid foramen and con-
necting the lateral sinus with the posterior auricular
vein or with an occipital vein. This is the largest and
most constant of the series. The existence of this
mastoid vein serves to give an answer to the question,
Why is it a common practice to apply leeches and
blisters behind the ear in certain cerebral affections 1
2. A vein connecting the superior longitudinal sinus
with the veins of the scalp through the parietal
foramen. 3. A vein connecting the lateral sinus with
the deep veins at the back of the neck through the
posterior coiidylar foramen (inconstant). 4. Minute
veins following the ninth nerve through its foramen,
and connecting the occipital sinus with the deep veins
of the neck. 5. Minute veins passing through the
foramen ovale, foramen lacerum and carotid canal to
connect the cavernous sinus with (respectively) the

chap, i.] THE SCALP. n

pterygoid venous plexus, the pharyngeal plexus, and
the internal jugular vein.

Then, again, many minute veins connect the veins
of the scalp with those of the diploe. Of the four
diploic veins, two (the frontal and anterior temporal)
enter into surface veins (the supraorbital and deep
temporal), and two (the posterior temporal and
occipital) enter into the lateral sinus.

Lastly, there is the well-known communication
between the extra- and intra-cranial venous circulation
effected by the commencement of the facial vein at
the inner angle of the orbit. In this communication
the angular and supraorbital veins unite with the
superior ophthalmic vein, a tributary of the cavernous
sinus.

Through these various channels, and through many
probably still less conspicuous, inflammatory processes
can spread from the surface to the interior of the skull.
Thus we find such affections as erysipelas of the scalp,
diffuse suppuration of the scalp, necrosis of the
cranial bones, and the like, leading by extension to
mischief within the diploe, to thrombosis of the
sinuses, and to inflammation of the meninges of the
brain. If there were no emissary veins, injuries and
diseases of the scalp and skull would lose half their
seriousness. Mischief may even spread from within
outwards along an emissary vein. Erichsen reports a
case where the lateral sinus was exposed in a com-
pound fracture. The aperture was plugged. Throm-
bosis and suppuration within the sinus followed, and
some of the pus, escaping through the mastoid vein,
led to an abscess in the neck.

The scalp nerves, especially such as are branches
of the fifth pair, are often the seat of neu-
ralgia. To relieve one form of this affection the
supraorbital nerve has been divided (neurotomy) at its
point of exit from the orbit, and a portion of the

12 SURGICAL APPLIED ANATOMY. [Chap. n.

nerve has been resected (neurectomy) in the same
situation.

The lymphatics from the occipital and posterior
parietal regions of the scalp enter the suboccipital and
mastoid glands ; those from the frontal and anterior
parietal regions go to the parotid glands, while some of
the vessels from the frontal region join the lymphatics
of the face, and end in the subm axillary glands.

CHAPTER II.

THE BONY VAULT OF THE CRANIUM.

Position of the sutures. — The bregma, or
point of junction of the coronal and sagittal sutures,
is in a line drawn vertically upwards from the
external auditory meatus, the head being in normal
position (Fig. 2). The lambda, or point of junction
of the lambdoid and sagittal sutures, lies in the
middle line, about 2f inches above the occipital
protuberance. The lambdoid suture is fairly re-
presented by the upper two-thirds of a line drawn
from the lambda to the apex of the mastoid process
on either side. The coronal suture lies along a line
drawn from the bregma to the middle of the zygo-
matic arch. On this line, at a spot about on a
level with the external angular process of the frontal
bone, and about 1J inches behind that process, is
the pterion, the region where four bones meet — the
squamous bone, the great wing of the sphenoid, the
frontal and parietal bones. The summit of the squa-
mous suture is just two inches above the zygoma.

In the normal subject all traces of the fontaiielles
and other uiiossified parts of the skull, disappear

chap, ii.] BONY VAULT OF THE CRANIUM. 13

before the age of four years. The anterior fontanelle
is the last to close, while the posterior is already filled
at t^ie time of birth. It is through or about the
anterior fontanelle that the ventricles are usually
tapped in paracentesis in cases of hydrocephalus. In
this operation the trochar is either entered at the sides

Fig. 2.— The Cranial Sutures. (After Gavoy.)

of the fontanelle at a sufficient distance from the
middle line to avoid the sinus, or is introduced
through the coronal suture at some spot other than its
middle point. It may be noted that in severe hydro-
cephalus the coronal and other sutures of the vault
are widely opened.

The condition known as cranio-tabes, a con-
dition assigned by some to rickets and by others
to inherited syphilis, is usually met with in the
vertical part of the occipital bone, and in the ad-
jacent parts of the parietal bones. In this condition
the bone is greatly thinned in spots, and its

14 SURGICAL APPLIED. ANATOMY. [Chap. n.

tissue so reduced that the affected district feels
to the finger as if occupied by parchment, or> as
some suggest, by cartridge paper. It is, on the other
hand, about, the site of the anterior fontanelle that
certain osseous deposits are met with on the surface
of the skull in some cases of hereditary syphilis
(Parrot). These deposits appear as rounded elevations
of porous bone situated upon the frontal and parietal
bones, where they meet in the middle line. These
bosses are separated by a crucial depression repre-
sented by the frontal and sagittal sutures on the
one hand, and the coronal suture on the other. They
have been termed " natiform " elevations by M.
Parrot, from their supposed resemblance, when viewed
collectively, to the nates. To the English mind they
would rather suggest the outlines of a "hot-cross
bun."

It is necessary to refer to the development of
tlie skull in order to render intelligible certain con-
ditions (for the most part those of congenital mal-
formation) that are not unfrequently met with.
Speaking generally, it may be said that the base of
the skull is developed in cartilage, and the vault in
membrane. The parts actually formed in membrane are
represented in the completed skull by the frontal
and parietal bones, the squamo-zygomatic part of the
temporal bone, and the greater part of the expanded
portion of the occipital bone. The distinction between
these two parts of the skull is often rendered very
marked by disease. Thus there are, in the museum
of the Royal College of Surgeons, the skulls of some
young lions' that were born m a menagerie, and that,
in consequence of mal-nutrition, developed certain
changes in their bones. A great part of each of these
skulls shows considerable thickening, the bone being
converted into a" porous structure ; and it is remark-
able to note that these changes are limited to such

Chap, ii.] BONY VAULT OF THE CRANIUM.

parts of the skull as are formed in membrane, the
base remaining free.

Among the more common of the gross mal-
formations of the skull also, is one that shows
entire absence of all that part of the cranium that is
formed in membrane, while the base, or cartilaginous
part, is more or less perfectly developed.

Meningocele is the name given to a congenital
tumour that consists of a protrusion of a part of the
cerebral membranes through a gap in an imperfectly
developed skull. When the protrusion contains brain,
it is called an encephalocele, and when that pro-
truded brain is distended by an accumulation of fluid
within the ventricles, it is called hydrencephalocele.
These protrusions are most often met with in the
occipital bone, and next in frequency in the fronto-
nasal suture, while in rarer cases they have been met
with in the lambdoid, sagittal, and other sutures, and
have projected through normal and
abnormal fissures at the base of
the skull into the orbit, nose, and
mouth. Their frequency in the
occipital bone may be in some
way explained by a reference to
the development of that part.
This bone at birth consists of
four separate parts (see Fig. 3),
a basilar, two condylar, and a
tabular or expanded part. In the
tabular part, about the seventh
week of foetal life four nuclei
appear, an upper and a lower pair.
These nuclei are to some extent
separated by fissures running inwards from
four angles of the bone, and those that run in
from the upper and lateral angles persist for some
time after birth. Meningoceles of the occiput are

Fig. 3.— The Occipital
Bone at Birth.

the

i6

SURGICAL APPLIED ANATOMY. [Chap. n.

always in the middle line, and occur through one
or other part of the vertical fissure. Since the upper
part of the vertical fissure closes later than the lower
part, it follows that the abnormal gap is more often
above than below the occipital protuberance. If
below the protuberance, the foramen magnum may
be opened up, or, on the other hand, the gap may
involve the entire bone in the vertical direction. The

Fig. 4.— Back View of Abnormal Skulls, showing Occipital and

Parietal Bones.
A, The "os epactal " ; B, parietal fissures ; c, the sagittal fontanelle.

lateral fissures may persist, and may simulate fractures,
for which they have, indeed, been mistaken ; or they
may be so complete as to entirely separate the highest
part of the occipital bone from the remainder. The
bone so separated is the os e"pactal of the French
(Fig. 4 A).

Parietal fissures. — In the developing parietal
bone, fibres concerned in ossification radiate towards
the periphery from a nucleus about the centre of the

chap. iL] BONY VAULT OF THE CRANIUM. 17

bone. An interfibrillar space, larger than the rest, is
seen about the fifth month to separate the loose osseous
fibres which abut on the posterior part of the sagittal
border from the stronger fibres which form the rest of
this border (Pozzi). This is the parietal fissure. It
usually closes and leaves no trace, but it may persist
in part as a suture-like fissure, and be mistaken for a
fracture (Fig. 4 B). If the fissure persists equally on
the two sides an elongated lozenge-shaped gap is left,
the sagittal fontanelle. It is situate about an inch
in front of the lambda (Fig. 4 c).

Necrosis is fairly common on the vault of the
skull, and most often attacks the frontal and parietal
bones, while, for reasons that are not very obvious, it
is rare in the occipital bone. The external table is
frequently necrosed alone, it being more exposed to
injury and less amply supplied with blood than is the
internal table. From the converse of these reasons
it happens that necrosis of the internal table alone is
but rarely met with. Necrosis involving the entire
thickness of the bone may prove very extensive, and
in a case reported by Saviardj practically the whole of
the cranial vault necrosed and came away. The
patient was a woman, and the primary cause of the
mischief was a fall upon the head when drunk.

Fractures of the skull. — It is not easy to
actually fracture the skull of a young infant. The skull
as a whole at this age is imperfectly ossified, the sutures
are wide, and between the bones there is much
cartilage and membrane. Moreover, the bones them-
selves in early life are elastic, and comparatively soft
and yielding. If a blow be inflicted upon the vault
in a young child the most probable effect, so far as
the bone itself is concerned, is an indenting or
bulging in of that bone unassociated with a fracture
in the ordinary sense. In this particular relation, the
skull of an infant is to that of an old man as a

1 8 SURGICAL APPLIED ANATOMY. [Chap. n.

cranium of thin tin would be to a cranium of strong
earthenware. The yielding character of the young
child's skull is well illustrated by the gross deformity
of the head that certain Indian tribes produce in their
offspring by applying tight bandages to the part in
infancy. In the Royal College of Surgeons' museum
are many skulls of " flat- headed " Indians, that show
to what an extreme this artificial deformity may be
carried. Gueniot also asserts that much deformity of
the head may be produced in infants by the practice
of allowing them to always lie upon one side of the
body. Here the deforming agent is simply the weight
of the brain.

Even in adults the skull is much less brittle than
is commonly supposed, and notions as to the break-
ability of the cranial bones derived from the study
of the dried specimen are apt to be erroneous. During
life, a sharp knife properly directed may be driven
through the cranial vault so as to cause only a simple
perforating wound without splintering, and without
fracture of the bone beyond the puncture. Such a
wound may be as cleanly cut as a wound through
thick leather, and a specimen in the London Hospital
museum serves well to illustrate this. A case reported
in the Lancet for 1881 affords a strange instance
of a knife penetrating the skull without apparently
splintering the bone. A man wishing to commit
suicide placed the point of a dagger against the skull
in the upper frontal region, and then drove it well
into the brain by a blow from a mallet. He expected
to fall dead, and was disappointed to find that no
phenomena of interest developed. He then drove the
dagger farther in by some dozen blows with the
mallet, until the blade, which was four inches long,
was brought to a standstill. The dagger was removed
with great difficulty, the patient never lost conscious-
ness, and recovered without a symptom.

Chap. II.] BONY VAULT OF THE CRANIUM. 19

The following anatomical conditions tend to
minimise the effects of violence as applied to the
skull : The density of the scalp and its great mo-
bility; the dome-like arrangement of the vault; the
number of the bones that compose the head, and
the tendency of the violence to be broken up amongst
the many segments ; the sutures which interrupt the
continuity of any given force, and the sutural mem-
brane, which acts as a kind of linear buffer ; the
mobility of the head upon the spine ; and the elas-
ticity of the cranial bones themselves.

In children the membranous layer between the
sutures is of considerable thickness, but, as age
advances, this membrane disappears, and the bones
tend to fuse together (synostosis). The sutures
begin to be obliterated about the age of forty, the
change commencing on the inner aspect of the
suture, and appearing first in the sagittal suture,
and last in the squamous. The synostosis may
be complete by the age of eighty (Tillaux), and
its onset is said to be coincident with the cessation
of increase in the weight of the brain. This latter
assertion is supported by the fact that it appears
earlier in the lower races of mankind. As age
advances, moreover, the skull bones become less
porous, and lose much of their elasticity. They are,
therefore, more readily fractured in the aged than in
the young.

As a rule, in fracture the entire thickness of the
bone is involved ; but the external table alone may be
broken, and may even be alone depressed, being
driven into the diploe, or, in the case of the lower
frontal region, into the frontal sinus. The internal
table may be broken without a corresponding fracture
in the outer plate ; and in nearly all cases of complete
fracture, especially in such as are attended with
depression, the internal table shows more extensive

SURGICAL APPLIED ANATOMY. [Chap. n.

splintering than does the external. There are many
reasons for this. The internal plate is not only
thinner than the external, but is so much more
brittle as to receive the name of the "vitreous table."
A force applied to the external table may be extremely
limited, and produce, as in a sabre cut, but a
limited lesion. As the force, however, travels
through the diploe it becomes broken up, and
reaches the inner plate as a much more diffused

form of violence. This
is especially the case
when parts of the
outer table are driven
in. Then, again, the
internal plate is a
part of a smaller
curve than is the ex-
ternal plate ; and,
lastly, Agnew assigns
a reason for the
greater vulnerability of the inner plate that has
reference to the general yielding of the bone. In
Fig. 5, AB represents a section of a part of the
vault through both
tables, and c D and
E F two vertical and
parallel lines. Now,
if force be applied
to the vault between
these parallel lines,
the ends of the arch,
A B, will tend to be-
come separated, and
the whole arch, yielding, will tend to assume the curve
shown in Fig. 6. In such case, the lines c D and E F
will converge above and diverge below (Fig. 6), so
that the violence would tend to force the bone

Fig. 6.

chap, ii.] BONY VAULT OF THE CRANIUM. 21

particles together at the outer table and asunder at
the inner table.

Fractures of the vault are due to direct
violence. The construction of the skull is such that
the fracturing force is resisted in many ways. (1) When
a blow is received on the vertex in the parietal region,
the force tends to drive the upper borders of the
two parietal bones inwards. Such driving in of these
borders must be associated with a corresponding
outward movement of the inferior borders. This
latter movement is forcibly resisted by the squamous
bone and the great wing of the sphenoid, which over-
lap the lower edge of the parietal bone. Moreover,
the force transmitted to the squamous bone is passed
on to the zygomatic arch, which takes its support
from the superior maxillary and frontal bones. This
arch then acts as a second resisting buttress, and this
transmission of force from the vertex to the facial
bones is said to be illustrated by the pain often
felt in the face after blows upon the top of the
head. (2) If the upper part of the frontal bone be
struck, the force is at once transmitted to the parietal
bones, because the upper part of the frontal bone
(owing to the manner in which its border is bevelled)
actually rests upon the two parietal bones, so the
same resistance is again called into action. If there be
any tendency for the inferior parts of the bone to move
outwards, as would certainly be the case while the mid-
frontal suture existed, such movement would be resisted
by the great wings of the sphenoid, and by the anterior
inferior angles of the parietal bones which embrace
or overlap these parts of the frontal. Thus it will be
seen that much depends upon the manner in which
the corresponding edges of the frontal and parietal
bones are bevelled. (3) Blows upon the occiput are
less distinctly provided for, and it must be owned
that a by no means heavy fall is sufficient to break

22 SURGICAL APPLIED ANATOMY. [Chap. n.

this bone. It must receive, however, much protection
from its connections with the two parietal and tem-
poral bones, and from its articulation with the elastic
vertebral column.

Fractures of the base of the skull may be
due to (1) direct or to (2) indirect violence, and, most
commonly of all, to (3) extension of a fracture from
the vault. (1) The base has been fractured by direct
violence by foreign bodies thrust through the nasal
roof, through the orbital roof, and through the base as
it presents in the pharynx. The posterior fossa can
also be fractured by violence applied to the nape of the
neck. (2) Of fractures by indirect violence the following
examples may be given : Blows applied to the lower
part of the frontal bone have been associated with no
lesion other than a fracture of the cribriform plate or
of the orbital part of the frontal, these parts being
much disposed to fracture on account of their extreme
tenuity. In falls upon the chin, the condyle of the
lower jaw has been so violently driven against the
glenoid cavity as to fracture the middle fossa of the
skull. Chassaignac gives a case where the condyle
was actually thrust into the cranial cavity, and
produced an abscess in the superimposed part of the
brain. When the body in falling has alighted upon
the feet, knees, or buttocks, the force has been trans-
mitted along the vertebral column, and has led to
fracture of the base in the occipital region. Such
accidents are most apt to occur when the spine is kept
rigid by muscular action, and the mechanism involved
is precisely similar to that whereby the head of a
broom is driven more firmly on to the broom-handle
by striking the extreme end of the stick against the
ground. The theory that the base is often broken by
contre-coup is pretty generally abandoned, although
there are a few cases that appear to support the
suggestion. Such a case was recorded by Mr.

Chap, ii.] BONY VAULT OF THE CRANIUM. 23

Hutchinson, and in it a fracture of the occipital bone
was associated with a like lesion in the cribriform
plate, the intervening part of the skull being un-
injured. (3) Fractures of the vault, and especially
linear fractures due to such diffused violence as
obtains in a fall upon the head, are very apt to spread
to the base. In so spreading they reach the base by
the shortest possible route, and without any regard to
the sutures encountered or to the density of the bones
involved. Thus, fractures of the frontal region of the
vault spread to the anterior fossa of the base, those of
the parietal region to the middle fossa, and those of
the occipital region to the posterior fossa. To this
rule there are but few exceptions. -To indicate more
precisely the exact bones involved in these three
districts, Mr. Hewett has divided the skull into three
zones. The anterior zone includes the frontal, the
upper part of the ethmoid, and the fronto-sphenoid ;
the middle, the parietals, the squamous, the anterior
part of the petrous portion, and the greater part of
the basi-sphenoid ; and the posterior, the occipital,
the mastoid, the posterior part of the petrous bone,
with a small part of the body of the sphenoid.

In all fractures of the base there is usually a dis-
charge of blood and of cerebro-spinal fluid externally.
(1) In fractures of the anterior fossa the blood usually
escapes from the nose, and is derived from the menin-
geal vessels, or in greater degree probably from the
torn mucous lining of the nasal roof. To allow of the
escape of cerebro-spinal fluid from the nose, there
must be, in addition to the fracture in the nasal roof,
a laceration of the mucous membrane below that
fracture, and of the dura mater and arachnoid above
it. In many cases of fracture in this part the blood
finds its way into the orbit, and appears beneath the
conjunctiva. (2) When the middle fossa is involved,
the blood escapes from the external auditory rneatus,

24 SURGICAL APPLIED ANATOMY. [Chap. n.

through a rupture in the tympanic membrane, and is
derived from the vessels of the tympanum and its
membrane, or from an intracranial extravasation, and
in some cases from a rupture of one of the sinuses
about the petrous bone. The blood may follow the
Eustachian tube, and may escape from the nose or
mouth, or be swallowed and subsequently vomited.
To allow of the escape of cerebro-spinal fluid by the
ear (" the serous discharge "), (A) the fracture must
have passed across the internal auditory meatus ; (B)
the tubular prolongation of the membranes in that
meatus must have been torn ; (c) there must be a com-
munication between the internal ear and the tympa-
num ; and (D) the membraiia tympana must have been
lacerated. (3) In fractures of the posterior fossa an
extravasation of blood may appear about the mastokl
process or at the nape of the neck, or may even
extend into the cervical region.

It may be added that in compound fractures of the
vault associated with tearing of the dura mater and
arachnoid, an escape of cerebro-spinal fluid has in a
few rare instances been noted, and that in cases of
free serous discharge from the ear after injury to the
head, but without fracture, the fluid is derived from
the mastoid cells, and escapes through a rupture in
the tympanic membrane.

The thickness of the skull cap varies greatly,
not only in different parts of the same skull, but also
in corresponding parts in different individuals. The
average thickness is one-fifth of an inch. The thickest
parts are at the occipital protuberance (where the
section may measure half an inch), the mastoid pro-
cess, and the lower part of the frontal bone. The
bone over the inferior occipital fossae is very thin,
while it is thinnest over the squamous bone. Here
the bone may be no thicker in parts than a visiting
card. The skull is also thinned over the sinuses and

chap, in.] THE CRANIAL CONTENTS. 25

grooves for the meningeal vessels. It is important to
remember in trephining that the inner table is not
always parallel with the outer.

CHAPTER III.

THE CRANIAL CONTENTS.

THE membranes of the brain.— The dura
mater, from its toughness, forms an excellent protec-
tion to the brain. It is very intimately adherent to
the bone over the whole of the base of the skull, and.
consequently in this situation extravasations between
the membrane and the bone are scarcely possible. Over
the vault its attachments are comparatively loose,
although it is more closely adherent along the lines of
the sutures. This lax attachment allows large hsemorr-
hagic and purulent extravasations to collect between
the dura mater and the bone. Such extravasations
usually lead to compression of the brain, and it may be
noted that in the great majority of all cases of com-
pression the compressing force is outside the dura
mater. Thus, in uncomplicated cases, when symptoms
of compression come on at the time of an accident, the
cause is probably depressed bone ; when they appear
after a short interval, the cause is probably extrava-
sated blood between the membrane and the bone ; and
when a long interval (days or weeks) has elapsed after
the accident, the cause is probably a collection of pus
in the same situation.

When blood is poured out between the dura mater
and the bone in cases of fracture, the vessel that, as a
rule, gives way, is the middle meningeal artery. In
thirty-one cases of such haemorrhage, this vessel was

26 SURGICAL APPLIED ANATOMY. [Chap. in.

the source of the bleeding in twenty-seven instances
(P. Hewett). The artery is most often torn, as it
crosses the anterior angle of the parietal bone. There
are many reasons for this : the bone where grooved by
the artery is very thin ; the artery is often so imbedded
in the bone that fracture without laceration of the
vessel would hardly be possible ; and lastly, the par-
ticular region of the artery is a part of the skull
peculiarly liable to be fractured. Failing this vessel,
the most frequent source of extra-meningeal haemorr-
hage is the lateral sinus, for reasons that will be
obvious.

With regard to the blood sinuses formed by the
dura mater, nothing remains to be added to what has
been already said (page 10), except, perhaps, to
observe that the relations between the internal
carotid artery and cavernous sinus are so intimate that
arterio- venous aneurism has followed injury involving
these parts. It will be seen also with what ease this
sinus could become thrombosed in cases of inflamma-
tion within the orbit by the extension of the mis-
chief along its great tributaries, the two ophthalmic
reins.

Sarcomatous growths, springing from the dura
mater or other of the meninges, may make their way
through the cranial bones, and project as pulsating
tumours beneath the scalp. Such growths are included
under the title of "fungus of the dura mater."

Between the dura mater and the arachnoid is the
subdural space, formerly known as the " cavity of
the arachnoid.1' According to Prescott Hewett, ex-
travasations of blood after injury are more common
in this space than in any other part within the skull.
The blood so poured out may become more or less
discoloured, and present in time the aspect of a thin
and peculiar membrane; or the collection may form
itself into a species of cyst (" arachnoid cyst ") that

chap, in.] THE CRANIAL CONTENTS. 27

was for some time a source of much confusion to
pathologists.

The subdural space contains a small amount of
fluid, and acts, probably, like the pleural and peri-
toneal sacs in preventing the effects of friction during
the movements of the brain.

The subaraclmoicl space is between the arach-
noid and the pia rnater, and it is here that the chief part
of the cerebro-spinal fluid is lodged. This space is larger
in some places than in others. It is insignificant over
the convexity of the brain, but is very extensive at
the base of the skull in the parts beneath the cere-
bellum, the medulla, the pons, and the interpeduncular
space as far forwards as the optic nerves. Thus these
very important parts of the brain do not rest upon
bone, but rest rather on the subarachnoid collection
of fluid as upon a water-bed, to use a comparison of
Mr. Hilton's. The only part of the base of the brain
that rests directly upon bone is that part in contact
with the orbital plates and lesser wings of the sphe-
noid. The posterior two-thirds of the brain rests
upon the " water-bed," and is thus admirably pro-
tected.

It is well known that the brain may be damaged
by centre-coup. That is to say, if the head be struck
at one particular part, the brain may be found unin-
jured at the spot struck, but damaged at a correspond-
ing place on the opposite side of the skull. The
cerebro-spinal fluid is much concerned in modifying
the effects of contre-coup. Thus, if the vertex be
struck, the important structures at the base of the
brain would be in the greatest danger of being
severely injured, did they lie in actual contact with
the bone. Moreover, when a blow falls upon the
occiput, there may be no damage to the brain beneath
the spot struck, but the yielding mass is thrown
forward within the skull, arid were it not for the

28 SURGICAL APPLIED A A ATOMY. [Chap. in.

" water-bed," the under parts of the cerebrum would
be torn against the many projections in the base of
the skull. As it is, the only part that usually suffers
is the under surface of the frontal lobe (a compara-
tively unimportant segment), which, being brought
violently in contact with the irregular orbital plate, is
readily contused. The subarachnoid space communi-
cates with the ventricles through the foramen of
Magendie. This foramen leads into the fourth ven-
tricle, and is an aperture in the pia mater that closes
in that ventricle. From the fourth ventricle fluid
can pass along the iter into the third ventricle, and
from thence to the lateral ventricles by the foramen of
Monro.

The cerebro-spinal fluid prevents the ill effects that
irregularities in the blood circulation might have upon
the brain, situate as it is within an unyielding cavity.
Jf the great nerve-centres in the lateral ventricles
are swollen by congestion, they are not met by an un-
yielding wall, but merely displace some of the cerebro-
spinal fluid through the foramen of Magendie, until
such time as their circulation is normal again.

Hilton has shown that closure of this foramen
may lead to that excessive accumulation of fluid
within the ventricles known as hydrocephalus. If the
brain, too, becomes enlarged by congestion, it is not
met by unyielding bone, but rather by an adjustable
water-bed, and during its period of enlargement it
merely displaces into the spinal part of the sub-
arachnoid space some of the fluid that surrounds it.
This mutual effect is well illustrated in a case reported
by Hilton of a man with a fracture of the base, from
whose ear cerebro-spinal fluid was escaping. The
discharge of this fluid was at once greatly in-
creased by expiratory efforts when the nose and
mouth were held closed, and the veins compressed
in the neck.

Chap. III.]

THE CRANIAL CONTENTS.

29

The relations of the brain to the skull.—

The lower level of the brain in front corresponds to a
line drawn across the forehead just above the eye-
brows. At the side of the head it corresponds
approximately to a line drawn from a point half an
inch above the external angular process of the frontal

Fig. 7.— Diagram to show the Eelations of the Main Fissures to the
Surface of the Skull.

to the upper part of the external auditory meatus.
A line drawn from this latter spot to the occipital pro-
tuberance corresponds to the lower level of the posterior
lobe, while below that line will lie the cerebellum
(Fig. 7). The commencement of the Sylvian fissure
corresponds to the pterion. Its ascending limb is
parallel to, and immediately behind, the coronal suture.
Its posterior, or horizontal limb, runs backwards
across the upper margin of the squamous suture.
The external parieto-occipital fissure is a little in front
of the lambda. The fissure of Rolando is some way
behind the coronal suture, and is not quite parallel to

30 SURGICAL APPLIED ANATOMY. [Chap. in.

it, being a little less than two inches behind the
suture above, and a little more than one inch behind
it below.

The temporo-sphenoidal lobe lies below a line drawn
horizontally backwards from the external angular
process. To find Broca's convolution (the posterior
part of the third left frontal convolution), a horizontal
line is drawn backwards from the external angular
process for two inches. The convolution is three-
quarters of an inch above the end of this line. The
upper borders of the optic thalamus and corpus
striatum are about on a level with the top of the
pinna. They are situate opposite the temporal region,
and the anterior limit of the corpus striatum about
corresponds to the pterion.

The motor centres on the cortex. — As an
aid to the localisation of certain lesions of the brain,
and as a means of explaining certain phenomena
when the cerebral cortex is damaged, a knowledge of
the cortical motor centres is most important. As
investigators do not agree entirely as to the exact
position of these centres upon the human brain, the
" cerebral localisation " of the principal authorities on
this subject is here given together without comment.
According to Charcot, (1) centre for movements of the
tongue, at the posterior end of the third frontal
conv. and contiguous part of the asc. frontal coiiv. ;
(2) centre for movements of lower part of face, at the
lower end of the two ascending convolutions ; (3)
centre for fore-arm and hand, on the middle third
of the asc. frontal conv. ; (4) centre for movements
of the lower limb, on the upper third of the asc.
frontal conv. and upper two-thirds of the asc. par.
conv. According to Hitzig, (1) motor centre for
upper limb, at upper part of asc. frontal conv. ;
(2) motor centre for lower limb, on asc. frontal
coiiv., just below preceding centre ; (3) motor centre

chap, in.] THE CRANIAL CONTENTS. 31

for- facial muscles, at middle part of asc. frontal
conv. ; (4) centre for muscles of mouth, tongue, and
jaws, at inf. part of asc. frontal conv. According to
Ferrier, (1) centre for rotation movements of head
and neck, at post, end of first frontal conv. ; (2) centre
for muscles of face, at post, end of second frontal

Fig. 8.— Skull with. Parietal Bone removed, showing principal part

of Cortex concerned in " cerebral localisation " (Gavoy).
a, Fissure of Rolando ; 6, ascending frontal convolution, with, in front of it, the

three frontal convolutions partly shown ; c, ascending parietal convolution ;

c, superior parietal lobule.

conv. ; (3) centre for articulate language, on post,
part of third frontal conv. ; ^4) centre for upper
limb, at upper end of asc. frontal conv. ; (5) centre
for lower limb, on upper two-thirds of asc. parietal
conv. and part of sup. par. lobule.

Of the brain generally little has to be said. In
a surgical sense, it presents itself simply as a large
mass of soft tissue that may be damaged by shaking
as gelatine may be shaken in a case. As it is of very

32 SURGICAL APPLIED ANATOMY. [Chap. in.

yielding structure, and does not entirely fill the
cranial cavity, it may, as it were, be thrown about
within the skull, and be damage I by collision with its
walls. Of the exact mechanism of concussion or
shaking of the brain little is known, and it cannot be
said that experiments, such as those of M. Gama,
with a bulb of isinglass within a glass matrass, tend to
throw much light upon the subject. In contusion or
bruising of the brain, it is noticed that the lesion is
very much more frequently situate on the under sur-
face, both as regards the cerebrum and cerebellum,
than on any other part (Prescott Hewett). To this
statement, however, there is the striking exception
that those parts of the base of the cerebrum that
rest upon the large basal collection of the cerebro-
spinal fluid are the least often contused. These parts
include the medulla, the pons, and the interpeduncular
space.

The brain is very lavishly supplied with blood-
vessels. The main arterial trunks (vertebral and
internal carotid) are both rendered tortuous before
entering the skull, with the object probably of
diminishing the effects of the heart systole upon the
brain. On entering, they are almost immediately
blended into an anastomosing circle (circle of Willis),
which has the effect of equalising the cerebral circu-
lation. Ligature of one common carotid may produce
no effect upon the brain, although the mortality after
this operation is mainly due to cerebral complications.
One carotid and the two vertebrals would appear to be
able to bring enough blood to the brain, which blood
will be as evenly distributed as hitherto by the circle
of Willis. Both common carotids have been ligatured,
or one carotid has been secured, when its fellow of the
opposite side has been occluded by disease, and 110
marked cerebral disturbances have followed. In no
case, however, has the patient recovered when the

Chap, iv.] THE ORBIT AND EYE. 33

interval between the closing of the two vessels was
less than a few weeks. The vertebral arteries can
carry a sufficient amount of blood to the brain if only
the strain be thrown upon them gradually, and the
brain be allowed to accommodate itself slowly to the
change. Plugging of any of the smaller cerebral
arteries by emboli, as a rule, leads at once to a marked
disastrous result. Such embolism is met with in
surgery in connection with aneurism of the common
carotid. In simply examining such aneurisms, a
little piece of the clot contained in the sac has been
detached, has been carried up into the brain, and has
produced a plugging of one of the cerebral vessels.
Thus, hemiplegia has followed upon the mere exami-
nation of a carotid aneurism, as in a case recorded by
Mr. Teale, of Leeds. Fergusson's treatment of
aneurism at the root of the neck, by displacing the
clots by manipulation, has been abandoned on this
same score. In the second case treated by manipula-
tion by this surgeon, a case of subclavian aneurism,
paralysis of the left side of the body followed at once
upon the first handling of the tumour.

CHAPTER IV.

THE ORBIT AND EYE.

THE orbit. — The antero-posterior diameter of il ^
orbit is about 1| inches, its vertical diameter at the
base a little over 1|- inches, and its horizontal diameter
at the base about 1J inches. The diameters of the
globe are as follows : transverse, 1 inch ; vertical and
antero-posterior, both O96 of an inch. The eye-
ball is therefore nearer to the upper and lower

D

34 SURGICAL APPLIED ANATOMY. [Chap. iv.

margins of the orbit than it is to the sides, and the
greatest interval between the globe and the orbital
wall is on the outer side. The interior of the orbit is
most conveniently reached by incisions made to the
outer side of the globe, and, in excision of the eye-
ball, the scissors are introduced on that side when the
optic nerve has to be divided. A propos of this last
matter, it may be noted that the readiest way to
reach the nerve is to follow the line of the outer wall
of the orbit, since a continuation of that line across
the sphenoidal fissure will hit the outer rim of the
foramen. The bones forming the floor, the roof, and
the inner wall of the orbital cavity, are very thin,
especially in the last-named situation. Thus, foreign
bodies thrust into the orbit have readily penetrated
into the cranial cavity, into the nose and ethmoidal
cells, and, when directed from above, into the aiitrum.
In several instances, a sharp pointed substance, such
as the end of a stick or foil, has been thrust into the
brain through the orbit, and has left but little
external evidence of this serious lesion. Nelaton
mentions a case in which the internal carotid artery
was wounded through the orbit.

A reference to the relations of the orbital walls will
show that a tumour may readily invade the orbit by
spreading from (1) the base of the skull, (2) from the
nasal fossse, (3) from the antrum, and (4) from the
temporal or zygomatic fossse. In any of these instances
the growth may enter the ,orbit by destroying the
intervening thin layers of bone, and, in tumours of
the antrum, this is the usual mode of entry. It
may, however, extend more readily from the cranial
cavity through the optic foramen or sphenoidal fissure,
from the nose through the nasal duct, and from the
two fossa3 named through the spheno-maxillary fissure.
Distension of the frontal sinus by retained mucus or
pus may lead to a prominent tumour at the upper and

Chap, iv.] THE ORBIT AND EYE. 35

inner margin of the orbit above the level of the
tendo oculi, which may cause displacement of the
globe downwards, outwards, and forwards. The bones
of the orbit are peculiarly apt to be the seat of ivory
exostoses, which may in time entirely occupy the orbital
cavity. At the upper and outer angle of the orbit a
congenital sebaceous cyst is sometimes met with. It
lies beneath the orbicularis muscle, and is often con-
nected at some depth with the orbital periosteum.

According to most French anatomists, the orbit is
divided into two distinct spaces by a process of fascia
known as the capsule of Tenon. The descriptions,
however, of this capsule are still of the most contra-
dictory character. Viewed in its simplest aspect, it
may be said to be attached all round to the margin of
the base of the orbit, at which line of attachment it
will be found to be connected with the orbital
periosteum. It then passes backwards behind the
globe, lying close to the sclerotic, and the fibres,
coming from all parts of the orbital margin, meet at
last at the optic nerve, with the outer sheath of which
the " capsule " is continuous. As thus viewed, this
fascia forms a dome for the eye-ball, and shuts it off
from the posterior part of the orbital cavity, just as
the diaphragm shuts the liver off from the thorax.
It has been maintained that the capsule of Tenon has
great influence upon the forward progress of orbital
abscess ; but this is difficult to understand, since, at
its very best, the capsule is but a feeble membrane,
lax in its attachments, and very loose in texture. It
probably has but a trifling influence upon intra-
orbital inflammations. Between the capsule and the
sclerotic is a lymph space lined with epithelioid cells,
which, with the capsule, forms a kind of socket for
the globe in its movements.

Tenon's capsule is pierced by the ocular muscles,
to each of which it gives a process that blends with

36 SURGICAL APPLIED ANATOMY, [dap. iv.

the muscle sheath. When the insertions of the recti
muscles are divided in cases of strabismus, the capsule
is distinctly seen after the conjunctiva has been cut
through, and requires also to be divided before the
section of the muscle can be properly made. The
capsule is of some importance in this procedure.
After its division, the muscle does not entirely
retract and lie shrunken within the orbit. Its con-
nections with the capsule still give it some hold upon
the globe, and still enable it to act upon that structure.
Moreover, from the capsule, as it is reflected about
the recti muscles, four processes are given off, one
corresponding to each rectus, which are attached to
the margin of the orbit. These attachments prevent
the muscles from entirely retracting, and, even when
the globe has been removed, they give them some
basis to act upon, and thus tend to preserve some
little mobility in the stump.

The orbit behind Tenon's fascia is occupied by a
large quantity of loose fat, in addition to the ocular
muscles, the vessels, and nerves. It is by the absorp-
tion of this fat that the sunken eye is produced in
cases of emaciation and prolonged illness. This
tissue affords a ready means for the spread of orbital
abscess. Such an abscess may follow injuries,
certain ocular inflammations, periostitis, etc., or may
spread from adjacent parts. The pus may occupy the
entire cavity, displacing the eye-ball forwards, limit-
ing its movements, and causing, by interference with
the circulation, great redness of the conjunctiva and
swelling of the lids.

Foreign bodies, some of them of remarkable size
and shape, have lodged for long periods of time in
the orbital fat without causing much trouble. Thus
Lawson reports a case where a piece of an iron
hat-peg, three inches long, was embedded in the
orbit for several days without the patient being

Chap, iv.] THE ORBIT AND EYE. 37

aware of it. A stranger case, in some ways, is that
reported by Furneaux Jordan : "A man, who was
employed in threshing, became the subject of severe
ophthalmia. At the expiration of several weeks, the
patient, whilst pressing his finger on the lower eyelid,
suddenly ejected from a comfortable bed of warm pus
a grain of wheat, which had shot forth a vigorous
green sprout." The orbital fat affords also an excel-
lent nidus for growing tumours. Fractures of the
inner wall of the orbit involving the nasal foss?e or
sinuses, may lead to extensive emphysema of the orbital
cellular tissue. The air so introduced may cause the
globe to protrude, may limit it's movements, may
spread to the lids, and will, in any case, be increased
in amount by blowing the nose, etc.

The orbital arteries are small, and seldom give
rise to trouble when divided in excising the globe,
since they can be readily compressed against the bony
walls of the cavity. Pulsating tumours of this part
may be due to traumatic aneurisms of one of the
orbital arteries, or may depend upon an arterio-venous
aneurism formed between the internal carotid artery
and the cavernous sinus. Pressure also upon the
ophthalmic vein (as it enters the sinus), by an aneurism
of the internal carotid vessel, may produce all
the symptoms associated with pulsating orbital
tumours.

The orbital nerves may be damaged in wounds
of the orbit, or in fractures of the orbit and of the
base of the skull. They may be pressed upon by
tumours from various parts, by aneurisms, hseniorr-
hagic and inflammatory effusions. Thus Lawson re-
cords a case in which the optic nerve was divided by a
stab through the upper eyelid, without the globe being
injured, and without any bone being fractured. The
same nerve has also been completely torn across in
fractures of the orbit, and has been pressed upon in

38 SURGICAL APPLIED ANATOMY. [Chap. iv.

fractures involving the lesser wing of the sphenoid.
The third, fourth, and sixth nerves, and the first divi-
sion of the fifth, may be affected in cases of aneurism
involving the internal carotid artery, where they lie in
relation with the cavernous sinus. They may readily
be pressed upon, also, by any growth involving the
sphenoidal fissure, such as a periosteal node springing
from the margin of the fissure, while the sixth nerve,
from its more intimate connection with the base of the
skull, has been directly torn across in a fracture in-
volving that part (Prescott Hewett).

In paralysis of the third nerve there is
drooping of the upper lid (ptosis) ; the eye is almost
motionless, presents a divergent squint from unop-
posed action of the external rectus muscle, and cannot
be moved either inwards, upwards, or directly down-
wards. Rotation, in a direction downwards and out-
wards, can still be effected by the superior oblique and
outer rectus muscles. The pupil is dilated and fixed ;
the power of accommodation is much impaired, there
is diplopia, and sometimes a little protrusion of the
globe from relaxation of the recti muscles. These
symptoms refer to complete paralysis of the nerve.
In cases of partial paralysis, only one or two of the
above symptoms may be present.

In paralysis of the fourth nerve there is often
but little change to be seen, since the function of the
superior oblique muscle, supplied by this nerve, may,
in part, be performed vicariously. " There is usually
only very slight defect in the mobility of the eye ;
what there is occurs chiefly in the inner and lower
angle of the field of vision ; there is deviation of the
eye inwards and upwards on lowering the object,
and simply upwards when it is turned far towards
the healthy side" (Erb). In any case there will
be diplopia, especially in certain positions of the
globe.

Chap. iv. j THE ORBIT AND EYE. 39

In paralysis of the sixth nerve there is con-
vergent strabismus, with consequent diplopia, and an
inability to rotate the eye directly outwards.

In paralysis of the first division of the fifth

there is a loss of sensation in all the conjunctiva, except
such as covers the lower lid (supplied by the palpebral
branch of the infraorbital nerve), loss of sensation in
the globe, and in the skin supplied by the supratrochlear
and supraorbital nerves, and in the mucous and cuta-
neous surfaces supplied by the nasal nerve. No reflex
movements (winking) follow upon irritation of the
conj unctiva, although the patient can be made to wink
on exposing the eye to a strong light, the optic nerve
in this case transmitting the impression to the facial
nerve. Sneezing also cannot be excited by irritating
the mucous membrane in the anterior part of the nose.
Destructive ulceration of the cornea may follow this
paralysis, due partly to damage to the trophic branches
contained in the paralysed nerve, partly to the anaes-
thesia which renders the part readily injured, and
partly to the loss of the reflex effect of the sensory
nerves upon the calibre of the blood-vessels, whereby
the inflammation is permitted to go uncontrolled
(Nefctleship).

In paralysis of the cervical sympathetic
there is narrowing of the palpebral fissure from
some drooping of the upper lid, apparent recession
of the globe within the orbit, and some narrow-
ing of the pupil from paralysis of the dilator
muscle of the iris, which muscle is supplied by the
sympathetic. The drooping of the upper lid may be
explained by the fact that each eyelid contains a layer
of unstriated muscle fibre. That in the upper lid arises
from the under surface of the levator palpebrse, and
is attached to the tarsal cartilage near its upper mar-
gin (Fig. 11). This layer of muscle, which, when in
action, would keep up the lid, is under the influence of

40 SURGICAL APPLIED ANATOMY. [Chap. iv.

the cervical sympathetic. The recession of the globe
is supposed by some to be due to paralysis of the
orbitalis muscle of H. Mtiller. This muscle bridges
over the spheno-maxillary fissure, is composed of
unstriated fibres, and is innervated by the sympathetic.
Contraction of the muscle (as produced by irritation
of the cervical sympathetic in animals) causes pro-
trusion of the globe, while section of the sympathetic
in the neck produces retraction of the eye-ball (01.
Bernard). No changes are observed in the calibre
of the blood-vessels of the globe.

The globe ; the cornea.— The thickness of the
cornea varies from -£% to -i- of an inch. One is
apt to be a little deceived as to its thickness,
and on introducing a knife into the cornea, the
instrument, if not entered at the proper angle, may
be thrust for some little distance among the laminae
of the part. In front the cornea is covered by
stratified epithelium. When this layer has been
removed by abrasion, a white deposit of lead salts may
take place in the exposed corneal tissue in cases where
lead lotions are used. The bulk of the cornea is made
up of a great number of fibrous lamellae, between
which are anastomosing cell-spaces containing the
corneal corpuscles. If the nozzle of a fine syringe
be thrust into the corneal tissue, the network of cell
spaces can be filled with injection (Recklinghausen's
canals). When suppuration takes place within the
proper corneal tissue, it is probably along these canals,
modified by inflammation, that the pus spreads, thus
producing onyx. The cornea contains no trace of
blood-vessels, except at its extreme periphery, where
the capillaries of the sclerotic and conjunctiva end in
loops. This lack of a direct blood-supply renders
the cornea prone to inflame spontaneously in the
cachectic and ill-nourished. When inflamed, the tissue
always becomes opaque. In the affection known as

Chap. IV.]

THE ORBIT AND EYE.

interstitial keratitis, blood-vessels from the arteries at
the margin of the cornea penetrate into the substance
of the cornea for some distance. As these vessels will be
some little way below the surface, and will be covered
by the hazy coriieal tissue that is the result of the
disease, their scarlet colour is much toned down, and
a strand of such vessels is called a " salmon patch."
In the condition known as pamius, the cornea

Fig. 9. — A Horizontal Section of the Globe through the middle.

a, Cornea ; 5, sclerotic ; c, choroid ; d, retina ; e, lens ; /, iris ; g, ciliary process ;
n, canal of Schlemm.

appears to be vascularised ; but here, owing to con-
tinued irritation, vessels, derived from the neighbour-
ing conjunctival arteries, pass over the cornea just
beneath its ephethelial covering, leaving the cornea
proper as bloodless as ever. The term arcus senilis is
applied to two narrow white crescents that appear at
the periphery of the cornea, just within its margin, in
the aged, and in certain morbid conditions. The

42 SURGICAL APPLIED ANATOMY. [Chap. iv.

crescents are placed at the upper and lower margins,
and their points meet midway on either side of the
cornea. They are due to fatty degeneration of the
corneal tissue, and the change is most marked in the
layers of the cornea just beneath the anterior elastic
lamina, i.e., in the part most influenced by the marginal
blood-vessels. In. spite of its lack of a direct blood-
supply, wounds of the cornea heal kindly. The cornea
is very lavishly supplied with nerves, estimated to
be from forty to forty-five in number. They are
derived from the ciliary nerves, enter the cornea
through the fore part of the sclerotic, and are dis-
tributed to every part of the tunic. In glaucoma,
a disease the phenomena of which depend upon greatly
increased intraocular pressure, the cornea becomes
ansesthetic. This depends upon the pressure to which
the ciliary nerves are exposed before their branches
reach the cornea. (See also Nerve supply of the eye-
ball, page 47.)

The sclerotic, choroid, and iris. — The sclerotic
is thickest behind, and thinnest about a quarter of
an inch from the cornea. When the globe is ruptured
by violence it is the sclerotic that most commonly
yields, the rent being most usually a little way from
the cornea, i.e., in or about the thinnest part of the
tunic. A rupture of the cornea alone from violence
is not common. The sclerotic may be ruptured while
the lax conjunctiva over it remains untorn. In such
a case the lens may escape through the rent in the
sclerotic, and be found under the conjunctiva. It is
mainly to the denseness and unyielding character of the
sclerotic that must be ascribed the severe pain (due to
pressure on nerves) experienced in those eye affections
associated with increased intraocular tension (glaucoma,
etc.). The choroid is the vascular tunic of the globe, and
carries its main blood-vessels. Between the choroid
and sclerotic are two thin membranes, the lamina

Chap, iv.] THE ORBIT AND EYE. 43

suprachoroidea and lamina fusea, Y/hich are separated
from one another vb}v;a lyi^ph' spaie. In injuries to
the globe, therefore, extensive bleeding may take place
between the'so^twb' epdts,' and ihdeed' a lilte hs&ncrr-
be' th'ev r^Jtoft sinipiy pi* ,a sucf

hage may be' th'ev r^Jtoft sinipiy pi* ,a sucfd'ei)
in the ocular tension produced by such an operation
as iridectomy or cataract extraction. The choroid
alone has been ruptured (usually at its posterior part)
as the result of a blow upon the front of the eye.
The choroid is one of the few parts of the body that
may be the seat of melanotic growths. These growths
are sarcomatous tumours containing a large amount
of pigment, and occur only where pigment cells are
found. In the choroid coat pigment cells are very
abundant. The iris is, from its great vascularity,
very easily inflamed. From its relations to the cornea
and sclerotic it happens that inflammation in those
tunics can spread without difficulty to the iris. On
the other hand, the vessels of the iris and choroid are
so intimately related that inflammations set up in the
iris itself have every inducement to spread to the
choroidal tunic. When the iris is inflamed its colour
becomes altered, owing to the congestion of the part
and to the effusion of lymph and serum that takes
place in its substance. The swelling to which it
becomes subject, together with the effusion, produce a
blurring of its delicate reticulated structure, as seen
through the cornea. Owing also to the swollen con-
dition of the little membrane, the pupil becomes
encroached on, and appears to be contracted, while the
movements of the membrane are necessarily rendered
very sluggish. If it be remembered that the greater
part of the posterior surface of the iris is in actual
contact with the lens capsule, it will be understood
that inflammatory adhesions may readily take place
between the two parts (Fig. 10). After iritis, therefore,
it is common to find the posterior surface of the iris

44 SURGICAL APPLIED ANATOMY. [Chap. iv.

(most often ii^ papillary margin) ?,dherent to the lens
cr^ule, by^bands af ; ly,inpSif eitiier entirely or in one
or moi'u different points. Such adhesions constitute
-p93,teriQr; sj^ie^hioB, the tterm . a;nte);iof , yynechise being
jappiiedj. to .adhesions ,betwetei^ she iris arid the cornea.
In iritis also the lens may become involved, and the
condition of secondary or inflammatory cataract be
produced. The iris is not very closely attached at its
insertion. Thus, in cases of injury to the eye, it may
be torn more or less from its attachments without
any damage being done to the other tunics. In one
method of making an artificial pupil, known as
iridodyalisis, the iris is seized close to its greater
circumference by a pair of forceps, and a gap made by
forcibly tearing it away from its insertion. In
cases of penetrating wounds of the cornea the
iris is easily prolapsed. It is so delicate and
yielding a membrane, that in performing iridec-
tomy the necessary piece of the iris can be
seized and pulled out through the cornea! incision
without offering sensible resistance. The membrane
also derives much support from its contact with the
lens, for in cases where the lens has been displaced into
the vitreous or has been removed by operation, the
iris is observed to be tremulous when the globe is
moved. Although very vascular, the iris seldom
bleeds much when cut, a circumstance that is pro-
bably due to the contraction of the muscular fibres
that exist so plentifully within it. Sometimes the
iris presents a congenital gap in its substance that
runs from the pupil downwards and a little inwards.
.This condition is known as coloboma iridis, and is due
to the persistence of the " choroidal cleft." In other
cases there can be seen, stretching across the pupil,
some shreds of the pupillary membrane. Normally
this membrane, which is apparent for a few days after
birth in some animals, is entirely absorbed before birth.

chap, iv.] THE ORBIT AND EYE. 45

It will now be convenient to take note of the
blood and nerve supply of the globe.

Blood supply of the eye-ball. — 1. The short
ciliary arteries (from the ophthalmic) pierce the sclerotic
close to the optic nerve, run some little way in the
outer coat of the choroid, and then break up into a
capillary plexus that makes up the main part of the
inner choroidal coat. In front this plexus gives some
vessels to the ciliary processes. The veins from these
vessels are disposed in curves as they converge to four
or five main trunks (vense vorticosse), which pierce the
sclerotic midway between the cornea and the optic
nerve. In the choroid they lie external to the
arteries.

2. The two long ciliary arteries (from the
ophthalmic) pierce the sclerotic to the outer side
of the optic nerve, and run forwards, one on either
side, until they reach the ciliary region, where they
break up into branches that, by anastomosing, form a
vascular circle about the periphery of the iris (the
circulus major). From this circle some branches pass
to the ciliary muscle, while the rest run in the iris in
a converging manner towards the pupil, and at the
margin of the pupil form a second circle (the circulus
minor).

3. The anterior ciliary arteries (from the muscular
and lachrymal branches of the ophthalmic) pierce
the sclerotic (perforating branches) about a line
behind the cornea, join the circulus major, and give off
branches to the ciliary processes, where they form
copious anastomosing loops. These arteries lie in the
sub-conjunctival tissue. Their episcleral, or non-per-
forating branches, are very small and numerous, and ;
are invisible in the normal state of the eye. In.
inflammation, however, of the iris and adjacent parts,
these vessels appear as a narrow pink zone of fine
vessels round the margin of the cornea, that run

46 SURGICAL APPLIED ANATOMY. [Chap. iv.

nearly parallel to one another, are very closely set,
and do not move with the conjunctiva. This zone is
known as the zone of ciliary congestion, or the circum-
corneal zone.

4. The vessels of the conjunctiva are derived from
"the lachrymal and two palpebral arteries. These
vessels, in cases of inflammation, are readily dis-
tinguished from those last described. They are of
comparatively large size, are tortuous, are of a bright
brick-red colour, can be easily moved with the con-
junctiva, and as easily emptied of their blood by
pressure. The differences presented by these two
sets of vessels serve in one way to distinguish in-
flammation of the conjunctiva from that involving
deeper parts. The conjunctival vessels around the
margin of the cornea form a closer plexus of anasto-
mosing capillary loops, which become congested in
severe superficial inflammation of the cornea, and
may then form a zone around the margin of the
cornea, which can, however, be distinguished from
the " ciliary zone " by the general characters just
named. The retina has a vascular system of its own,
supplied through the arteria centralis retince, which is
nowhere in direct communication with the choroidal
vessels, except just at the entrance of the optic nerve.
Indeed, the outer layers of the retina which are in
relation with the choroid coat are entirely destitute of
vessels. Thus, when the central artery of the retina
becomes plugged, sudden blindness follows, and as the
meagre collateral circulation that is established by the
minute anastomoses about the entrance of the nerve
is quite insufficient, the retina soon becomes oedema-
tous and inflamed. A permanent plugging of the
central artery means, therefore, a practical extinction
of the vascular system of the retina.

In cases of haemorrhage between the choroid and
retina the blood must come from the choroidal vessels ;

Chap, iv.] THE ORBIT AND EYE. 47

and in haemorrhage into the vitreous, which often
follows injury, the blood may be derived from the
retinal vessels, since they run in the inner layers of
that membrane, or from the vessels in the ciliary
region.

Nerve supply of the eye-ball. — 1. The ciliary
nerves derived from the lenticular ganglion and the
nasal nerve pierce the sclerotic close to the optic nerve,
and pass forwards between the sclerotic and the
choroid, supplying those parts. They enter the ciliary
muscle, form a plexus about the periphery of the iris,
and then send fibres into the iris, which form a fine
plexus as far as the pupil. They send branches through
the fore part of the sclerotic to the cornea. Thus the
eye-ball obtains through these nerves its sensory fibres
from the nasal branch of the first division of the fifth,
its motor fibres for the ciliary muscle and sphincter
iridis from the third nerve, and many sympathetic
fibres, among which are those that supply the dilator
muscle of the iris. 2. The conjunctiva is supplied by
four nerves : above, the supratrochlear ; on the inner
side, the infratrochlear ; on the outer side, the lachry-
mal (all branches of the first division of the fifth) ; and
below by the palpebral branches of the second division
of the fifth. As the ciliary nerves pass forwards
between the choroid and the sclerotic, it will be seen
that they are readily exposed to injurious pressure
against the unyielding sclerotic in cases of increased
intraocular tension.

The sensation of the globe itself is derived
solely from the first division of the fifth. In inflam-
matory affections of the globe, as in corneitis or iritis,
besides the pain actually felt in the eye, there is
pain referred along other branches of the first division
of the fifth. There is pain over the forehead along the
supratrochlear, supraorbital, and lachrymal branches
(circum-orbital pain), and pain down the side of the

48 SURGICAL APPLIED ANATOMY. [Chap. iv.

nose following the nasal nerve. Or the pain may spread
to the second division of the fifth, and discomfort be
felt in the temporal region (orbital branch of second
division), or be referred to the upper jaw and upper
teeth. These affections are associated also with much
lachrymation, the lachrymal gland being also supplied
through the first division of the fifth. Photophobia,
or intolerance of light, is common in inflammatory
affections of the eye. In this condition there is spasm
of the orbicular muscle, keeping the eye closed, or
closing it on the least exposure to irritation. Here
the nerve most active is the branch of the facial to
the orbicularis, and the reflex irritation reaches that
nerve either through the branches of the fifth in the
cornea and conjunctiva, or through the disturbed
optic nerve. Photophobia is most marked in super-
ficial affections of the cornea, and is often much
benefited by a seton in the temporal region. This
acts apparently by counter -irritation of another
division (the second) of the fifth nerve supplied to
the region of the temple, The relations between
the nasal nerve and the orbital contents receive
many illustrations in practice. Thus, if the front
of the nose be struck, or the skin over its lower
part be irritated, as by squeezing a painful boil,
profuse lachrymation will frequently be produced.
Snuff, too, by stimulating the nasal branch of the
ophthalmic nerve, often makes the eyes of the un-
initiated to water ; and it is well known that there are
many disturbances about the nose, and the anterior
part of the nasal fossae, that can "make the eyes
water." Herpes zoster often provides a remarkable
illustration of the iutimate relation between the nasal
nerve and the eye. In this affection, when the regions
of the supraorbital and supratrochlear branches of the
first division are alone implicated, the eye is usually
unaffected ; but when the eruption extends over the

Chap, iv.] THE ORBIT AND EYE. 49

part supplied by the nasal nerve, i.e., runs down the
side of the nose, then there is very commonly some
inflammation of the eye-ball. In frontal neuralgia
watering of the eye (irritation of the lachrymal branch)
is very frequently met with.

The dangerous area of the eye. — Pene-
trating wounds of the cornea alone, or of the sclerotic
alone, behind the ciliary region, are by no means
serious • but wounds involving the ciliary body, or its
immediate vicinity, are apt to assume the gravest
characters. Inflammation in the ciliary region is
peculiarly obnoxious, on account of the important
vascular and nerve anastomoses that take place in the
part. Indeed, as regards blood and nerve supply, there
is no more important district in the eye-ball. From
the ciliary body also inflammations can spread, more
or less, directly to the cornea, iris, choroid, vitreous,
and retina. Plastic, or purulent inflammation of the
ciliary body, after injury, is the usual starting point
of sympathetic ophthalmia. In this terrible affection
destructive inflammation is set up in the sound eye,
which is, however, not usually involved until two or
three months after the other eye has been injured.
u Although at present the exact nature of the process
which causes sympathetic inflammation is unknown,
and though its path has not been fully traced out, it is
certain (1) that the change starts from the region
most richly supplied by branches of the ciliary nerves,
viz., the ciliary body and iris ; (2) that its first effects
are generally seen in the same part of the sympathising
eye ; (3) that the exciting eye has nearly always been
wounded, and in its anterior part ; and that decided
plastic inflammation of its uveal tract is always
present ; (4) that inflammatory changes have in some
cases been found in the ciliary nerves and optic nerve
of the exciting eye. The morbid influence has of late
years been generally believed to pass along the ciliary

50 SURGICAL APPLIED ANATOMY. [Chap. iv.

nerves, but the earlier hypothesis of transmission
along the optic nerve has recently been revived, and
further, the blood-vessels, lymphatics, and even the
blood itself, are, at the present time, claimed by
different authors as probable channels " (Nettleship).

The lens measures \ of an inch from side to side,
and ~oi an inch from before backwards. It, together
with its capsule, is in all parts perfectly transparent
and perfectly non-vascular. The lens may easily be
loosened or displaced by partial rupture of its
suspensory ligament, and may find its way into the
anterior chamber, or, more commonly, back into the
vitreous. The lens, if disturbed, may swell, and by
the pressure thus exercised cause great damage to the
important structures adjacent to it. The capsule is
very brittle and elastic, and when torn its edges curl
outwards. It has to be lacerated in all cataract opera-
tions, and may be ruptured by many forms of violence
applied to the eye-ball. When the capsule is wounded
the aqueous humour enters, and is imbibed by the
lens fibres, which in consequence swell up, and become
opaque, thus producing a traumatic cataract. In the
various forms of cataract the whole lens, or, more
commonly, some portion of it, becomes the seat of
opacity. This often commences in the nucleus, and
for a long while remains limited to that part ; or it
may first involve the cortex, and in such a case the
opacity takes the form of a series of streaks that point
towards the axis of the lens, and are dependent upon
the arrangement of the lens fibres.

Of the retina it is only necessary to observe that
its connection with 'the choroid is so slight that it
may easily be detached from that membrane by
haemorrhagic, or other effusions, and may indeed be so
detached by a simple blow upon the globe. Even
when extensively detached it remains, however, as
a rule, attached at both the optic disc and the ora

Chap, iv.] THE ORBIT AND EYE. 51

serrata. The optic nerve as it passes from the brain
receives its perineural sheath from the pia mater, and,
in addition, two other sheaths ; an outer from the
dura mater, and an inner from the arachnoid. These
sheaths remain distinct and separate, and the two
spaces enclosed may be injected, the outer from the sub-
dural, the inner from the subarachnoid space. Thus
inflammatory affections of the cerebral meninges can
readily extend along the optic nerve to the optic disc
through these spaces in the nerve sheath, while in
cases of intracranial disease other than meningeal. the
mischief may extend from the brain to the disc along
the interstitial connective tissue in the nerve. These
connections may serve in part to explain the frequent
association of optic neuritis with intracranial disease.

The aqueous and vitreous humours. —
The aqueous fills the space between the capsule and
suspensory ligament of the lens and the cornea. The
iris divides this space into two parts, the anterior
and posterior chambers. Since, however, the iris is
largely in actual contact with the lens, it happens
that the posterior chamber is represented by a little
angular interval between the iris, the ciliary processes,
and the zonula of the lens (Fig. 10). The cornea at
its circumference breaks up into bundles of fibres,
which are partly continued into the front of the iris,
and which constitute the ligamentum pectinatum
iridis. Between the processes of this ligament there
are intervals which lead into certain cavernous spaces
called the spaces of Fontana. These spaces in their
turn communicate with a large circular canal situate
in the sclerotic close to its junction with the cornea,
and known as the canal of Schlemm. This space is
in communication with the veins of the anterior part
of the sclerotic,* and thus through this somewhat

* The precise manner in which these spaces communicate with
the neighbouring veins has not been demon stratedhistologically. The
statement is founded mainly upon the experiments of Schwalbe.

SURGICAL APPLIED ANA TO MY. [Chap. iv.

complicated channel the aqueous chamber is brought
into relation with the venous circulation. This relation
probably explains the ready absorptive powers of the

aqueous. Thus,
if pus finds its
way into the
anterior cham-
ber (hypopyon)
it is usually
readily absorb-
ed. The same
applies to mode-
rate extravasa-
tions of blood
in the chamber,
and the speedy
removal of such
effusions con-
trasts with the
difficulty that is
experienced in
the absorption
of blood from

Fig. 10.— Section of Globe, showing Iris, Lens the vitreOUS

Ciliary Region, etc. (After Allen Thomson.) chamber. The

a, Cornea; 6, sclerotic; c, lens ; d.iris; e, ciliary process ; , , £ f,

f, conjunctiva ; g, canal of Sehlemm ; h, canal of Petit ; treatment OI SOlt
i, anterior marpiu of vitreous humour ; j, choroid , , -• ,1

covered by retina ; k, aqueous chamber. Cataracts by the

" needle opera-
tion" depends for its success upon the absorptive
powers of the aqueous. In this procedure, the
lens capsule having been torn through, and the
cataract broken up with needles, the removal of the
opaque debris is left to the aqueous, and it is not long
before its efficacy in that direction is seen.

The vitreous takes little active share in ocular
maladies. It maybe secondarily affected in ^inflamma-
tion of adjacent parts, may be the seat of haemorrhages,

chap. iv. j THE ORBIT AND EYE. 53

and is often occupied by opaque bodies of various
kinds. Foreign bodies have lodged in the vitreous
for considerable periods without causing any symp-
toms. The muscse volitantes that so often trouble the
myopic are due to little opaque matters in the vitreous,
and very often have exactly the appearance that the
corpuscles of the vitreous present when seen under the
microscope.

The vitreous is readily separated from the retina
except behind, opposite the disc where the artery to
the lens enters in the foetus.

Glaucoma is a disease the symptoms of which
are all dependent upon an increase in the intraocular
tension of the globe. The increased tension is due
to an excess of fluid within the eye-ball, and this would
appear to be due to certain changes, seldom absent
in the glaucomatous, that interfere with the normal
escape of this fluid. Normally there is a constant
movement of fluid from the vitreous through the
suspensory ligament into the posterior chamber, and
thence round the pupillary margin of the iris to the
anterior chamber. From the anterior chamber the fluid
can escape into the veins through the gaps in the liga-
mentum pectinatum already alluded to (Fig. 10). It is
remarkable that in nearly every case of glaucoma these
gaps are occluded by the complete obliteration of the
angle between the periphery of the iris and the cornea,
which angle is normally occupied by the ligamentum
pectinatum. The relief given to glaucoma by iri-
dectomy appears to depend upon the circumstance
that the operation practically opens up again these
channels of communication from the aqueous, since
the procedure, to be successful, should involve an in-
cision so far back on the sclerotic as to fully pass
through the angle just alluded to. It is needful also
that the iris should be removed quite up to its at-
tachment, and that the portion resected should be

54 SURGICAL APPLIED ANATOMY. [Chap. iv.

considerable. The symptoms of glaucoma are all
explained by the effects of the abnormal tension. Thus,
the ciliary nerves are compressed against the unyield-
ing sclerotic, and give rise to intense pain, while the
disturbance in their function shows itself in the fixed
and dilated pupil and in the anaesthetic cornea.
Perhaps the first parts to suffer from compression are
the retinal blood-vessels, and the effect upon them will
be most obvious at the periphery of the retina, i.e.,
at the extreme limit of the retinal circulation. Hence
follows that gradually narrowing of the visual field
which is constant in glaucoma, while the pressure
upon the optic nerve produces those flashes of light
and other spectra which occur in the disease. The
weakest part of the sclerotic is at the disc at the
lamina cribrosa. This part rapidly yields under the
pressure, and so produces the " glaucomatous cup."
Pressure in the opposite direction pushes the lens
forward, and thus narrows the anterior chamber ;
while the general interference with the ocular circula-
tion is shown in the distended vessels that appear
upon the globe.

The eyelids. — The skin over the eyelids is ex-
tremely thin and delicate, and shows readily through
its substance any extravasation of blood that may
form beneath it. Its laxity, moreover, renders it very
well adapted for certain plastic operations that are
performed upon the part. Its loose attachments
cause it to be readily influenced by traction, and the
shrinking of cicatrices below the lower lid is very apt
to draw that fold away from the globe, and so produce
the condition of eversion of the lid known as ectropion.
The contraction of the conjunctiva after inflammatory
conditions, or after it has been subjected to destructive
agencies, is prone, on the other hand, to curl either lid
inwards towards the globe, and to thus produce entro-
pion. The lids present many transverse folds ; one of

Chap. IV.]

THE ORBIT AND EYE.

55

these on the upper lid, deeper and more marked than

the rest, divides the lid into two parts, the part below

being that that covers the globe, the part above being

that in relation with the

soft structures of the

orbit. In emaciation

the lid becomes much .

sunken in the line of "*

this fold. Incisions

should follow the direc-

tion of these folds. The

lids are very freely sup-

plied with blood, and

are often the seat of

nsevi and other vascular

growths. Rodent ulcer

so frequently attacks this

part that it was origi-

nally known as " Jacob's

ulcer of the eyelid."

The following layers
are found in either lid
in order : (1) The skin;
(2) the subcutaneous
tissue; (3) the orbicu-
laris palpeferarum ; (4)
the tarsal cartilage and
ligament ; (5) the layer
of Meibomian glands ;
and (6) the conjunctiva. ri?; 11<^e^ti1c/,r1,

\ ' J Upper Eyelid. (After Waldeyer.

In the upper lid the

a

18

Skin; 6% orbicularis6,>its ciliary part.

c» involuntary muscle of eyelid ; d, con-
junctiva; «, tarsal cartilage; /, Meibo-
raian gland ; g, modified sweat gland;
h, eyelashes ; { post tarsal glands.

fnnnrl TVTQcn'rxr ir\ fLa
tlie

tarsal cartilage. The
subcutaneous tissue is very lax, and hence the lids
swell greatly when osdematous, or when inflamed,
and when the seat of hsemorrhai^e. On this

56 SURGICAL APPLIED ANATOMY. [Chap. iv.

account it is inadvisable to apply leeches to the
lids, on account of the extensive " black eye" that
may follow. This tissue is peculiar in containing no
fat. At the edge of the lids are found the eyelashes,
the orifices of the Meibomian glands, and of some
modified sweat and sebaceous glands. This edge, like
other points of junction of skin and mucous mem-
brane, is apt to be the seat of irritative affections.
Being a free border also, the circulation is terminal,
and stagnation in the blood current is not difficult to
produce. Sycosis, an inflammation involving the
hair follicles and some of the glands at the edge of the
lid, is among the most common of ophthalmic affec-
tions. The common stye also is a suppuration in the
connective tissue or in one of the glands at the
margin. On everting the lid the Meibomian glands
can be seen through the conjunctiva as lines of
yellowish granules. The common tarsal cyst is a
retention cyst developed in one of these glands.

The conjunctiva. — The ocular part of this
membrane is thin, very loosely attached, and not very
extensively supplied with blood ; the palpebral portion
is thicker, more closely adherent, and more vascular.
At the edge of the cornea the conjunctiva becomes
continuous with the epithelium covering that tunic.
The looseness of the ocular conjunctiva allows it to be
freely moved about, and is of great value in some
operations : as, for example, in Teale's operation for
symblepharon, where a bridge of conjunctiva, dis-
sected up from the globe above the cornea, is drawn
down over the cornea to cover a raw surface in
contact with the lower lid. This lax tissue favours
the development of oedema (chemosis), which in
extreme cases may reach such a degree that the patient
cannot close his eye. The vessels also, being feebly
supported, are prone to give way under no great
provocation. Thus, subconjunctival haemorrhages may

Chap, iv.] THE ORBIT AND EYE. 57

occur from severe vomiting, or during a paroxysm of
whooping cough. Blood also may find its way beneath
the membrane in fractures of the base of the skull.
Haemorrhages beneath the membrane are unlike other
extravasations "(bruises), in that they retain their
scarlet colour. This is due to the fact that the
thinness of the conjunctiva allows oxygen to reach the
blood and retain for it an arterial character. Severe
inflammation of the conjunctiva may lead to con-
siderable cicatricial changes, as is the case in other
mucous membranes, and especially, perhaps, in the
urethra. The contraction of the conjunctiva after
destructive processes is apt to lead to entropion. If
both the ocular and the corresponding part of the
palpebral conjunctiva have been destroyed, the two
raw surfaces left will readily adhere; the lid will
become fused to the globe, and the condition called
symblepharon be produced. This condition concerns
the lower lid, and is generally brought about by lime
or other caustics being accidentally introduced be-
tween the under lid and the globe.

In one common form of inflammation of this
membrane a number of little "granulations" appear
upon the palpebral conjunctiva. These are not
real granulations, since no true ulceration of the
part takes place, but they appear to be made up,
some of nodules of adenoid tissue, others of en-
larged mucous follicles and of hypertrophied papillae,
all of which structures are normally found in the
membrane. The condition is known as " granular
lids," and is associated with the formation of much
new tissue in the deeper parts of the membrane.
From the absorption of this new tissue and of
these granulations a contracting cicatrix results,
leading to much puckering of the membrane, and
often to entropion and inversion of the eyelashes.
In purulent ophthalmia the cornea is in great risk of

58 . SURGICAL APPLIED ANATOMY. [Chap. iv.

destruction, owing to the strangulation of its vessels,
and to the effects possibly of the discharge directly
upon the membrane.

The lachrymal apparatus. — The lachrymal
gland is invested by a special fascia which separates
it from the general cavity of the orbit ; and, according
to Tillaux, this little body can be removed without
opening the greater space of the orbit. The gland
may inflame, and become so enlarged as to appear as
a tumour, which may displace the globe downwards
and inwards, and press forwards the oculo-palpebral
fold of conjunctiva. If an abscess forms, it most
usually breaks through the skin of the upper lid.
Cysts of the gland (dacryops) are due to obstruction
and distension of some of its ducts.

The lachrymal sac is situated at the side of the
nose, near the inner canthus, and lies in a groove on
the lachrymal and superior maxillary bones. On its
outer side, and a little anteriorly, it receives the
lachrymal canals. In front of the sac is the tendo oculi.
If the two lids be forcibly drawn outwards this tendon
can be readily felt and seen, and is the great guide to
the sac. It can also be felt as it is tightened, when the
lids are firmly closed. It crosses the sac at right angles,
and at about the junction of its upper third with its
lower two- thirds. A knife entered immediately below
the tendon would about open the middle of the sac, and
it may be noted that a lachrymal abscess, when about to
discharge, always points below the tendon. Epiphora,
or overflow of tears, is due in the main to two causes :
(1) To an obstruction in any part of the lachrymal
passages from the puncta to the opening of the nasal
duct in the nose ; (2) to any cause that removes the
lower punctum from its contact with the globe, as
may be the case in ectropion, in entropion, in
swelling of the lower lid, etc. Facial palsy causes
epiphora, because, the orbicular muscle being relaxed,

Chap, v.] THE EAR. 59

the punctum falls away from the globe, and, moreover,
the passage of the tears is no longer aided by the
suction action effected by the muscle in the process of
winking. The canaliculi may readily be slit up by
a proper knife, and a probe can without difficulty be
passed down the nasal duct from the lachrymal sac.
The duct is a little over half an inch in length, and
the probe that traverses it should pass downwards,
and a little backwards and outwards.

As affections of the lachrymal sac are often very
painful, it may be noted that the nerve supply of the
sac is derived from the infratrochlear branch of the
nasal nerve.

CHAPTER V.

THE EAR.

THE pinna and external auditory meatus.

— The pinna may be congenitally absent, or may be
supplemented by supernumerary portions of the
auricle, which may be situated upon the cheek or
side of the neck. In the latter situation they are
sometimes found at the hinder part of a " branchial
fistula." (See page 146.) The pinna may present a con-
genital fistula, which is due to defective closure of the
first visceral cleft. This cleft is represented in the
normal ear by the Eustachian tube, the tympanum,
and the external auditory meatus, the pinna being
developed from the integument behind the cleft.
In these congenital fistulse, when well marked, -
the pinna is cleft just in front of the tragus, or
through the helix, and there is more or less failure in
the closing of the meatus and tympanum, while the
membrana tympani will be more or less deficient, or

60 SURGICAL APPLIED ANATOMY. [Chap. v.

entirely absent. In other cases the " fistula " appears
merely as a narrow sinus or a depression, running
through and from the helix. Accidental removal of
the pinna is usually associated with but comparatively
little diminution in the acuteness of hearing.

The skin covering the auricle is thin and closely
adherent. The subcutaneous tissue is scanty, and
contains but very little fat. In inflammatory condi-
tions of the surface, such as erysipelas, the pinna may
become extremely swollen and very great pain be
produced from the tenseness of the parts. The pinna
and cartilaginous meatus are very firmly attached to
the skull, so that the body, if not of great weight,
may be lifted from the ground by the ears.

In chronic gout, little deposits of urate of soda
(called tophi) are often met with in the pinna, and are
usually placed in the subcutaneous tissue at the edge
of the helix. M. Paul has pointed out that, when
ear-rings are worn, the usual hole made by the ring
may become converted into a vertical slit, or the ear-
ring ,may cut its way out, leaving a slit in the lobule.
This it may do several times if re-applied, thus pro-
ducing many slits in the same lobule. He considers
such conditions as absolutely diagnostic of scrofula.*

The external auditory meatus is about 1J
inches long. It is directed forwards and inwards,
having the same direction as the petrous bone. The
external meatus, the promontory, the cochlea, and the
internal meatus lie nearly in the same line. The
canal has a vertical curve about its middle, with the
convexity upwards. To straighten the canal for the
introduction of specula and other instruments, the
pinna should be drawn upwards and a little outwards
and backwards. The osseous part forms a little more
than one-half of the tube, and is narrower than the

* See "Scrofula and its Gland Diseases," by the Author.
Loud., 1882.

Chap. V.]

THE EAR.

61

cartilaginous part. The narrowest portion of the
meatus is about its middle. The outer orifice is ellip-
tical, with its greatest diameter directed from above
downwards ; therefore specula should be elliptical in

Fig. 12.— Section through the external Meatus, Middle Ear, and
Eustachian Tube (Tillaux).

a, External auditory meatus; 6, tympanum ; c, Eustachian tube; d, internal
auditory meatus ; et cochlea ; /, ossicles \ a, inembrana tympani ; h. styloid
process.

shape rather than round. The inner end of the tube,
on the other hand, is slightly wider in the transverse
direction. Owing to the obliquity of the membrana
tympani, the floor of the meatus- is longer than the
roof. The cartilaginous segment of the tube presents
many sebaceous glands that may be the seat of minute
and very painful abscesses. It also presents numerous

62 SURGICAL APPLIED ANATOMY. [Chap. v.

cerumiiious glands, which secrete the cerumen of the
ear, and which, when their secretion is excessive,
may produce the plugs of wax that often block the
meatus. There are neither hairs nor glands in the
lining of the bony part of the tube.

The skin of the meatus, when inflamed, may pro-
duce an extensive muco - purulent discharge — otitis
externa. Polypi are apt to grow from the soft parts
of the canal, and exostoses from its bony wall.
Foreign bodies are frequently lodged in the meatus,
and often involve great difficulties in their extraction.
It would appear that in many cases more damage is
done by the surgeon than by the intruding substance.
Mason reports three cases where a piece of slate-pencil,
a cherry-stone, and a piece of cedar-wood were lodged
in the canal for respectively forty years, sixty years,
and thirty years.

The upper wall of the meatus is in relation
with the cranial cavity, from which it is only
separated by a thin layer of bone. Thus, abscess or
bone disease in this part may readily lead to menin-
gitis. A case is reported where an inflammation of
the cerebral membrane followed upon the retention of
a bean within the meatus. The anterior wall of the
canal is in relation with the temporo-maxillary joint
and with part of the parotid gland. This may serve
in one way to explain the pain often felt in moving
the jaw when the meatus is inflamed, although, at the
same time, it must be remembered that movement of
the lower maxilla produces a movement in the carti-
laginous meatus, and that both the canal and the joint
are supplied by the same nerve (the auriculo-temporal).
From its relation to the condyle of the jaw, it follows
that this wall of the meatus has been fractured by
that condyle in falls upon the chin. Tillaux states
that abscess in the parotid gland may spread into the
meatus through the anterior wall of the passage.

Chap, v.] THE EAR. 63

The posterior wall separates the meatus from the
niastoid cells, and through this partition inflammation
may extend from one part to the other, especially as
the cartilage of the tube is deficient at its upper and
posterior parts. The inferior wall of the bony meatus
is very dense and substantial, and corresponds to the
vaginal and styloid processes.

Blood supply. — The pinna and external meatus
are well supplied with blood by the temporal and
posterior auricular arteries, the meatus receiving also
a branch from the internal maxillary. In spite of
this supply, the pinna is frequently the seat of
gangrene from frost-bite. This is due to the fact that
all the vessels are superficial and are close beneath the
surface, that the part is much exposed to cold, and
that the pinna lacks the protection of a covering of
fat. The same conditions predispose to gangrene of
the nose from external cold. Bloody tumours
(hsematomata) are often met with on the pinna, and
are said to be more common in lunatics. They
appear to be frequently due to injury, and consist of
an extravasation between the perichondrium and the
cartilage.

Nerve supply. — The outer surface of the pinna
is supplied by the auriculo-temporal nerve, with the
exception of the skin over the antitragus, the vertical
part of the antihelix, the corresponding part of the
helix and its fossa, and the lobule, which parts are
all supplied by the great auricular nerve. The inner
surface is almost entirely supplied by the latter nerve,
the small occipital nerve giving a branch to the
upper extremity, and Arnold's nerve a branch to the
back of the concha, near the mastoid process. The
meatus is supplied mainly by the auriculo-temporal,
with, in addition, a contribution from Arnold's nerve,
which goes to the lower and back part of the canal,
not far from its commencement. Arnold's nerve, a

64 SURGICAL APPLIED ANATOMY. [Chap. v.

little branch from the pneurno - gastric, has been
credited with a good deal in connection with the
nerve relations of the ear. After a heavy dinner,
when the rose-water comes round, it is common to see
the more experienced of the diners touch the lower
part of the back of the ear with the moistened
serviette. This is said to be very refreshing, and is
supposed to prove to be an unconscious stimulation of
Arnold's nerve, a nerve whose main trunk goes to
the stomach. Hence, this little branch has been
facetiously termed "the alderman's nerve."

Ear coughing, car sneezing1, ear yawning*
• — It is not uncommon to have a troublesome dry
cough associated with some mischief in the meatus.
Sometimes the mere introduction of a speculum will
make the patient cough. A case is reported, where
a troublesome cough persisted for eighteen months,
and at once ceased on the removal of a plug of wax
from the ear. In such cases, the irritation is pro-
bably conveyed to the trunk of the vagus by Arnold's
nerve, and is then referred to the respiratory tracts
which are so extensively supplied by that trunk. By
means of this little branch the ear is brought into
very direct connection with the great nerve of the
lung. Dr. Woakes has carefully investigated the
matter of ear-sneezing, & propos of a case where
troublesome sneezing was set up by a plug of wax in
the meatus. He considers that the irritation in this
case also is conveyed to the respiratory organs by
Arnold's nerve. The relation of this small nerve to
the nerve of the stomach is illustrated by a case
cited by Arnold, where severe chronic vomiting was
at once cured by extracting from each ear of a child
a bean that had been introduced in play.

In the repeated yawning that is sometimes set up
by ear ailments, the irritation is no doubt conveyed
from the meatus by the auriculo- temporal nerve.

Chap.v.j THE EAR. 65

This nerve is a branch of the third division of the
fifth, and it is from this same division that the branches
come off that supply the muscles of the jaw.

The inferior dental nerve, that goes to the lower
teeth, is a branch of the same division, as is. also the
gustatory nerve ; and the somewhat direct connection
of these nerves with the ear may explain the frequent
association of ear-ache and tooth-ache, and the fact
that disease in the anterior part of the tongue
(gustatory nerve) is often attended by pain in the
ear.

It is a common practice to introduce ear-rings,
with the idea of relieving obstinate affections of the
eye. How such a treatment can act, if it acts at
all, is hard to understand. It is true that the main
nerve-supply of the eye and of the conjunctiva comes
from the fifth nerve, but, unfortunately for any nerve
theory, the lobule of the ear is only supplied by the
great auricular nerve. If the ear-ring, in such cases,
were introduced through the upper part of the ear,
supplied as it is in front by the fifth nerve, some
connection might be traced.

Hilton reports a case of obscure pain in the ear
which was found to be due to an enlarged gland in the
neck, that pressed upon the trunk of the great auri-
cular nerve.

Membrana tympani.— This membrane is very
obliquely placed, forming with the horizon an angle
of 45°. At birth it is much more nearly horizontal,
the angle being one of only 10°. In cretins, and in
some idiots, it is said to retain this inclination through
life. Owing to the sloping downwards of the bony
wall of the meatus at its inner end, that wall forms
with the lower edge of the membrana a kind of sinus
in which small foreign bodies may readily lodge (Fig.
12). The ring of bone to which the membrane is
attached is deficient at its upper and anterior part.
F

66 SURGICAL APPLIED ANATOMY. [Chap. v.

The gap so formed is called the notch of Hivini, and is
occupied by loose connective tissue, covered by a con-
tinuation of the lining of the meatus, and through it pus
may escape from the middle ear into the auditory canal
without perforating the membrane. When the mem-
brane gives way owing to a violent concussion trans-
mitted through the air, it often gives way opposite the
notch, its attachments here being obviously less secure
than elsewhere. The membrane possesses but little
elasticity, as shown by the very slight gaping of the
part after it has been wounded. It is for this reason,
among others, that perforations made in the membrane
by the surgeon heal so very rapidly. The membrane
has been ruptured during fits of sneezing, coughing,
vomiting, etc. The same lesion has followed a box on
the ear, and even simple concussion such as that pro-
duced by a loud report.

The umbilicus, or deepest point of the depression
in the diaphragm, is just below the centre of the entire
membrane, and corresponds to the attachment of the
end of the handle of the malleus. The rest of the
handle can be seen through the membrane during life.
The head of the malleus is in no connection with the
membrane, being above its highest limits. The seg-
ment of the membrane above the umbilicus is very
freely supplied by vessels and nerves ; it corresponds
to the handle of the malleus, and to the chain of
ossicles, and is opposite to the promontory and the
two fenestrse. The chorda tympani nerve also runs
across this supra-umbilical portion. The segment
below the umbilicus, on the other hand, corresponds
to no very important parts, and is less vascular and
less sensitive. Paracentesis of the tympanum through
the membrana tympani should therefore always be
performed in the sub-umbilical segment.

The membrane is supplied by the stylo-mastoid
artery, and the tympanic branch of the internal max-

Chap, v.] THE EAR. 67

illary, and obtains its nerve-supply from the auriculo-
temporal.

The tympanum. — The width of the tympanic
cavity, as measured from its inner to its outer wall,
varies from -^th to ^th of an inch. The narrowest
part is that between the umbilicus of the membrana
and the promontory. A fine rod thrust through the
centre of the membrana tympani would hit the pro-
montory on the inner wall of the cavity. Above
the promontory is the fenestra ovalis, and below and
behind it the fenestra rotunda. Skirting the upper
and posterior margin of the inner wall of the tympa-
num is the aqueduct of Fallopius, containing the
facial nerve. The wall of the aqueduct is so thin that
inflammatory mischief can readily extend from the
middle ear to the facial nerve. The upper wall is
very thin, and but little bone separates it from the
cranial cavity. The suture between the squamous
and petrous bones is found in this wall, and by means
of the sutural membrane that separates the bones in
the young inflammatory changes may readily spread
from the tympanum to the meninges. The floor is very
narrow. Its lowest part is below the level of both
the membrana tympani and the orifice of the Eusta-
chian tube, and hence pus may readily collect in this
locality. It is separated by a thin piece of bone from
the internal j ugular vein behind, and from the internal
carotid artery in front. Fatal haemorrhage from the
latter vessel has occurred in connection with destruc-
tive changes in this part of the ear. The posterior
wall presents the openings of the mastoid cells.
These cells are often the seat of suppurative collec-
tions, and may be opened by a proper trephine applied
to the surface of the mastoid process about half an
inch behind the ear. These cellular spaces in the
bone are in close relation with the lateral sinus, and
thus it happens that thrombosis of the sinus has

68 SURGICAL APPLIED ANATOMY. [Chap. v.

sometimes occurred in connection with mischief in the
cells. The mastoid cavities, like the tympanum, con-
tain air, and in cases where the outer surface of the
bone has been spontaneously perforated, a tumour has
appeared on the skull that contained air, and that
could be increased in size by forcing air into the ear
through the Eustachian tube. Such tumours are
known as pneumatoceles, and the process that leads
originally to the perforation of the bone is of obscure
nature. In some cases it seems to have been simply
atrophic, and in other instances to have been due to
" caries sicca."

On the anterior wall of the tympanum is the open-
ing of the Eustachian tube. This tube is one and
a half inches long, and by opening into the pharynx
serves to keep a proper supply of air in the tym-
panum, and so equalise the pressure upon the two
sides of the membrane. The pharyngeal orifice of the
tube is usually shut. During swallowing, however, it
is opened, by the action probably of the tensor palati
muscle. If the nose and mouth be closed, and the
cheeks blown out, a sense of pressure is produced in
both ears. The hearing, at the same time, is dulled,
and the change is due to the bulging out of the mem-
brana tympani by the air thus forced into the tym-
panum. This method of inflating the middle ear is
known as Yalsalva's method.

In " Politzer's method " of passing air into the
Eustachian tube, the patient's mouth is closed, while
into one nostril the nozzle of a caoutchouc bag filled
with air is introduced, and the nostrils then held
firmly closed. The patient is asked to swallow a
mouthful of water, while at the same moment the bag
is forcibly emptied, and the air, having no other means
for escape, is thus driven into the open Eustachian
tube. The surgeon listens for the little noise caused
by the entrance of the air by means of a tube that

chap, v.] THE EAR. 69

passes between the patient's meatus and his own. Pro-
longed closure of the Eustachian tube leads to deaf-
ness, and thus impairment of hearing may follow upon
great thickening of the mucous membrane of the tube
due to the extension of inflammatory mischief from
the pharynx. In the deafness associated with enlarged
tonsils, the hypertrophic change extends to the mucous
lining of the tube, and in the cases of many pharyngeal
growths and nasal polypi, the orifice of the tube is
mechanically obstructed. The near relation of the
pharyngeal end of the tube to the posterior nares
serves to explain a case where suppuration in the rnas-
toid cells followed upon plugging of the nares for
epistaxis. A probe passed up the Eustachian tube
from the pharynx would hit the joint between the
incus and the stapes, arid would then enter the mastoid
cells (Tillaux).

The upper edge of the pharyngeal orifice of the
tube is about half an inch below the basilar process,
half an inch in front of the posterior wall of the
pharynx, half an inch behind the posterior end of
the inferior turbinated bone, and half an inch above
the soft palate (Tillaux).

Just behind the elevation formed at the orifice of
the Eustachian tube, there is a depression in the wall
of the pharynx, known as the fossa of Rosenmuller.
It may be mistaken for the orifice of the tube, and
may readily engage the point of an Eustachian
catheter. To pass the Eustachian catheter, the in-
strument is carried along the floor of the nares with
its concavity downwards, " until its point can be felt
to drop over the posterior edge of the hard palate
into the pharynx. The instrument should now be
withdrawn until its point can be felt to rise again on
the posterior edge of the hard palate; having arrived
at this point, the catheter should be pushed onwards
about one inch, and during its passage its point should

70 SURGICAL APPLIED ANATOMY. [Chap. vi.

be rotated outwards through a quarter of a circle."*
This manoeuvre should engage it on the orifice of the
tube.

Blood supply. — The tympanum is supplied by
the following arteries, the tympanic of the internal
maxillary and internal carotid, the petrosal of the
middle meningeal, and the stylo-mastoid of the pos-
terior auricular. It is the distribution of the main
trunk of the last-named vessel that gives some reason
for the practice of applying blisters behind the ear in
disease located in the deeper parts. The fact that
some of the tympanic veins end in the superior petrosal
and lateral sinuses, gives another explanation of the
frequent occurrence of thromboses of those channels
in inflammatory affections of the middle ear.

The chorda tympani nerve, from its exposed
position in the tympanum, is very likely to be damaged
in suppurative disease of the middle ear ; and Urban-
tschitsch has stated that such disease in this part may
be associated with anomalies of taste.

CHAPTER VI.

THE NOSE AND NASAL CAVITIES.

1. THE nose. — The skin over the root, and the
greater part of the dorsum, of the nose, is thin and lax.
Over the abe, however, it is thick, very adherent to
the deeper parts, and plentifully supplied with
sebaceous and sweat glands. Inflammation of the
integuments over the cartilaginous portion of the
nose is apt to be very painful, and to be associated
with much vascular engorgement. The pain depends

* Smith and Walsham's " Operative Surgery," p. 12. 2nd ed 1876.

Chap. VI.] NOSE AND NASAL CAVITIES. 71

upon the tenseness of the part, which prevents it from
swelling without producing much pressure upon the
nerves, while the engorgement depends upon the free
blood-supply of the region, and the fact that the edge
of the nostril being a free border, the circulation there
is terminal, and apt therefore to favour congestion.

The great number of sebaceous glands about the
lower part of the nose renders it a favourite spot for
acne. It is here that the form of acne termed acne
hypertrophica is met with ; a condition that produces
the appearance known as " grog-blossoms." The nose,
too, is frequently attacked by lupus, and it is indeed
over the dorsum of the nose that lupus erythematosus
is most commonly met with. Rodent ulcer also is apt
to appear in this region, especially in the fold between
the ala of the nose arid the cheek.

The integument of the nose is very well supplied
with blood, and for this reason the part is well suited
for the many plastic operations that are performed
upon it. Wounds in this region heal kindly, and even
the extensive wound made along the line between the
nose and the cheek in removal of the upper jaw leaves
very little deformity. In many reported cases portions
of the nose have been entirely severed, and have
united to the face on being immediately re-applied.
In spite of its full blood-supply, the nose, for reasons
already given when speaking of the pinna (page 63),
is prone to gangrene from exposure to severe cold.
A specimen in the museum of the Royal College of
Surgeons illustrates a remarkable form of gangrene of
the nose. The specimen is the larynx of a man who
cut his throat, and lost a great quantity of blood.
Before he died his nose sloughed.

The skin over the root of the nose is supplied by
the nasal branch of the first division of the fifth ; as
is also the skin over the alse and in the region of the
nostril. The middle or greater part of the side of the

72 SURGICAL APPLIED ANATOMY. [Chap. vi.

nose is supplied by the second division of the fifth, and
is the seat of pain in neuralgia of that trunk. The
fact that the nasal nerve is a branch of the ophthalmic
trunk, and has intimate connections with the eye,
serves to explain the lachrymation that often follows
painful affections about the nostril, as, for example,
when the edge of the nostril is pinched (page 48).

The cartilaginous part of the nose is often
destroyed by lupus, by syphilitic ulceration, and other
destructive affections. The parts so lost have been
replaced by the various methods included under the
head of rhinoplasty. It is well to bear in mind
the limits of the cartilaginous segment of the nose, and
to remember that in introducing a dilating speculum
the instrument should not be passed beyond those
limits. In the subjects of inherited syphilis the bridge
of the nose is often found to be greatly depressed.
This depends upon no actual loss of parts, but rather
upon imperfect development from local mal-nutrition,
that mal-nutrition following upon a severe catarrh
of the mucous membrane. The deformity only
occurs, therefore, in those who have had "snuffles"
in infancy.

The nasal bones are often broken by direct
violence. The fracture is most common through the
lower third of the bones, where they are thinnest and
least supported. It is rarest in the upper third,
where the bones are thick and firmly held, and where,
indeed, considerable force is required to produce a
fracture. Since no muscles act upon the ossa nasi,
any displacement that occurs is clue solely to the
direction of the force. Union takes place after these
fractures with greater rapidity than perhaps obtains
after fracture of any other bone in the body. In one
case noted by Hamilton, " the fragments were quite
firmly united on the seventh day." If the mucous
membrane of the nose be torn, these fractures are apt

Chap. VI.] NOSE AND NASAL CAVITIES. 73

to be associated with emphysema of the subcutaneous
tissue, which is greatly increased on blowing the nose.
The air in such cases is derived, of course, from the
nasal fossae. In fractures of the upper third of the ossa
nasi the cribriform plate may be broken, but it is ques-
tionable whether this complication can occur when the
fracture is limited to the lower third of the bones. The
root of the nose is a favourite place for ineniiigoceles
and encephaloceles, the protrusion escaping through
the suture between the nasal and frontal bones. Such
protrusions, when occurring in this place, are often
covered by a thin and vascular integument, and have
been mistaken for neevoid growths.

2. The nasal cavities.— The anterior nares
have somewhat the shape of the heart on a playing-
card, and the aperture as a whole measures about
1^ inches vertically, and a little less than \\ inches
transversely, at its widest part. The plane of the
nostril is a little below that of the floor of the nares.
To examine the nasal cavities, therefore, the head
should be thrown back, and the nose drawn upwards.
The anterior nares can be well explored by the finger
introduced into the nostril, and the nasal apertures are
just so wide on each side of the septum as to allow the
finger to be passed far enough back to reach another
finger introduced into the posterior nares through the
mouth. An effectual way of removing soft polypi in
the adult is by tearing them away by the two fingers
so introduced. The operation is a little rough. By
the most gentle introduction of the finger into the
nostril it is often possible to feel the end of the
inferior turbiriated bone. The anterior nares, and
front of the nasal cavities, can be well explored by
Houge's operation. In this procedure the upper lip
is everted, and a transverse cut made through the
mucous membrane into the soft parts that connect the
upper lip with the upper jaw. The incision extends

74 SURGICAL APPLIED ANATOMY. [Chap. vi.

between the second bicuspid teeth of either side.
The soft parts connecting the upper lip and nose to
the bone are divided without damaging the skin, and
the flap is dissected up until the nares are sufficiently
exposed.

The posterior nares. — If a little mirror,
somewhat similar to that used in laryngoscopy, be
cautiously introduced behind the soft palate through
the mouth, and illumined from the mouth, the following
parts may, under favourable circumstances, be seen :
the posterior nares, the septum, the, middle and
inferior turbinated bones, the Eustachian tube, and
the mucous membrane of the upper part of the
pharynx.

This mode of examination is very difficult to carry
out, and is known as posterior rhinoscopy. The parts
just named can all be felt by the finger introduced
behind the soft palate through the mouth. The
posterior nares are often plugged to arrest severe
bleeding from the nose, and in order to cut a proper
sized plug it is desirable to bear in mind the dimen-
sions of the apertures. Each aperture is of regular
shape, and measures about half an inch transversely
by one and a quarter inches in the vertical direction
in a well-developed adult skull.

As regards the nasal cavities generally, it is
well to note that the floor is wider at the centre
than at either end, that the vertical diameter is
greater than the transverse, and is greatest also about
the centre of the fossae. Forceps introduced into the
nose, therefore, are most conveniently opened if
opened vertically.

From a reference to the relations of the nasal
fossce, it will be understood that inflammation of the
lining membrane (coryza) may extend to the pharynx
via the posterior nares ; may extend up the Eusta-
chian tube and cause some deafness ; may reach the

Chap. VI.] NOSE AND NASAL CAVITIES. 75

lachrymal sac and conjunctiva through the nasal
duct ; and may extend to the frontal sinuses and the
aiitrum, producing frontal headache and cheekache.
These relationships are often demonstrated in a severe
" cold in the head." From the nearness of the nasal
fossae to the cranial cavity it happens that meningitis
has followed upon purulent inflammations of the nose.
Foreign bodies of various kind are often lodged in the
nose, and may remain there for some years. Thus
Tillaux reports the case of an old woman aged 64,
from whose nose he removed a cherry stone that had
been there for twenty years.

In washing out the nasal cavities with the " nasal
douche" the fluid is introduced by means of a
syphon. The nozzle of the syphon tube is introduced
into one nostril, the mouth is kept open, and the
fluid runs through that nostril, passes over the soft
palate, and escapes from the other nostril. The latter
cavity is therefore washed out from behind forwards.
The course of the fluid depends upon the fact, that
when the mouth is kept open, there is such a dis-
position to breath through it alone, that the soft
palate is drawn up and the nares cut off from the
pharynx.

The roof of each nasal fossa is very narrow, being
only about \ of an inch in width. It is mainly formed
by the thin cribriform plate, but its width is such that
the danger of the roof being penetrated by so large
a substance as a pair of polyp forceps has been greatly
exaggerated. The cranial cavity has, however, been
opened up through the roof of the nose by penetrating
bodies introduced both by accident and with homicidal
intent. Fracture of this part also has been associated
with very copious escape of cerebro-spinal fluid through
the nostrils. A meningocele may protrude through
the nasal roof. In a case reported by Lichtenberg,
the mass hung from the mouth, having passed through

76 SURGICAL APPLIED ANATOMY. [Chap. vi.

a congenital fissure in the palate. It was mistaken
for a polyp, was ligatured, and death resulted from
intracranial inflammation.

The septum is seldom quite straight. The devia-
tion may be congenital, or may follow an injury. It
has been pointed out that a deviation of the septum
may seriously interfere with the singing voice. The
nose also is seldom quite straight, and French authors
ascribe this to some deviation of the septum, often de-
pendent upon the practice of always blowing the nose
with the same hand. If the deviation of the septum
be considerable, it may more or less block one nostril,
and, until the opposite nostril is examined, be mis-
taken for a septal tumour encroaching upon the cavity.
The flattened nose in acquired syphilis is usually due
to destruction of the septum, and more or less implica-
tion of the adjacent bones. Workmen exposed to the
vapour of bichromate of potash are liable to a peculiar
perforation of the septum known as " bichromate
disease."

Outer wall. — The inferior turbinated bone may
interfere with the introduction of a Eustachian catheter
if the curve of the instrument be too great. The
anterior end of the bone is about J of an inch behind
the orifice of the nostril. The opening of the nasal
duct is about one inch behind the orifice of the nostril,
and about f of an inch above the nasal floor. The
height of the inferior meatus is about J of ,an inch.
The middle meatus is widely open in front, and unless
care be taken to keep the point of any instrument
well towards the floor of the fossa, it is easier to pass
the instrument into the middle than into the inferior
meatus. The opening into the aiitrum is about the
centre of the middle meatus, and is nearly one inch
above the floor of the nasal fossae. The middle tur-
binated bone is high up. Its highest point — its an-
terior extremity — is nearly on a level with the teiido

Chap. VI.] NOSE AND NASAL CAVITIES. 77

oculi. At the front part of the middle meatus the
infundibulum opens. Rhinolithes (stone-like masses
of calcareous matter, formed, as a rule, around foreign
substances) are most often found in the inferior
meatus.

The width of the nasal floor is about half an inch,
or a little over. Its smooth surface greatly favours
the passage of instruments.

The mucous membrane lining the nasal cavi-
ties varies in parts. It is very thick and vascular
over the turbinate bones and over the septum, while
over the nasal floor, and in the intervals between the
turbinate bones, it is very much thinner. . The mucous
membrane lining the various sinuses and the antrum
is conspicuously thin and pale. The membrane is pro-
vided with many glands, which are most conspicuous
over the lower and hinder parts of the outer wall, and
over the posterior and inferior parts of the septum.
These glands may be the subject of considerable hyper-
trophy. They are capable of providing also a very
copious watery secretion, which has, in some cases of
chronic coryza following injury, been so free as to be
mistaken for an escape of cerebro-spinal fluid. There
is also much adenoid, or lymphoid, tissue in the nasal
mucous membrane, which is the primary seat of the
chief scrofulous affections that invade this part. Over
the inferior turbinated bone the mucous membrane
is very thick, lax, and vascular, and when the seat of
chronic inflammation, it may present itself as a large
movable fold that has often been mistaken for a polyp.
From the comparatively lax attachment of the mucous
membrane of the septum to the parts beneath, it
happens that hsematomata (localised extravasations
of blood) are often met with beneath the septal
mucous membrane after a blow on the nose.

Polypi are often met with in the nose. They
are of two kinds, the mucous or myxomatous polyp

78 SURGICAL APPLIED ANATOMY. [Chap. vi.

that springs usually from the mucous membrane
over the middle or inferior turbinate bones, and the
fibrous or sarcomatous polyp that usually takes origin
from the periosteum of the nasal roof, or from that of the
base of the skull. Polypi of the latter kind spread in
every available direction. They expand the bridge ,of
the nose, close the nasal duct and cause epiphora,
depress the hard palate and encroach upon the mouth,
invade the antrum and expand the cheek, grow down
into the pharynx, pushing forwards the velum palati,
and may penetrate even through the inner wall of the
orbit. In one remarkable case quoted in the Lancet
for 1877, a tumour springing from the sheath of the
superior maxillary nerve just after its exit from the
foramen rotundum, projected into the nasal fossse. It
was mistaken for a polyp, and attempts to remove it
led to meningitis and death.

The blood supply of the nasal cavity is exten-
sive, and is derived from the internal maxillary,
ophthalmic, and facial arteries. With regard to the
veins, it may be noted that the ethmoidal veins that
come from the nose enter the ophthalmic vein, while
in children a constant communication exists between
the nasal veins and the superior longitudinal sinus
through the foramen caecum. This communication
may also be maintained in the adult. These connec-
tions may, in part, serve to explain the occurrence of
intracranial mischief as a consequence of certain in-
flammatory affections of the nasal cavities. Bleeding
from the nose, or epistaxis, is a common, and often a
serious circumstance. Its frequency is to a great ex-
tent due to the vascularity of the mucous membrane,
to its laxity, and to the fact that the veins, especially
those over the lowest turbinate bone, form extensive
plexuses, and produce a kind of cavernous tissue. The
epistaxis is often due, therefore, to interference with
the venous circulation, as seen in cases of cervical

Chap. VI.] NOSE AND NASAL CAVITIES. 79

tumour pressing upon the great veins, in the paroxysms
of whooping cough, and the like. The beneficial
effect of raising the arms in epistaxis is supposed to
depend upon the extra expansion of the thorax thus
produced, and the aspiratory effect thus brought to
bear upon the cervical veins. The bleeding may be
copious and long continued. Thus Spencer Watson
reports a case where the epistaxis continued on and off
for twenty months without obvious cause. Martineau
mentions an instance in which 12 Ibs. of blood were
lost in sixty hours, and Fraenkel records a case where
75 Ibs. of blood are said to have escaped from first to
last. In several instances the haemorrhage has proved
fatal. The seat of the bleeding is often not easy to
detect, even when the examination is post mortem.

The nerve supply of these parts is derived from
the olfactory nerve, and from the first and second
divisions of the fifth nerve. The lachrymation that
often follows the introduction of irritants into the
front of the nares, may be explained by the fact that
that part of the cavity is supplied freely by the nasal
nerve, a branch of the ophthalmic trunk. As an ex-
ample of transference of nerve force in the opposite
direction, may be noted cases where. a strong sunlight
falling upon the eyes has produced an attack of sneezing.
The olfactory nerves are situated high up in the cavity,
and thus, in smelling intently, the individual sniffs
deeply and dilates the nostril. The inability to dilate
the nostril in facial paralysis, may explain the partial
loss of smell sometimes noted in such cases. It is said
(Althaus) that anosmosia, or loss of the sense of smell,
when following upon an injury to the head, may
be due to a rupture of the olfactory nerve-fibres, as
they pass through the cribriform foramina. Surgery
affords some examples of the possible violence of the
act of sneezing. Thus a man sneezed vigorously when
his hand was firmly supported upon an object, and

8o SURGICAL APPLIED ANATOMY. [Chap. vi.

produced a subcoracoid dislocation of his shoulder
(Lancet, 1878). In another case, the ninth rib on the
left side was fractured during a fit of sneezing (Med.
Times, 1862). Mr. Pitts (Lancet, 1883) has, how-
ever, reported the strangest case of all, a case in which
all the coverings of a large femoral hernia were rup-
tured during the act of sneezing, so that the bowels
escaped.

Some of the lymphatics of the nasal fossae enter
certain glands placed behind the pharynx, in front of the
rectus capitis anticus major. Hence, as Fraenkel has
pointed out, " retro-pharyngeal abscess may arise in
consequence of diseases of the nose." Other lympha-
tics go to the submaxillary and parotid lymph glands,
and it is common to find the former set of glands en-
larged in nose affections, especially in the scrofulous.

The sinuses. — These may be briefly dealt with.
The frontal sinuses are not present in early youth, but
develop as age advances. They are practically formed
from the diploe. Large frontal sinuses do not neces-
sarily imply large external prominences over the
glabella and superciliary eminences. They often de-
velop more as the brain shrinks, and appear then to
follow, as it were, the receding brain. Bony tumours
often grow from the interior of these sinuses, and are
known as enostoses. It is obvious that a depressed
fracture may exist over a frontal sinus, without the
cranial cavity being damaged. In such cases, the in-
spissated contents of the sinus have been mistaken
for brain matter escaping. Since the sinuses commu-
nicate with the nose, much emphysema may follow
upon fracture of the sinus wall. Insects have found
their way into these cavities. " Centipedes are par-
ticularly liable to be found in the frontal sinuses,
where they may remain for years, the secretions of
these cavities furnishing them with sufficient nourish-
ment " (Fraenkel). Larvse have also been found here,

Chap. VI.] NOSE AND NASAL CAVITIES. 8 1

and maggots that have developed within the nose
have managed to make their way to the frontal
sinuses. A case is reported where epistaxis, extend-
ing over many years, was due to an insect (the pen-
tastoma tsenioides) that had settled in these sinuses.
One day it was sneezed out, and no further bleeding
occurred (Med. Times, 1876). The last-named para-
site is said to be often met with in the frontal sinus
of the dog. The antrum exists at birth, but attains
its largest dimensions in old age. Tumours of various
kinds are apt to develop in this cavity, and to distend
its walls in various directions. Thus the growth
breaks through the thin inner wall and invades the
nose, it pushes up the roof of the cavity and invades
the orbit, it encroaches upon the mouth through the
floor of the antrum, and makes its way also through the
somewhat slender anterior wall into the cheek. The
densest part of the antrum wall is that in relation to
the malar bone, and this part does not yield. There
is little inducement for any growth to spread back-
wards, although it sometimes invades the zygomatic
and ptery go -maxillary fossse. As the infraorbital
nerve runs along the roof of the antrum, while the
nerves of the upper teeth are connected with its walls,
these structures are pressed upon in growths springing
from the antrum, and much neuralgia of the face
and teeth often produced. In tapping the antrum,
a spot is usually selected just above the second
bicuspid tooth, since the bone is here thin and is
conveniently reached. In some cases it is suffi-
cient to extract a molar tooth, since the fangs of
these teeth often enter the cavity of the antrum.
The teeth usually selected are either the first or the
third molar.

As the result of a fall, one of the upper teeth has
been entirely driven into the antrum and lost to view.
In one case, reported by Haynes Walton, an upper
G

&2 SURGICAL APPLIED ANATOMY. [Chap. vn.

incisor was found lying loose in the antrum three
and a half years after the accident that had driven it
there.

CHAPTER VII.

THE FACE.

THE parts of the face, other than those already
dealt with, will be considered under the following
heads: (1) The face generally; (2) the parotid
region • and (3) the upper and lower jaws and parts
connected with them. The lips will be considered
with the "cavity of the mouth" (chap. viii.).

1. The face generally .—The skin of the face
is thin and fine, and is more or less intimately adhe-
rent by a delicate subcutaneous tissue to the parts
beneath. The skin generally is very freely supplied
with sebaceous and sudoriparous glands, and hence
the face is very commonly the seat of acne, an erup-
tion that specially involves the sebaceous follicles. It
happens from the thinness of the skin, and from the
absence of dense fasciae, that facial abscesses usually
soon point and seldom attain large size.

The cellular tissue of the face is lax, and readily
lends itself to spreading infiltrations, so that in
certain inflammatory affections the cheeks and other
parts of the face may become greatly swollen. In
general dropsy, also, the face soon becomes " puffy,"
the change first appearing, as a rule, in the lax tissue
of the lower lid. The skin over the chin is peculiarly
dense and adherent to the parts beneath, and in most
respects closely resembles the integument of the scalp.
When such parts of the integuments of the face as
cover prominent bones, such as the parts over the

Chap, vii.] THE FACE. 83

malar bone, the chin, the upper lid, are struck by a
blunt instrument or in a fall, the wound produced
has often the appearance of a clean incised wound,
just as obtains in contused wounds of the scalp.

The mobility of the facial tissues renders this
part very suitable for the performance of plastic
operations of various kinds, and their vascularity
generally insures a ready and sound healing. Al-
though there is a large quantity of fat in the subcu-
taneous tissue in this region, yet fatty tumours are
singularly rare upon the face. They appear, indeed,
to avoid this region. Thus M. Denay reports the case
of a man who had no less than 215 fatty tumours
over different parts of his body, but not one upon his
face. The thickness of the tissues of the cheek and
lips favour the embedding of foreign substances in
those parts. Thus, a tooth that has been knocked
out has remained for some time embedded in the lip.
Henry Smith reports a remarkable case, where he
removed a piece of tobacco-pipe three inches long from
the cheek, in the tissues of which it had been em-
bedded for several years. The soft tissues of the
cheek greatly favour the spread of destructive pro-
cesses. Thus in cancrum oris, a form of gangrene of
the face attacking the young, the whole cheek may
be lost in a few days. Great contraction is apt to
follow upon loss of substance in the cheek, so that in
some cases the jaws may be firmly closed, as is seen after
recovery from advanced cancrum oris. The face is
peculiarly liable to be the seat of certain ulcers, espe-
cially the rodent and lupoid ulcer, and is the part
most often attacked by " malignant pustule," a disease
transmitted to man from cattle afflicted with a malady
known in this country as " murrain," and in France as
" charboii."

Blood supply. — The tissues of the face are very
vascular, and are liberally supplied with blood-vessels in

84 SURGICAL APPLIED ANATOMY. [Chap.vn.

all parts. The finer vessels of the skin often appear per-
manently injected or varicose in the drunken, or in those
who are exposed to cold, or are the subjects of certain
forms of acne. Thus, nsevi, and the various forms of
erectile tumour, are common about the face. For a
like reason also wounds of the face, while they may
bleed readily when inflicted, are apt to heal with
singular promptness and accuracy. All wounds,
therefore, of this part should have their edges care-
fully adjusted as soon after the accident as possible.
Extensive flaps of skin that have been torn up in
lacerated wounds often retain their vitality in almost
as marked a manner as do like flaps torn up from the
scalp. Extensive injuries of the face associated with
great loss of substance are often repaired in a most
remarkable manner, as has been illustrated in gunshot
wounds, where a considerable portion of the face and
upper jaws has been blown away. The low mortality
after severe injuries to the face is due, however, not
only to the excellent powers of repair the part pos-
sesses, but also to the fact that the face contains no
organs essential to life, that its bones are soft and thin
and do not favour extensive splitting, and that there
are several passages and cavities in the region through
which discharges may escape. One of the most
terrible instances of injury not immediately fatal is
reported by Longmore : " An officer of Zouaves,
wounded in the Crimea, had his whole face and lower
jaw carried away by a ball, the eyes and tongue in-
cluded, so that there remained only the cranium, sup-
ported by the neck and spine." He lived twenty
hours.

The pulsations of the facial artery can be best felt
at the lower border of the jaw, where the vessel
crosses just in front of the anterior border of the
masseter muscle. It is here covered only by the integu-
ment and platysma, and can be readily compressed

Chap, vii.] THE FACE. 85

against the bone, or ligatured. The anastomoses of the
artery upon the face are so free, that, when the vessel
is divided, both ends, as a rule, require to be secured.
The facial vein is only in contact with the artery near
the lower border of the jaw ; on the face it is sepa-
rated from it by a considerable interval. The vein is
not so flaccid as are most superficial veins; it remains
more patent after section, it possesses no valves,
and communicates at one end indirectly with the
cavernous sinus, and at the other with the internal
jugular vein in the neck. This vein has also another,
but less direct, communication with the iiitracranial
veins. It is as follows : the facial vein receives the
" deep facial vein " from the pterygoid plexus, and
this plexus communicates with the cavernous sinus by
means of some small veins which pass through the
foramen ovale and the fibrous tissue of the foramen
lacerum medius. These dispositions of the facial vein
may serve to explain the mortality of some inflamma-
tory affections of the part. Thus, carbuncle of the face
is not unfrequeiitly fatal by inducing thrombosis of the
cerebral sinuses, and a like, complication may occur in
any other diffuse and deeply- extending inflammatory
condition. The unusual patency also of the facial
vein favours septic absorption, and its direct commu-
nication with the great vein in the neck may explain
those abrupt deaths from thrombosis that have fol-
lowed upon the injection of facial naevi in infants.

Nerve supply. — The nerves of the face are very
liberally distributed, the fifth being the sensory nerve,
the facial the motor. It follows, from the great
number of nerve filaments about the part, that severe
irritants applied to the face may set up a widespread
nerve disturbance. Dr. George Johnson mentions a
case where a piece of flint embedded in a scar on the
cheek set up facial neuralgia, facial paralysis, and
trismus, and induced a return of epileptic attacks. The

86 SURGICAL APPLIED ANATOMY-. [Chap.vn.

positions of the supra and infraorbital foramina and
of the mental foramen are indicated as follows. The
supraorbital foramen is found at the junction of the
inner with the middle third of the upper margin of the
orbit. A straight line drawn downwards from this
point so as to cross the gap between the two bicus-
pids in both jaws, will hit both the infraorbital and
mental foramina. The infraorbital foramen is a little
over a quarter of an inch below the margin of the
orbit. The dental foramen in the adult is midway
between the alveolus and the lower border of the
jaw, and is a little over a quarter of an inch below
the cul-de-sac of mucous membrane between the lower
lip and jaw. At puberty the foramen is nearer to the
lower border of the maxilla, and in old age it is close
to the alveolus. The infraorbital nerve has been
divided for neuralgia at its point of exit, the nerve
being reached either by external incision or through
the mouth by lifting up the cheek. In other cases the
floor of the orbit has been exposed, the infraorbital
canal (the anterior half of which has a bony roof) has
been opened up, and large portions of the trunk of the
nerve have been in this way resected. The inferior
dental nerve has been divided at the mental foramen
by an incision made through the mucous membrane.
Its trunk has been reached and a part excised through
a trephine hole made in the body of the lower jaw.
It has been divided also before its entry into the
dental foramen in the following manner : The mouth
being held widely open, an incision is made from the
last upper molar to the last lower molar just to the
inner side of the anterior border of the coronoid
process. The cut passes through the mucous mem-
brane down to the tendon of the temporal muscle.
The finger is introduced into the incision, and passed
between the ramus of the jaw and the internal ptery-
goid muscle until the bony point is felt that marks the

Chap, vii.j THE PAROTID REGION. 87

orifice of the dental canal. The nerve is here picked
up with a hook, isolated, and divided.

The buccal nerve may be the seat of severe neu-
ralgia, and may be thus divided through the mouth :
" The surgeon places the finger-nail upon the outer lip
of the anterior border of the ascending ramus of the
lower jaw at its centre, and divides in front of this
border the mucous membrane and the fibres of the
buccinator vertically. He then seeks for the nerve,
separating the tissues with a director, and divides it "
(Stimson).

The malar bone. — Such is the firmness of this
bone, and so direct is its connection with the skull,
that violent blows upon it are very apt to be associated
with concussion. Resting as it does upon com-
paratively slender bones, it is very rare for the malar
bone to be broken alone. It may, indeed, be driven
into the superior maxillary bone, fracturing that
structure extensively, without being itself in any way
damaged. A fracture of the malar bone may lead to
an orbital ecchymosis, precisely like that which often
attends a fracture of the skull base.

2. The parotid region.— The main part of the
parotid gland is lodged in a definite space behind the
ramus of the lower jaw. This space is increased in
size when the head is extended, and when the inferior
maxilla is moved forwards, as in protruding the chin. In
the latter movement, the increase in the antero-posterior
direction is equal to about three-eighths of an inch.
It is diminished when the head is flexed. When the
mouth is widely opened the space is diminished below,
while it is increased above by the gliding forwards of
the condyle. These facts should be borne in mind
in operating upon and in exploring the parotid space.
It will be found also that in inflammation of the
parotid much pain is produced by all those move-
ments that tend to narrow the space occupied by the

88 SURGICAL APPLIED ANATOMY. [Chap. vn.

gland. The obliquity of the ram us of the jaw in
infancy and old age causes the lower part of the space
to be, in the former instance relatively, and in the
latter instance actually, larger than it is in the adult.
The gland is closely invested by a, fascia derived
from the cervical fascia. The superficial layer of the
parotid fascia is very dense, is continuous behind with
the fibrous sheath of the sterno-mastoid, and in front
with that of the masseter. Above it is attached to
the zygoma, while below it joins the deep layer. The
deep layer is slender, is attached to the styloid process,
forms the stylo-maxillary ligament, and is connected
with the sheaths of the pterygoid muscles and the
pterygoid process. The gland is, therefore, encased
in a distinct sac of fascia, which is entirely closed
below, but is quite open above. Between the anterior
edge of the styloid process and the posterior border
of the external pterygoid muscle there is a gap in
the fascia, through which the parotid space communi-
cates with the connective tissue about the pharynx.
It is well known that in post-pharyngeal abscesses
there is very usually a parotid swelling, and in several
instances the pus, or at least some portion of it, has
been evacuated in the parotid region. In these cases
the matter most probably extends from the pharyngeal
to the parotid region, through the gap just described.
From the disposition of the fascia it follows that very
great resistance is offered to the progress of a parotid
abscess directly outwards through the skin. The
abscess often advances upwards to the temporal, or
zygomatic fossse, in the direction of least resistance,
although progress in that line is resisted by gravity.
It frequently makes its way towards the buccal
cavity or pharynx, or it may break through the
lower limits of the fascia and reach the neck. It
must be borne in mind that the gland is in direct
contact with the cartilaginous meatus, with the ramus

Chap. VII.]

THE PAROTID REGION.

89

of the jaw and other bony parts, and is closely
related with the temporo-maxillary joint. Thus, a

Fig. 13.— A Horizontal Section through the Face and Neck just above
the level of the Lower Teeth (Braune).

«, Orbicularis oris and, behind it, the buccinator ; 6, internal pterygoid ; c, mas-
seter ; dt stylo-glossus, stylo-pharyngpus, and styloid process; e, splenius
capitis ; /, digastric ; g, sterno-mastoid ; h, obliquus superior : i, trachclo-
raastoid ; j, biventer cervicis and cornplexus ; k, trapeziua ; I, tonsil ; m, facial
artery ; n, facial vein ; o, gustatory nerve ; p, inferior dental nerve and artery ;
q, styloid process ; r, external carotid artery ; s, internal carotid artery ;
t, vagus ; w, parotid gland ; x, internal jugular vein, with the vagus, spinal
accessory, and hypo-glossal nerves to its inner side ; y, vertebral artery ;
2, odontoid process; 1, occipital artery.

90 SURGICAL APPLIED ANA TOMY. [Chap. vn.

parotid abscess has burst into the meatus, has led to
periostitis of the bones adjacent to it, and has incited
inflammation in the joint of the lower jaw.

In several cases reported by Yirchow, the pus
appears to have found its way into the skull along
branches of the fifth nerve, for the environs of the
Gasserian ganglion were found infiltrated with pus.
The auriculo-temporal and great auricular nerves sup-
ply the gland with sensation, and the presence of these
nerves, together with the unyielding character of the
parotid fascia, serve to explain the great pain felt in
rapidly-growing tumours and acute inflammation of
the gland. The pain is often very distinctly referred
along the course of the auriculo-temporal nerve. Thus,
a patient with a parotid growth, recently under my
care, had pain in those parts of the pinna and temple
supplied by the nerve, pain deep in the meatus, at
a spot that would correspond to the entrance of the
meatus branch of the nerve, and pain in the joint of
the lower jaw, which is supplied by the auriculo-
temporal.

The, most important, structures in the gland are
the external carotid artery, with its two terminal
branches, and the facial nerve. The artery, as
Tillaux has pointed out, is behind the ramus of the
jaw, as high up as the junction of the inferior with
the middle third of its posterior border. It then
enters the parotid gland, and, passing a little back-
wards and outwards, comes nearer to the surface,
and at the level of the condyle of the jaw breaks
into its two terminal branches. The artery, there-
fore, does not enter the gland at its inferior border,
and is not in actual relation with the parotid space
at its lowest part. The vessel, moreover, is not
parallel with the edge of the ramus, but passes
through the parotid gland with some obliquity.

The facial nerve is represented by a line drawn

Chap, vii.i THE PAROTID REGION. 91

across the gland, in a direction forwards and a
little downwards from the spot where the anterior
border of the mastoid process meets the ear. The
nerve is not quite so intimately bound up in the gland
as is the carotid artery, and in rapidly-growing
tumours of the gland facial paralysis from pressure
upon this nerve is not uncommon.

It follows, from these and other relations of the
parotid, that its entire removal as a surgical procedure
is an anatomical impossibility. In opening a parotid
abscess, a- cut is usually made over the angle of the
jaw, and a director pushed upwards into the substance
of the gland, after the plan advised by Hilton. The
gland is separated by a mere layer of fascia from the
internal carotid artery, the internal jugular vein, the
vagus, glosso-pharyngeal, and hypoglossal nerves (Fig.
13). Thus, in stabs in the parotid region it may be
difficult at first to tell whether the internal or the
external carotid is wounded. It has been suggested
that the cerebral hypersemia, sometimes noticed in
severe parotitis (mumps), may be due to the pressure
of the enlarged gland upon the internal jugular vein,
with which it is in the closest contact.

Many lymphatic glands are placed upon the sur-
face and in the substance of the parotid gland. They
receive lymph from the frontal and parietal regions of
the scalp, from the orbit, the posterior part of the
nasal fossae, the upper jaw, and the hinder and upper
part of the pharynx. When enlarged, these glands
may form one species of " parotid tumour."

Stenson's duct is about two and a half inches
long, and has a diameter of one - eighth of an
inch, its orifice being the narrowest part. At the
anterior border of the masseter muscle the duct
bends suddenly inwards to pierce the buccinator
muscle. The bend is so abrupt that the buccal
segment of the duct may be almost at right angles

92 SURGICAL APPLIED ANATOMY. [Chap. vn.

with the masseteric. This bend should be taken
into consideration in passing a probe along the duct
from the mouth. The course of the duct across
the masseter is represented by a line drawn
from the lower margin of the concha to a point
midway between the ala of the nose and the red
margin of the lip. It lies about a finger-breadth
below the zygoma, having the transverse facial artery
above it and the facial nerve below it. The duct has
been ruptured subcutaneously, leading to extravasa-
tion of saliva. Wounds of the duct are apt to lead to
salivary fistulge. When the fistula involves the buccal
segment of the duct it may be cured by opening the
duct into the mouth on the proximal side of the
fistula. Fistulse of the masseteric segment are, on
the other hand, very difficult to relieve. At least one-
half of the buccal part of the duct is embedded in the
substance of the buccinator muscle. A salivary
fistula over the masseter may involve the parotid
gland itself, or that part of it known as the socia
parotidis. Inflammatory conditions may spread to
the parotid from the mouth along Stenson's duct.

3. The upper and lower jaws, and parts
connected with them.

The superior maxilla (for antrum, see Nose,
page 81 ; for hard palate, see Mouth, page 110).
— This bone, on account of its fragility, and the
manner in which it is hollowed out, is very readily
fractured. The fracture may be due to direct violence,
as by a blow from a " knuckle-duster," or it may
be broken by a force transmitted from the lower
jaw through the teeth, as in cases of severe blows or
falls upon the chin. It may be broken by a blow
upon the head, when the chin is fixed, no other bone
being damaged \ and, lastly, it may be crushed, as
above stated, by the driving in of the malar bone.
The displacement of the fragments depends upon the

Chap, vii.] THE UPPER JAW. 93

direction and degree of the force employed, no
muscles having effect. The bone being very vascular,
serious injuries, involving great loss of substance, are
often wonderfully repaired. Its hollowness, and the
cavities that it helps to bound, render it possible
for large foreign bodies to be retained in the
deeper parts of the face. Thus, Longmore reports
" the case of Lieutenant Fretz, of the Ceylon Rifles,
who was able to do his military duties for nearly
eight years, with the breech and screw of a burst
musket lodged in the nares, part of the tail-pin and
screw protruding through the hard palate into
the mouth." The bone may undergo extensive
necrosis, especially in that form of necrosis in-
duced in workers in match-factories by exposure
to the fumes of phosphorus. In one case (Med.
Times, 1862) of necrosis following measles the
mischief was limited to the premaxillary, or incisive
bone.

Excision of the superior maxilla. — The
entire bone has been frequently removed when the
seat of an extensive tumour, and under certain other
conditions. The bony connections to be divided in the
operation are the following : (1 ) The connection with
the malar bone at the outer side of the orbit ; (2) the
connection of the nasal process with the frontal, nasal,
and lachrymal bones ; (3) the connections of the orbital
plate with the ethmoid and palate (this plate is often
left behind, or is cut through near the orbital margin) ;
(4) the connection with the opposite bone and the
palate in the roof of the mouth ; and (5) the connection
behind with the palate bone, and the fibrous attachments
to the pterygoid processes. In the four first-named
instances, the separation is effected by a cutting
instrument ; in the last-named, by simply twisting out
the bone. Soft parts divided: These may be con-
sidered under three heads : (1) Tho parts cut in the first

94 SURGICAL APPLIED ANATOMY. [Chap. vn.

incision ; (2) in turning back the flap ; and (3) in sepa-
rating the bone.

(1) The following are the parts cut in order from
above downwards in the usual, or " median," incision,
an incision commencing parallel with the lower
eyelid, and continued down the side of the nose,
round the ala, and through the middle of the upper
lip : Skin, superficial fascia, orbicularis palpebrarum,
palpebral branches of infraorbital nerve and artery,
lev. labii superioris, angular artery and vein, lev.
labii sup. alseque nasi, lateralis nasi artery and vein,
nasal branches of infraorbital nerve, compressor
iiaris, depressor alse nasi, attachment of nasal carti-
lage to bone, orbicularis oris, sup. coronary artery
and vein, and mucous membrane of lip. Various
branches of the facial nerve to the muscles may be
cut. (2) In turning back the flap, the muscles above
named will be dissected up, together with the tendo
oculi, the levator anguli, the buccinator, a few fibres
of the masseter, and, on the orbital plate, the inferior
oblique muscle. The infraorbital nerve and artery
will be cut as they leave their foramen. In the flap
itself will be the trunks of the facial artery and vein,
the transverse facial artery, and the facial part of the
facial nerve. (3) In separating the nasal process, the
lachrymal sac and infratrochlear nerve will be damaged,
and the nasal duct and external branch of the nasal
nerve cut across. In separating the bones below,
the coverings of the hard palate are divided, and the
attachment of the soft palate to the palate-bone,
unless the removal of that process can be avoided.
uAny attempt to dissect off and preserve the soft
covering of the hard palate is futile" (Heath).
Posteriorly, the trunk of the infraorbital nerve is
again divided (this time in front of Meckel's ganglion),
together with the posterior dental and infraorbital
arteries, and some branches of the spheric-palatine

Chap. vii.] THE LOWER JAW. 95

artery. The deep facial vein from the pterygoid
plexus will probably be cut, and, lastly, near the
palate will also be divided the large palatine nerve
and the descending palatine artery.

It will be seen that no large artery is divided in
the operation. The inferior turbiiiated bone comes
away, of course, with the maxilla.

The inferior maxilla. — Fracture. — This bone
is to a great extent protected from fracture by its horse-
shoe shape, which gives it some of the properties of a
spring, by its density of structure, by its great
mobility, and by the buffer-like inter-articular carti-
lages that protect its attached extremities.. The bone
is usually broken by direct violence, and the fracture
may be in any part. The symphysis is rarely broken,
on account of its great thickness. The ramus is pro-
tected by the muscular pads that envelope its two
sides, and the coronoid process is still more out of the
risk of injury, owing to the depth at which it is
placed and the protection it derives from the zygoma.
The weakest part of the bone is in front, where its
strength is diminished by the mental foramen, and by
the large socket required for the canine tooth. It is
about this part, therefore, that fracture is the most
common. The bone may be broken near, or even
through, the symphysis by indirect violence, as by a
blow or crushing force that tends to approximate the
two rami. Thus, the jaw has been broken near the
middle line by a blow in the masseteric region. The
amount of displacement in fractures of this bone varies
greatly, and is much influenced by the nature and
direction of the force. In general terms, it may be
said that, when the body of the bone is broken, the
anterior fragment is drawn backwards and downwards
by tihe jaw depressors, the digastric, mylo-hyoid,
genio-hyoid, and genio-hyo-glossus ; while the hinder
fragment is drawn up by the elevators of the jaw,

g6 SURGICAL APPLIED ANATOMY. [Chap. vn.

the masseter, int. pterygoid, and temporal. It must
be remembered that the mylo-hyoid muscle will be
attached to both fragments, and will modify the
amount of displacement. Fractures of the ramus
are seldom attended with much displacement, muscular
tissue being nearly equally attached to both fragments.

In fractures of the body of the bone, the dental
nerve often marvellously escapes injury, a fact that is
explained by the supposition that the bones are not
usually sufficiently displaced to tear across the nerve.
Weeks after the accident, however, the nerve has
become so compressed by the developing callus as to
have its function destroyed.

One, or both, condyles have often been broken by
falls or blows upon the chin.

The gums being firm and adherent, it follows
that they are usually torn in fractures of the body of
the maxilla, and hence the bulk of the fractures in
this part are compound.

The temporo- maxillary articulation is
supported by a capsule which varies greatly in thick-
ness in different parts. By far the thickest part of
the capsule is the external part (the external lateral
ligament). The internal part is next in thickness,
while the anterior and posterior portions of the
capsule are thin, especially the former, which is very
thin. Thus, when this joint suppurates, the pus is
least likely to escape on the external aspect of the
Articulation, and is most likely to find an exit through
the anterior part of the capsule, although this part is
to a great extent projected by the attachments of the
external pterygoid muscle. ^ Immediately behind the
condyle of the jaw are the bony meatus, and, a little to
the inner side, the middle ear. In violent blows upon
the front of the jaw, these structures may be damaged,
and it is interesting to note that the strongest liga-
ment of the joint (the external lateral) has a direction

chap, vii.] THE LOWER JAW. 97

downwards and backwards, so as to immediately
resist any movement of the condyle towards the
slender wall of bone that bounds the meatus and
tympanum. Were it not for this ligament, a blow
upon the chin would be a much more serious accident
than it is at present. It follows, from the proximity
of the joint to the middle ear, that disease in the
articulation may be set up by suppuration in this
part. In one case (Holmes' " System of Surgery "),
suppurative disease, spreading from the middle ear,
not only involved the joint, but induced necrosis of
the condyle of the lower jaw. The necrosed condyle
was removed entire from the auditory meatus, into
which cavity it had projected.

Dislocation. — This joint permits only of one
form of dislocation, a dislocation forwards. It may
be unilateral or bilateral, the latter being the more
usual, and it can only occur when the mouth happens
to be wide open. Indeed, the dislocation is nearly
always due to spasmodic muscular action when the
mouth is open, although in some few cases it has been
brought about by indirect violence, as by a downward
blow upon the lower front teeth, the mouth being
widely opened. It has occurred during yawning,
violent vomiting, etc. In more than one case the
accident happened while a dentist was taking a cast
of the mouth. Hamilton quotes a bilateral dislocation
in a woman during the violent gesticulations incident
to the pursuit of scolding her husband. When the
mouth is widely opened the condyles, together with
the interarticular nbro-cartilage, glide forwards. The
nbro-cartilage extends as far as the anterior edge of the
eminentia articularis, which is coated with cartilage
to receive it. The condyle never reaches quite so far as
the summit of that eminence. All parts of the capsule
save the anterior are rendered tense. The coronoid
process is much depressed. Now if the external
H

98 SURGICAL APPLIED ANA TOMY. [Chap. VIL

pterygoid muscle (the muscle mainly answerable for
the luxation) contract vigorously, the condyle is soon
drawn over the eminence into the zygomatic fossa, the
interarticular cartilage remaining behind. On reaching
its new position it is immediately drawn up by the
temporal, internal pterygoid, and masseter muscles, and
is thereby more or less fixed. A specimen in the
Musee Dupuytren shows that the fixity of the
luxated jaw may sometimes depend upon the catching
of the apex of the coronoid process against the malar
bone.

Excision of the inferior maxilla. — Con-
siderable portions of the lower jaw can be excised
through the mouth without external wound. In
excising one entire half of the maxilla a cut is made
vertically through the lower lip down to the point of
the chin, and is then continued back along the inferior
border of the jaw, so as to end near the lobule of
the ear, after having been carried vertically upwards
in the line of the posterior border of the ramus. The
soft parts divided may be considered under three
heads : (1) Those concerned in the first incision ; (2)
in clearing the outer surface of the bone ; (3) in
clearing the inner surface of the bone.

1. (a) In the anterior vertical cut : Skin, etc.,
orbicularis oris, inferior coronary and inferior labial
vessels, branches of submental artery, levator menti,
mental vessels and nerve, some radicles of anterior
jugular vein. (5) In the horizontal cut : Skin, etc.,
platysma, branches of superficial cervical nerve,
branches of supramaxillary part of facial nerve, facial
artery and vein at edge of masseter, and inframax-
illary branch of facial nerve (not necessarily divided).
i (c) The posterior vertical incision would not go down
to the bone, and would merely expose the surface of the
parotid gland, and part of posterior border of masseter
muscle.

Chap, viz.] THE LOWER JAW. 99

2. In clearing the outer surface the following
parts are dissected back : Levator menti, the two
depressor muscles, buccinator, masseter (crossed by
part of parotid gland, transverse facial vessels, facial
nerve and Stenson's duct), masseteric vessels and nerve,
temporal muscle.

3. In clearing the inner surface : Digastric, genio-
hyoid, genio-hyo-glossus, and mylo-hyoid muscles, a
few fibres of superior constrictor, internal pterygoid
muscle, inferior dental artery and nerve, mylo-hyoid
vessels and nerve, internal lateral ligament, rest of
insertion of temporal muscle, mucous membrane.

Parts in risk of being damaged. — The facial nerve,
if the posterior vertical incision be carried too high up.
The internal maxillary artery, temporo-maxillary vein,
auriculo-temporal nerve (structures all closely related
to the jaw condyle), external carotid artery, lingual
nerve, the parotid, submaxillary, and sublingual glands.
After subperiosteal resection the entire bone has been
reproduced.

The lower jaw may be entirely absent, or may be
of dwarfed dimensions, or be incompletely formed.
These conditions are congenital, and depend upon
defective development of the maxillary part of the
first branchial arch. They are often associated with
branchial fistulse, supernumerary ears, macrostoma,
and like congenital malformations.

With regard to the nerves connected with the
jaws little need be said. The upper teeth are supplied
by the second division of the fifth, the lower by the
third. Some remarkable nerve disturbances have
followed, by reflex action, upon irritation of the
dental nerves. Thus cases of strabismus, temporary
blindness, 'and- T.v?y- neck haVe" beet reported- 0,3 due
to the ireitali'^iT' of carious teeth.- - Hilfoa" gives
the case of a man who was much troubled by a
carious *xk>th in t~h& lower jaw (st^plred i>y the third

ioo SURGICAL APPLIED ANATOMY. [Chap. vm.

division of the fifth), and who developed a patch of
gray hair over the region supplied by the auriculo-
temporal nerve (a branch also of the third division).

The muscles of mastication are often attacked
by spasm. When the spasm is clonic the chattering
of the teeth is produced that is so conspicuous a
feature in rigor. When the spasm is tonic the mouth
is rigidly closed, and the condition known as trismus,
or lockjaw, is produced. Trismus is among the
first symptoms of tetanus. It is also very apt to be
produced by irritation of any of the sensory branches
of the third division of the fifth, since the motor nerve-
supply of the muscles themselves is derived from that
trunk. Thus trismus is very common in caries of the
lower teeth, and during the " cutting " of the lower
wisdom tooth. It is much less common in affections
of the upper set of teeth, since they are supplied by
a more remote division of the fifth nerve.

CHAPTER Till.

THE MOUTH, TONGUE, PALATE, AND PHARYNX.

THE lips. — The principal tissues composing the
lips have the following relation to one another pro-
ceeding from without inwards : (1) Skin ; (2) super-
ficial fascia ; (3) orbicularis oris ; (4) coronary vessels ;
(5) mucous glands ; and (6) mucous membrane. The
free border of the lip is very sensitive, many
of the nerves having end-bulbs closely resembling
tactile corpuscles, Tke rppsr li'p* ?V Supplied with
sensation "by ^ the secohd* division <)$'• the- 'fifth nerve,
and the idwer lip by the "third division. Over these
labial -nerv?^ ?, crop of herpes often appears (herpes

Chap, viii.] THE MOUTH. 101

labialis). The free border of the lower lip is more
frequently the seat of epithelioma than is any other
part of the body. The lips contain a good deal of
connective tissue, and may swell to a considerable
size when inflamed, or cedematous. They are very
mobile, and are entirely free for a considerable extent
from bony attachment of any kind. It follows that
destructive inflammations of the lips, and such losses
of substance as accompany severe burns, produce much
contraction and deformity of the mouth. Contracting
cicatrices, also, in the vicinity of the mouth are apt
to drag upon the lips, everting them, or producing
kindred distortions. It is fortunate that the laxity of
the tissues around the mouth, and the general vascu-
larity of the part, greatly favour the success of the
many plastic operations performed to relieve these
deformities.

The lips are very vascular, and are often the seat
of nsevi and other vascular tumours. The coronary
arteries are of large size, and their pulsations can
generally be felt when the lip is pinched up. These
vessels run beneath the orbicularis oris muscle, and
are consequently nearer to the mucous membrane than
they are to the skin. When the inner surface of the
lip is cut against the teeth, as the result of a blow,
these arteries are very apt to be wounded. As
such wounds are concealed from view the consequent
haemorrhage has sometimes given rise to an erroneous
diagnosis. Thus, Mr. Erichsen quotes the case of a
drunken man, the subject of such a wound, who,
having swallowed, and then vomited, the blood escap-
ing from a coronary artery, was for a while supposed
to be suffering from an internal injury. As the anas-
tomoses between the arteries of the lip are very free,
it is usually necessary to tie both ends of the vessel
when it has been cut across.

The mucous glands in the submucous tissue are

102 SURGICAL APPLIED ANATOMY. [Chap.vm.

large and numerous. From closure of the ducts of
these glands, and their subsequent distension, result
the "mucous cysts" that are so common about the
lips. It has been shown (Holmes' "System of
Surgery," vol. ii.) that one form of enlarged lip may
depend upon a general hypertrophy of these glands
in the submucous tissue. " Hare-lip " is noticed
below in connection with the subject of cleft palate.

The buccal cavity. — The following points may
be noticed in the examination of the interior of the
mouth. On the floor of the mouth, and on either side
of the frsenum linguae, can be observed a small papilla
indicating the orifice of Wharton's duct. The duct of
Bartholin (one of the ducts of the sublingual gland)
runs along the last part of Wharton's duct, and opens
either with it or very near it. Wharton's duct is
singularly indistensible, and hence is partly explained
the intense pain usually observed when that duct
is obstructed by a calculus. The near proximity of
this duct to the lingual nerve may serve also to
account for the pain in some cases. The submaxillary
gland can be made out through the mucous membrane
at a point a little in front of the angle of the jaw,
especially when the gland is pressed up from the
outside. On the floor of the mouth, between the
alveolus and the anterior part of the tongue, is a
well-marked ridge of mucous membrane, that is
directed obliquely forwards and inwards to the
Whartonian papilla near the frsenum. It indicates
the posi fcion of . the sublingual gland, and also, so far
as it goes, the line of Wharton's duct and the lingual
nerve. These structures lie beneath the gland, which
is itself covered only by the mucous membrane.
The ducts of the sublingual gland, some ten to
twenty in number, open into the mouth along the
ridge of mucous membrane just referred to. Ranula,
a cystic tumour filled with mucous contents, is often

chap, viii.] THE MOUTH. 103

met with over the site of the sublingual gland, and
is due to the dilatation of one of the gland ducts
that has become obstructed, or to an occluded mucous
follicle. The mucous membrane of the floor of the
mouth, as it passes forwards to be reflected on the
gums, is attached near to the upper border of the
jaw. The genio-hyo-glossus is attached near the
lower border. Between these two parts (the mucous
membrane and the muscle) there is, according to
Tillaux, a small space lined with squamous epithelium.
To this cavity the name is given of the sublingual
bursa muccsa. It is constricted in its centre by the
frsenum linguae, and is said to be the seat of mischief
in " acute ranula."

When the mouth is widely opened the pterygo-
maxillary ligament can be readily seen and felt
beneath the mucous membrane. It appears as a
prominent fold running obliquely downwards behind
the last molar teeth. A little below and in front of
the attachment of this ligament to the lower jaw, the
gustatory nerve can be felt as it lies close to the bone
just below the last molar. This nerve is sometimes
divided for the relief of pain in cases of carcinoma
of the tongue. Mr. Moore's method of dividing it is
as follows : " He cuts the nerve about half an inch
from the last molar tooth, at a point where it crosses
an imaginary line drawn from that tooth to the angle
of the jaw. He enters the point of the knife nearly
three-quarters of an inch behind and below the tooth,
presses it down to the bone, and cuts towards the
tooth " (Stimson). This nerve, as it lies against
the bone, has been crushed by the slipping of the
forceps in the clumsy extraction of the lower molar
teeth.

The coronoid process of the lower jaw can be
easily felt through the mouth, and is especially distinct
when that bone is dislocated. It may be noted that

104 SURGICAL APPLIED ANATOMY. [Chap.vm.

a fair space exists between the last molar tooth and
the ramus of the inferior maxilla, through which a
patient may be fed by a tube in cases of trismus, or
anchylosis of the jaw.

A congenital cyst is sometimes found in the floor
of the mouth between the tongue and the lower jaw,
that contains sebaceous matter and hairs. Such cysts
have been supposed to be due to the imperfect closure
of the first branchial cleft, the cleft immediately
behind the first branchial arch, about which the lower
jaw is developed.

The gums are dense, firm, and very vascular. In
the bleeding that follows the extraction of teeth much
of the blood is supplied by them. The gums are
particularly affected in mercurial poisoning, and are
also especially involved in scurvy. In chronic lead-
poisoning a blue line often appears along their margins.
This is due to a deposit of lead sulphide in the gum
tissues, which is thus derived : Food debris collected
about the teeth in decomposing produces hydrogen
sulphide, which, acting upon the lead circulating in
the blood, produces the deposit. The blue line, there-
fore, is said not to occur in those who keep the teeth-
clean.

The tongue. — On the under surface of the tongue,
less than half an inch from the frsenum, the end of the
ranine vein can be seen beneath the mucous membrane.
Two elevated and fringed lines of mucous membrane
may be seen on the under surface of the organ
converging towards its tip. They indicate the position
of the ranine artery, which is more deeply placed than
the vein, close to which it lies. It is extremely rare
for the tongue to be the seat of congenital defect. The
author of the able monograph on the tongue in
Holmes' " System of Surgery " has discovered only
one instance of congenital absence of the organ.
Fournier gives a case where the tongue was so much

chap, viii.] THE TONGUE. 105

longer than usual that the chest could be touched
with its tip while the head was held erect.

In rare cases the fraeninn linguae may be

abnormally short, constituting the condition known
as "tongue-tie," which is really a very uncommon
affection. The frsenum when divided should be cut as
near the jaw as possible, so as to avoid the ranine
vessels. Division of these vessels in relieving tongue-
tie has led to fatal haemorrhage, the bleeding being
encouraged by the efforts of sucking. " If the frsenum
and subjacent muscle fibres be too freely divided,
energetic sucking on the part of a hungry child may
tear the wound of these very lax tissues farther and
farther open, until the tongue, having lost all its
anterior support, turns over into the pharynx, and is
firmly embraced by the muscles of deglutition, which
force it down upon the epiglottis, and the latter upon
the larynx, until suffocation is produced " (Holmes'
" System of Surgery," vol. ii.). In complete anaesthesia,
as in that produced by chloroform, when all the
muscular attachments of the tongue are relaxed, the
organ is apt to fall back and to press down the epi-
glottis, so causing suffocation.

The tongue is firm and dense, but contains, never-
theless, a sufficient amount of connective tissue to
cause it to swell greatly when inflamed. Foreign
bodies may easily be embedded in its substance. In
the Lancet for 1846 is noted a case where a portion
of a fork is said to have been buried in the tongue for
thirty-two years. The surface epithelium is thick,
and in chronic superficial inflammation of the organ
it often becomes heaped up, forming dense opaque
layers — ichthyosis linguae, plaques des fumeurs,
leucoma, etc. From the mucous glands, situated
chiefly beneath the mucous membrane near the base
of the tongue, the mucous cysts are developed that are
sometimes met with in this part.

io6 SURGICAL APPLIED ANATOMY. [Chap. vm.

The tongue is very vascular, and is in consequence
often the seat of nsevoid growths. Its main supply is
from the lingual artery. This vessel approaches the
organ from the under surface, and as cancer usually
shows a tendency to spread towards the best blood-
supply, it is to be noticed that carcinoma of the tongue
nearly always tends to spread towards the deep attach-
ment of the member. At the same time it must be
observed that the main lymphatics follow the same
course as the main blood-vessels. The vascularity
of the tongue is the great bar to its easy removal,
haemorrhage being the complication most to be dreaded
in such operations.

The tongue is well supplied with nerves, that endue
it not only with the special sense of taste, but also
with common sensation. According to Weber's ex-
periments, tactile sensibility is more acute on the tip
of the tongue than it is on any other part of the
surface of the body. It should be borne in mind that
the lingual nerve supplies the forepart and sides of
the tongue for two-thirds of its surface, while the
glosso-pharyngeal nerve supplies the mucous mem-
brane at its base, and especially the papillae vallatse.
In painful affections of the tongue in the district sup-
plied by the lingual nerve, the patient often is troubled
with severe pain deep in the region of the meatus of
the ear. The pain in such instances is referred along
the course of the third division of the fifth, of which
trunk the lingual nerve is a branch. In like manner
spasmodic contraction of the masticatory muscles is
sometimes found to accompany painful lingual ulcers
when involving the region of the gustatory nerve.
There would seem to be but little connection between
an abscess over the occipital region and wasting of one
half of the tongue. But Sir James Paget reports the
following case : "A man received an injury to the
back of his head that was apparently not severe. In

chap, viii.] THE TONGUE. 107

time the right half of the tongue began to waste, and
continued to waste until it was less than half the size
of the unaltered side. A.n abscess formed over the
occiput, from which fragments of the lower part of
the occipital bone were removed. After the removal of
all the dead bone the tongue began to recover, and in
one month had nearly regained its normal aspect."
Here the atrophy was due to wasting of the lingual
muscles produced by pressure upon the hypoglossai
nerve, which leaves the skull through the anterior
condyloid foramen in the occipital bone (Clin. Soc.
Trans., vol. iii.). The case illustrates the importance
of remembering even small foramina, and the structures
they give passage to.

The tongue contains much lymphoid tissue, a
considerable part of which is massed under the
mucous membrane at the posterior part of the organ.
The lymphatics also are large and numerous, and for
the most part follow the ranine vessels. With regard
to glandular infection in lingual cancer, it is well to
note that these lymphatics enter one or two small
glands lying on the hyo-glossus muscle before they
reach the deep glands in the neck, where they finally
end.

In the strange congenital affection known as macro-
glossia the tongue becomes much enlarged, and in some
cases may attain prodigious dimensions. Thus, in one
case it measured six and a half inches in length and
ten inches in circumference. It has protruded so far
from the mouth as to reach even to the episternal
notch. It has been so large as to deform the teeth
and alveolus, and in one case dislocated the jaw.
The enlargement is primarily due to the greatly
dilated condition of the lymphatic channels of the
organ (hence the name, lymphangioma cavernosum,
proposed by Yirchow), and to an increased develop-
ment of lymph tissue throughout the part. The

io8 SURGICAL APPLIED ANATOMY. [Chap. vin.

portion most conspicuously affected is the base of the
tongue, where the lymphatics are usually the most
numerous.

Excision.— Many different methods have been
adopted for the removal of the entire tongue. It has
been removed through the mouth by the ecraseur or
the scissors, the latter operation being performed with
or without previous ligature of the lingual arteries in
the neck. It is difficult, however, to fully expose the
deeper attachments of the organ through the com-
paratively small orifice of the mouth. To obtain
more room the cheek has been slit up in one pro-
cedure, while the lower lip and symphysis of the
lower jaw have been divided in another.

In another series of operations the tongue has
been reached, or the organ has been fully exposed, by
an incision made between the hyoid bone and the
inferior maxilla. More recently Kocher has exposed
the tongue from the neck, and has reached it by an
incision commencing near the ear and following the
anterior border of the sterno-mastoid muscle as far
as the hyoid bone, whence it turns upwards along the
anterior belly of the digastric muscle.

In the removal of the entire organ, the following
parts are of necessity divided : The frsenum, the
mucous membrane along the sides of the tongue, the
glosso-epiglottic folds, the genio-hyo-glossus, hyo-
glossus, stylo-glossus, palato-glossus muscles, the few
fibres of the superior and inferior linguales muscles
that are attached to the hyoid bone, the terminal
branches of the gustatory, glosso-pharyngeal, and hypo-
glossal nerves, the lingual vessels, and, at the side of
the tongue near its base, some branches of the ascend-
ing pharyngeal artery, and of the tonsilar branch of
the facial artery.

The palate. — The arch of the hard palate varies
in height and shape in different individuals, and it

Chap, viii.] THE PALATE. 109

has been said that the arch is particularly narrow and
high in congenital idiots. The outline of this arch is
of some moment in operations upon the palate.

Cleft palate. — The palate is often the seat of a
congenital cleft. The cleft is precisely in the middle
line. It may involve the uvula or the soft palate
alone, or may extend forwards and involve the hard
palate as far as the alveolus. If it extend beyond the
alveolus, the cleft will leave the middle line and will
follow the "suture between the superior maxillary bone
and the os incisivum, appearing therefore between the
incisor and canine teeth. Sometimes at the end of
the cleft the upper lip is fissured (hare-lip). Hare-lip
is never in the middle line, but corresponds to the
suture just named, and is therefore opposite the interval
between the lateral incisor and canine teeth. Some-
times the cleft in the palate on reaching the alveolus
will run on either side of the os incisivum, so that that
bone is entirely separated from the superior maxilla.
Such cases are associated with double hare-lip, and the
os incisivum appears as a nodule attached to the nose
and suspended in the centre of the gap. The bone in
these cases contains, as a rule, the germs only of the
central incisors, the lateral incisors having been lost in
the cleft. Hare-lip very commonly exists without any
cleft of the palate. Except in very rare instances, a
cleft of the hard palate will not exist without a cleft
of ' the soft. In some cases the os incisivum may be
entirely absent, and then the double hare-lip that
exists may appear as a large median gap in the lip.
When the hard palate is entirely cleft the edges of the
cleft are more or less perpendicular, whereas when
the cleft is very slight as regards its antero-posterior
length, the palate tends to preserve more or less of its
normal curve.

The buccal cavity, when first formed in the foetus,
exists as a wide cleft in the face bounded above by the

no SURGICAL APPLIED ANATOMY. [Chap. vm.

fronton asal process, at the sides by the superior maxil-
lary processes, and below by the first visceral arch,
around which the lower jaw is formed. The nasal
and buccal cavities are one. " The separation of the
cavity of the mouth, strictly so called, from the nasal
fossse, is effected by the development of the palatal or
pterygo-palatal processes of the maxillary plate, which,
advancing inwards from the two sides, meet and
coalesce with each other and with the septum descend-
ing from above in the middle line. . . . When the
union of the opposite parts takes place, the naso-
palatine canal is left as the vestige of the previous
fissures. The median union of the palate begins in
front about the eighth week in the human embryo,
and reaches the back part, when completed, in the
ninth and tenth weeks " (Allen Thomson, in Quain's
" Anatomy ").

In this way the hard and soft palates are formed,
and the upper lip completed ; and it will be under-
stood that hare-lip and cleft palate depend simply
upon imperfect closure of the foetal gap between the
nasal and buccal cavities.

The mucous membrane covering the hard
palate is peculiar in that it is practically one with
the periosteum covering the bones ; and, therefore, in
dissecting up this membrane the bone is bared, as the
mucous membrane and the periosteum cannot be
separated. The membrane is thin in the middle line,
but is much thicker at the sides near the alveoli, the
increased thickness depending mainly upon the intro-
duction of a number of mucous glands beneath the
surface layers, such glands being absent in the middle
line. The density and toughness of the soft covering
of the hard palate render ' it very easy to manipulate
when dissected up in the form of flaps in the opera-
tion for cleft palate.

The main blood-supply of both the bones of the

Chap, viii.] THE PALATE. in

hard palate and its mucous covering is derived from
the descending palatine branch of the internal maxil-
lary artery. This vessel, which is practically the only
vessel of the hard palate, emerges from the posterior
palatine canal near the junction of the hard palate
with the soft, and close to the inner side of the last
molar tooth. The vessel runs forwards and inwards,
to end at the anterior palatine canal. Its pulsations on
the palate can often be distinctly felt. In dissecting up
muco-periosteal flaps from the hard palate, it is most
important to make the incision in. the mucous mem-
brane, close to, and parallel with, the alveolus, so that
this artery may be included in the flap and its vitality
therefore not be endangered. By such an incision,
also, unnecessary bleeding is avoided. In dissecting
up the flap it should be remembered that the artery
runs much nearer to the bone than to the mucous
surface.

The soft palate is of uniform thickness, its
average measurement being estimated at about a
quarter of an inch. When the soft palate is cleft, the
edges of the fissure are approximated during swallow-
ing by the uppermost fibres of the superior constrictor.
This approximation may narrow the cleft to one-third
or one-half of its previous size. The muscles that
tend to widen the cleft are, in the main, the levator
palati and tensor palati. It is necessary that these
muscles should be divided before attempting to close
the cleft by operation. The levator palati crosses the
palate obliquely from above downwards and inwards
on its way to the middle line, lying nearer to the
posterior than the anterior surface of the velum. The
tensor palati turns round the hamular process, and
passes to the middle line in a nearly horizontal direc-
tion. The hamular process can be felt through the
soft palate just behind and to the inner side of the last
upper molar tooth. There are three principal methods

112

SURGICAL APPLIED ANATOMY. [Chap. vm.

of dividing these muscles : (1) Ferguson's : A small
knife, with the blade at right angles to the stem, is
passed through the cleft, and is made to divide the
levator palati by an incision on the posterior aspect
of the palate, transverse to the direction of the
muscle* The tensor is not di-
vided in this procedure. (2)
Pollock's : A thin narrow knife,
with the cutting-edge upwards, is
introduced into the soft palate a
7 little in front, and to the inner
side of the hamular process. The
tendon of the tensor muscle is
above the knife, and is cut as
the knife is pushed upwards and
inwards. The knife is inserted
until its point presents at the
upper part of the cleft. As
it is being withdrawn, it is made

Fig. 14.— The Muscles of
the Soft Palate, from
behind.

a, Levator

. . lati ; 6, tensor to cut the posterior surf ace of

ati; c, hamular pro- - — -

, azygos uvulse; /, the
point of entry of the
knife in Pollock's opera-
tion ; above it is the line
of incision made on with-
drawing the knife.

cess ; d, waii of pharynx ; the velum to a sufficient depth

-; azygos uvulae; /.the j-"--j ,1 i

»oint .of^entry of the to divide the levator palati
(Fig. 14). (3) Bryant's: Here
the palate muscles are divided
by a cut with the scissors that
involves the entire thickness of the velum, the cut
being at the side of the velum, and nearly parallel
with the cleft.

The blood supply of the soft palate is derived from
the descending palatine branch of the internal maxil-
lary artery, the ascending pharyngeal artery, and the
ascending palatine branch of the facial artery. The
latter vessel reaches the velum by following the levator
palati muscle, and must be divided in the section
made of this muscle in the procedures just described.
The pharynx is about five inches in length. It
is much wider from side to side than from before

Chap, viii.] THE PHARYNX. 113

backwards. It is widest at the level of the tip of the
greater. cornua of the hyoid bone, where it measures
about two inches. It is narrowest where it joins the
gullet opposite the cricoid cartilage, its diameter here
being less than three-quarters of an inch. The
pharynx is not so large a space as supposed, for it
must be remembered that during life it is viewed
very obliquely, and erroneous notions are thus
formed of its antero - posterior dimensions. The
distance from the arch of the teeth to the com-
mencement of the gullet is about six inches, a
measurement that should be borne in mind in ex-
tracting foreign bodies. Foreign bodies passed into
the pharynx are most apt to lodge at the level of
the cricoid cartilage, a point that, in the adult, is a
little beyond the reach of the finger. The history of
foreign bodies in the pharynx shows that that cavity
is very dilatable, and can accommodate for some time
large substances. Thus, in a case reported by Dr.
Geoghegan, a man of sixty, who had for months some
trouble in his throat for which he could not account,
was supposed to have cancer. On examination, how-
ever, a plate carrying five false teeth, and presenting
niches for five natural ones, was found embedded in
the pharynx, where it had been lodged for five
months. The plate had been swallowed during sleep
(Med. Press, 1866). In the Lancet for 1868 is an
account of a mutton chop that became lodged in
the pharynx of a gluttonous individual. The
chop presented the ordinary vertebral segment of
bone, together with one and a half inches of rib,
and was " pretty well covered with meat." At-
tempts to remove it failed, and it was finally
vomited up. Among the strangest foreign bodies
in this part, are live cat-fish, that are said to have
jumped into the mouths of bathers while swimming.
Dr. Norman Chevers ("Manual of Med. Jurisprudence
I

T 1 4 SURGICAL APPLIED ANA TOMY. [Chap. vm.

for India ") quotes : " Natives of India are not in-
frequently brought to hospital dying of suffocation
and alarm, with a large cat-fish impacted in the
fauces." In one case (Indian Med. Gaz., 1878) the
fish had thought fit to take a firm hold of the uvula,
and declined to leave go until its head had been
pinched with forceps.

The walls of the pharynx are in relation with the
base of the skull, and with the upper six cervical
vertebrae. The arch of the atlas is almost exactly on a
line with the hard palate. The axis is on a line with
the free edge of the upper teeth. The termination
of the pharynx corresponds to the sixth cervical
vertebra. The upper vertebrse can be examined, as
regards their anterior surface, from the mouth. When
the bones about the pharynx are diseased, the necrosed
parts may be discharged by that cavity. Thus por-
tions of the atlas and axis have been expelled by the
mouth, as have also been some fragments of compara-
tively large size thrown off by the occipital and
sphenoid bones.

The mucous membrane of the pharynx is vascular,
and readily inflamed ; and such inflammations are
peculiarly dangerous, in that they may spread to the
lining membrane of the larynx. Much adenoid tissue
is distributed in the mucous membrane of the pharynx,
and it is this tissue that is the primary seat of inflam-
mation in scrofulous pharyngitis. The tissue imme-
diately outside the pharynx walls is lax, and favours the
spread of effusion. Thus, in acute inflammation of the
pharynx, the effusion has been found to extend along
the oesophagus, reaching the posterior mediastinum,
and advancing even to the diaphragm. In the lax
connective tissue between the pharynx and the spine
abscess is not infrequent, due, as a rule, to caries of
the vertebrse (post-pharyiigeal abscess). In this con-
nective tissue, and opposite the axis, is also found a

chap, viii.] THE PHARYNX. 115

lymphatic gland that receives lymphatics from the
nares. This gland may prove the seat of a suppura-
tion. Such collections may. so push forward the pos-
terior pharyngeal wall as to depress the soft palate,
or may cause severe dyspnoea by interference with the
larynx. The matter may discharge itself through the
mouth, or may reach the neck by passing behind the
great vessels and the parotid gland, presenting ulti-
mately beneath or at one border of the sterno-mastoid
muscle.

Many structures of importance are in relation with
the lateral walls of the pharynx, the principal being the
internal carotid artery, the vagus, glosso-pharyngeal,
and hypoglossal nerves. The internal carotid is so
close to the pharynx that its pulsations may be felt
by the finger introduced through the mouth. These,
and other deep structures in the neck, may be wounded
by foreign bodies, that, passing in at the mouth, have
been thrust through the pharynx into the cervical
tissues. The internal jugular vein is at some distance
from the pharynx, especially at its upper part (Fig.
13). Langenbeck has three times extirpated the pha-
rynx for malignant disease, but without success. He
reaches it from the neck through an incision, that,
beginning below the jaw, midway between the sym-
physis and angle, is carried over the great cornu of
the hyoid bone, and ends close to the cricoid cartilage.
The posterior belly of the digastric and the stylo-hyoid
muscles are detached from the hyoid bone, while the
omo-hyoid muscle, the lingual, facial, and superior
thyroid arteries, and the superior laryngeal nerve are
divided.

The tonsil is lodged between the anterior and
posterior palatine arches. It is in relation externally
with the superior constrictor muscle, and corresponds,
as regards the surface, to the angle of the lower jaw.
It is questionable whether the enlarged tonsil, when

n6 SURGICAL APPLIED ANATOMY. [Chap. vm.

it is the subject of other than malignant enlargement,
can ever be felt externally. When hypertrophied, the
mass tends to develop towards the middle line, where
no resistance is encountered, and to effect but little
change in its external relations. The mass, often mis-
taken for the enlarged tonsil in the neck, is formed of
enlarged glands, situate near the tip of the great cornu
of the hyoid bone. These glands receive the tonsillar
lymphatics, and are almost invariably enlarged in all
tonsil affections. It must be remembered that many
structures are interposed between the tonsil and the
skin, and as the hypertrophied body projects freely
into the pharyngeal cavity, one would not expect that
it could be readily felt, even were the interposed
tissues less extensive than they are. The tonsil is
closely enough attacned to the pharyngeal wall to be
affected by the movements of the pharyngeal muscles.
Thus it is moved inwards by the superior con-
strictor muscle during the act of swallowing, and may
be drawn outwards, on the other hand, by the stylo-
pharyngeus muscle. The ease with which a tonsil can
be reached depends, other things being equal, upon
the extent to which it can be withdrawn by the stylo-
pharyngeus, and upon the development of the anterior
palatine arch, which, to some extent, hides the tonsil.
A child with a prominent anterior palatine arch, con-
taining a well-developed palato-glossus muscle, and
with a vigorous stylo-pharyngeus, can for a long time
elude the tonsil guillotine.

Deafness is often complained of when the tonsil is
hypertrophied. This is not due to closure of the
Eustachian tube by the direct pressure of the enlarged
mass. Such pressure is anatomically impossible. The
large tonsil may, however, affect the patency of the
tube, by disturbing the soft palate, and through it the
tensor palati muscle, which is much concerned in keep-
ing often the Eustachian tube. The deafness in these

Chap, viii.] THE PHARYNX. 117

cases is probably due rather to an extension of tlie
hypertrophic process to the lining membrane of the
tube than to any pressure effects, since it is usually
not improved until some time after the tonsil has
been removed. The tonsil tissue is for the most part
collected around a number of recesses. The decom-
position of retained epithelial structures within those
recesses produces the foetid breath often noticed in
cases of enlarged tonsil, and probably incites the
attacks of inflammation to which such tonsils are
liable.

The tonsil is very vascular, receiving blood from
the tonsillar and palatine branches of the facial
artery, from the descending palatine branch of the
internal maxillary, from the dorsalis linguse of the
lingual and from the ascending pharyngeal. Hence the
operation of removing the tonsil is often associated
with free bleeding. The internal carotid artery is close
to the pharynx, but is some way behind the gland
(Fig. 13). The vessel is, indeed, about four-fifths of
an inch posterior to that body, and is in comparatively
little danger of being wounded when the tonsil is ex-
cised. The internal jugular vein is a considerable
distance from the tonsil. Of important cervical struc-
tures, the nearest to the tonsil is the glosso-pharyngeal
nerve. The ascending pharyngeal artery is also in
close relation with it. Although of small size, bleed-
ing from this vessel has proved fatal, as the following
interesting case, reported by Mr. Morrant Baker, will
show : A man, aged 23, fell when drunk, and grazed
his throat with the end of a tobacco-pipe he was
smoking at the time. He thought nothing of the
accident. In two days he came to the hospital
with what appeared to be an acutely-inflamed tonsil.
The tonsil was punctured, but nothing escaped save a '
little blood. Severe haemorrhages occurred from the
tonsil wound, and on the fourth day after the accident

n8 SURGICAL APPLIED ANATOMY. [Chap. ix.

one inch of the stem of a clay pipe was discovered
deeply embedded in the glandular substance. It was
removed, and the common carotid tied. The patient,
however, never rallied from the previous severe hae-
morrhages, and soon died. The autopsy showed that
the stem of the pipe, which had not been missed by
the patient, had divided the ascending pharyngeal
artery (St. Bart's Hosp. .Reports, 1876).

CHAPTER IX.

THE NECK.

Surface anatomy.— Bony points. — The hyoid
bone is on a level with the fourth cervical vertebra,
while the cricoid cartilage is opposite the sixth. The
upper margin of the sternum is (during expiration)
on a level with the disc between the second and third
dorsal vertebrae. At the back of the neck there is a
slight depression in the middle line which descends
from the occipital protuberance, and lies between the
prominences formed by the trapezius and complexus
muscles of the two sides. At the upper part of this
depression the spine of the axis can be made out on
deep pressure. Below this, the bony ridge formed by
the spines of the third, fourth, fifth, and sixth cervical
vertebrae can be. felt, but the individual spines cannot
usually be distinguished. At the root of the neck the
spinous process of the vertebra prominens is generally
very obvious. The transverse process of the atlas may
be felt just below and in front of the tip of the mastoid
process. By deep pressure in the upper part of the
supraclavicular fossa, the transverse process of the
seventh cervical vertebra can be distinguished. If

chap, ix.] THE NECK. 119

deep pressure be made over the line of the carotid
vessels at the level of the cricoid cartilage, the promi-
nent anterior tubercle of the transverse process of the
sixth cervical vertebra can be felt. This is known as
the " carotid tubercle." The carotid artery lies directly
over it, and in ligaturing that vessel some surgeons
make important use of this tubercle as a landmark. If
a horizontal section of the neck, in a muscular subject,
taken about the level of the sixth cervical vertebra,
be viewed, it will be observed that the whole of the
body of the vertebra divided will lie within the an-
terior half of the section.

The middle line. — In the receding angle below
the chin the hyoid bone can be felt, and its body and
greater cornua well made out. About a finger's
breadth below it is the thyroid cartilage. The details
of this latter are readily distinguished, and below it
the cricoid cartilage, crico-thyroid space, and trachea
can be easily recognised. The separate rings of the
trachea cannot be felt. The trachea is less easily made
out, as it passes down the neck. As it descends it
takes a deeper position, and at the upper border of
the sternum lies nearly one and a half inches from the
surface.

The rima glottidis corresponds to the middle of the
anterior margin of the thyroid cartilage.

Unless enlarged, the thyroid gland cannot be made
out with certainty. According to Mr. Holden, the
pulse of the superior thyroid artery can be felt at its
upper and anterior part.

The anterior jugular veins descend on either side
of the middle line upon the sterno- hyoid muscles.
They commence in the submaxillary region, pierce the
fascia just above the inner end of the clavicle, and,
passing behind the origin of the sterno -mastoid
muscle, are lost to view. The inferior thyroid veins
lie in front of the trachea, below the isthmus.

120 SURGICAL APPLIED ANATOMY. [Chap. ix.

The side of the neck. — Muscles. The sterno-
mastoid muscle, especially in thin subjects and when
thrown into action, is a prominent feature in the
neck. The anterior border of the muscle is very
distinct. The posterior border is less prominent,
especially at its upper part. A communicating branch
from the facial vein generally runs along the anterior
border of the muscle to meet the anterior jugular vein
at the lower part of the neck. The interval between
the sternal and clavicular parts of the muscle is
generally well marked. If a needle be thrust through
this interval, quite close to the clavicle, it would just
touch the bifurcation of the innominate artery on the
right side and would pierce the carotid vessel on the
left. The posterior belly of the digastric muscle
corresponds to a line drawn from the mastoid process
to the anterior part of the hyoid bone. The anterior
belly of the omo-hyoid follows an oblique line drawn
downwards from the fore-part of the hyoid bone, so as
to cross the line of the carotid artery opposite the
cricoid cartilage. The posterior belly can be made
out in thin necks, especially when in action, running
nearly parallel with and just above the clavicle.
Although not taking quite the same direction, yet the
posterior borders of the sterno-mastoid and anterior
scalene muscles practically correspond to one another.

Vessels. — The common carotid artery is represented
by a line drawn from the sterno-clavicular joint to a
point midway between the angle of the jaw and the
mastoid process. The vessel bifurcates at the upper
border of the thyroid cartilage. The omo-hyoid
crosses it opposite the cricoid cartilage, and at about
the same level the artery is crossed by the middle
thyroid vein. The line of the internal jugular vein is
just external to that for the main artery. The
superior thyroid artery comes off just below the great
cornu of the hyoid bone, and curves forwards and

Chap, ix.] THE NECK. 121

downwards to the upper edge of the thyroid cartilage.
The lingual arises opposite the tip of the great cornu,
and runs just above that process on its way to the
tongue. The facial artery is very tortuous, but its
general course in the neck is represented by a line
drawn from the anterior border of the masseter at the
lower border of the jaw to a point just above the tip
of the great cornu, while the occipital follows a line
that starts from the latter point and runs across the
base of the mastoid process.

The external jugular vein follows a line di*awn
from the angle of the jaw to the middle of the clavicle.

The subclavian artery describes a curve at the base
of the posterior triangle. One end of the curve
corresponds to the sterno-clavicular joint, the other
end to the centre of the clavicle, the summit of the
curve rising to a point about half an inch above that
bone. In the angle between the posterior edge of
the sterno-mastoid and the clavicle the pulsations of
the artery may be felt. Just above the bone the
artery may be compressed against the first rib. The
compression is most easily applied when the arm is
well drawn down, and the direction of the pressure
should be downwards and inwards.

The subclavian vein lies below the artery, and is
entirely under cover of the clavicle.

The suprascapular and transverse cervical arteries
run parallel with the clavicle, the former quite behind
the bone, the latter just above it. The pulsations of
the latter vessel can generally be felt.

Nerves. — The position of the chief superficial
nerves of the neck may be fairly indicated by six
lines, all drawn from the middle of the posterior border
of the sterno-mastoid muscle. A line drawn forwards
from this spot so as to cross the sterno-mastoid at
right angles to its long axis, corresponds to the super-
ficial cervical nerve. A second line drawn up across

122 SURGICAL APPLIED ANATOMY. [Chap. ix.

the muscle to the back of the pinna, so as to run
parallel with the external jugular vein, corresponds to
the great auricular nerve ; and a third line, running
along the posterior border of the sterno-mastoid
muscle to the scalp marks the course of the small
occipital nerve. These lines, continued downwards, so
as to cross the sternum, the middle of the clavicle,
and the acromion, will indicate respectively the supra-
sternal, supraclavicular, and supra-acromial nerves.

The spinal accessory nerve reaches the anterior
border of the sterno-mastoid muscle at a point about
one inch below the tip of the mastoid process. It
emerges from beneath that muscle about the middle
of its posterior border, crosses the posterior triangle,
and passes beneath the edge of the trapezius at a spot
on a level with the spine of the vertebra prominens.

The phrenic nerve commences deeply at the side
of the neck, about the level of the hyoid bone, and
runs downwards to a point behind the sternal end of
the clavicle. About the level of the cricoid cartilage
it lies beneath the sterno-mastoid (which covers it
wholly in the neck) about midway between the anterior
and posterior borders of the muscle. The brachial
plexus can be felt, and even seen in very thin sub-
jects. Its upper limits may be represented by a line
drawn across the side of the neck from a point about
opposite to the cricoid cartilage, to a spot a little ex-
ternal to the centre of the clavicle.

The neck. — The skin in the subm axillary region
is lax and thin, and is often found of considerable
value for making flaps in plastic operations about the
mouth. The platysma myoides is closely connected
with the skin, and to its action is due the turning-in
of the edges of such wounds as are athwart the line
of direction of the muscle. The amount of subcu-
taneous fat in the cervical region varies in different
parts. In the suprahyoid region it is apt to undergo

chap, ix.] THE NECK, 123

extensive development, producing the diffused lipoma
known as " double-chin."

The skin over the nape of the neck is very dense
and adherent, and these two circumstances, in addition
to the free nerve-supply of the parts, serves to explain
the severe pain that often accompanies inflammation in
this region. Anthrax, or carbuncle, is very commonly
met with at the root of the neck, in the middle line.
Why it especially selects this spot it is difficult to
say. It may be noted, however, that this region has
no very extensive blood supply, that the middle line
of the body is in all parts of comparatively slight
vascularity, and that at the nape of the neck
covered and uncovered parts of the body meet, so
that the spot is liable to considerable fluctuations
of temperature. Setons and issues were, in less
recent times, often applied to the dense integuments
at the back of the neck, just below the occiput.
These measures were accredited with not infrequently
producing tetanus, and, in such cases, it is probable
that the nerve irritation started in the great occipital
nerve.

When the sterno-mastoid muscle of one side is
rigidly contracted, either from paralysis of the opposite
muscle or from spasmodic contraction, or from some
congenital defect, the condition known as wry-neck is
produced. The position of the head in wry-neck
illustrates precisely the effect of the sterno-mastoid
when in full action. The head is bent a little
forwards, the chin is turned towards the sound
side, and the ear on the affected side leans towards
the sterno - clavicular joint. In many cases the
trapezius and scalene muscles are also affected.
Spasmodic contraction of the muscle may be due
to reflex irritation. Thus, it has accompanied inflam-
mation of the cervical glands in the posterior triangle.
Such inflammation has irritated some branches of the

124 SURGICAL APPLIED ANATOMY. [Chap. ix.

cervical plexus, and the sterno-mastoid muscle,
although it is supplied mainly by the spinal accessory
nerve, receives a nerve from that plexus (viz., from
the second cervical). The course of the reflex dis-
turbance in such cases is therefore not difficult to
follow. A like contraction has also been produced
by direct irritation of the second cervical nerve in
cases of disease of the first two cervical vertebrae.
For the relief of some forms of wry-neck, the sterno-
mastoid muscle is divided subcutaneously, as in an
ordinary tenotomy operation, about half-an-inch above
its attachment to the sternum and clavicle. Two
structures stand considerable risk of being wounded
in this operation, viz., the external jugular vein lying
near the posterior border of the muscle, and the ante-
rior jugular which follows its anterior border, and
passes behind the muscle, just above the clavicle, to
terminate in the first-named vein. With common
care, there should be no risk of wounding the great
vessels at the root of the neck.

There is a curious congenital tumour, or indura-
tion, sometimes met with in this muscle in the newly
born. It is usually ascribed to syphilis, but, in most
cases, is probably due to some tearing of the muscle
fibres during the process of delivery.

The cervical fascia. — The layers of fascia that
occupy the neck, and that are known collectively as
the deep cervical fascia, are dense structures, having a
somewhat complex arrangement and a great amount
of importance from a surgical point of view. This
fascia limits the growth of cervical tumours and
abscesses, and modifies the direction of their progress,
but I do not think that its effect in this matter is
quite so definite as is usually maintained. It is true
that deep-seated cervical abscesses are often found to
follow just such a course as the arrangement of the
fascise would lead us to suppose, while, on the other

Chap, ix.] THE CERVICAL FASCIA. 125

hand, instances are by no means uncommon where the
abscess or growth appears to ignore these membranes
and adopt a course of its own.

The deep cervical fascia may be divided into (a)
the superficial layer, and (b) the deeper processes.
(a) The superficial layer forms a complete investment
for the neck, and covers in all the cervical structures,
excepting the platysma and some superficial veins and
nerves, with the completeness of a perfectly-fitting
cravat. It commences behind at the spinous processes
of the vertebra, and, having invested the trapezius
muscle, starts, at the anterior border of that muscle,
as a single layer, to cross the posterior triangle. Ar-
riving at the posterior border of the sterno-mastoid
muscle, it splits, to enclose that structure, appearing
again as a single layer at the anterior border of the
muscle, from whence it passes to the middle line of
the neck to join the fascia of the opposite side,
entirely covering in on its way the anterior triangle.
The part that occupies the posterior triangle is
attached above to the mastoid process and superior
curved line of the occipital bone, and below to the
clavicle, so that the space is completely closed in by
the fascia in all parts, although, just above the
clavicle, it is pierced by the external jugular vein on
its way to the deeper trunks. Over the anterior
triangle, the fascia is attached above to the border of
the lower jaw. Behind that bone it passes over
the parotid gland to the zygoma, forming the parotid
fascia, while a deeper layer passes beneath the gland
(between it and its submaxillary colleague), to be
attached to points at the base of the skull. It is from
this deeper part that the stylo-maxillary ligament is
developed. In front the fascia is attached to the
hyoid bone, and just below the thyroid body it
divides into two layers again, one to be attached to
the front of the sternum, and the other to the back.

126

SURGICAL APPLIED ANATOMY. [Chap. ix.

Both these layers lie in front of the depressors of the
hyoid bone, and they form between them a little
space (which extends so far laterally as to enclose the
sternal head of the sterno-mastoid), the widest part of
which is below, and which there corresponds in width

Fig. 15.— Transverse Section through the lower part of the Neck, to
show the arrangements of the Cervical Fascia (Diagrammatic).

a, Trapezius ; 6, sterno-mastoid ; c, depressors of hyoid bone ; d, platysma ;
e, anterior spinal muscles ; /, scalenus anticus ; g, carotid artery ; h, external
jugular vein ; i, posterior spinal muscles ; T, trachea, with gullet behind and
thyroid body in front.

to the thickness of the sternum. It will be perceived
that, in dividing the sternal head of the sterno-
mastoid , the operation is performed within this little
chamber formed by the two layers just named, and it
is well to note that the anterior jugular vein also
occupies this chamber on its way to the external
jugular trunk. This superficial layer of the fascia,
considered generally, would oppose in all parts the

Chap, ix.] THE CERVICAL FASCIA. 127

progress of abscesses or growths towards the surface,
and would encourage or compel them to take a deeper
position.

(6) The deeper processes. (1) From the super-
ficial layer, a process comes off near the anterior
border of the sterno-mastoid muscle, which, passing
beneath the depressors of the hyoid bone, invests
the thyroid body and front of the trachea, and
passes down, in front of that tube and of the
large vessels, to the fibrous layer of the pericar-
dium. (2) The pre vertebral fascia is a layer that
descends on the prevertebral muscles behind the
pharynx and gullet. It is attached above to the base
of the skull, and, below, descends into the thorax,
behind the O3sophagus. Laterally, it joins the carotid
sheath, and is then prolonged outwards and down-
wards over the scalene muscles, the brachial plexus,
and subclavian vessels. It follows these vessels
beneath the clavicle, where it forms the axillary
sheath, and becomes connected with the under surface
of the costo-coracoid membrane. (3) The sheath of
the carotid artery and its accompanying vein and
nerve are derived in part from fascia No. 1, and in
part from fascia No. 2.

The effects of this disposition of the fascia may be
illustrated by noting the course probably taken by
cervical abscesses in various positions. (1) An abscess
in the posterior triangle will be bounded towards the
surface by the superficial layer of fascia. Towards
tfae floor, or deep part, of the triangle it will be
bounded by the lateral portion of fascia No. 2. The
abscess may extend some way under the clavicle until
arrested by the union of the costo-coracoid membrane
with fascia No. 2. It would readily extend under the
edge of the trapezius muscle, and could pass beneath
the sterno-mastoid muscle and carotid artery to the
anterior and deeper parts of the neck. (2) An abscess

128 SURGICAL APPLIED ANATOMY. [Chap ix.

in the anterior triangle in front of the depressors of
the hyoid bone would probably come forward, owing
to the thinness of the fascia in front of it ; but, if
pent up, it would tend to progress towards the
anterior mediastinum, or into the lateral parts of the
neck in front of the carotid vessels. (3) An abscess
behind the hyoid depressors and about the trachea or
thyroid body, or in the immediate vicinity of the
carotid vessels (an abscess situate, in fact, between
the deep fasciae Nos. 1 and 2) would find itself in
a narrow strait, and, after pressing much upon
adjacent parts, would most readily spread down-
wards into the mediastinum. (4) An abscess imme-
diately in front of the spine, and beneath the deep
fascia No. 2, might extend down into the posterior
mediastinum, or move towards the posterior and
lateral parts of the neck, following the brachial
plexus, and so reach the posterior triangle, or even
the axilla.

In many cases a cervical abscess has burst into the
gullet, or trachea, and even into the pleura. In some
instances the great vessels have been opened up. In
one remarkable case reported by Mr. Savory (Med.
Chir. Trans., 1881), not only was a considerable
portion of the common carotid artery destroyed by
the abscess, but also a still larger portion of the
internal jugular vein, and a large part of the vagus
nerve. This, and like examples of the destructive
action of some cervical abscesses, depend, no doubt,
upon the unyielding character of the cervical fascia,
which hems in the pus on all sides, and drives it
to resort to desperate measures to effect an escape.
"It is noteworthy," remarks Mr. Jacobson, " that
communications between abscesses and deep vessels
have usually taken place beneath two of the strongest
fasciae in the body, the deep cervical fascia and the
fascia lata" (Hilton's " Best and Pain ").

chap, ix.] CUT THROAT. 129

Cut throat and wounds of the neck. — The

skin of the neck is so elastic and mobile that it is
readily thrown into folds when a knife, and especially
a blunt knife, is drawn across it. Thus, in cases
of cut throat several distinct skin-cuts may be found
that were all produced by one movement of the knife.
The wound in cut throat, whether suicidal or homi-
cidal, most frequently involves the thyro-hyoid
membrane, next in frequency the trachea, and then
the thyroid cartilage.

1. If the wound be above the hyoid bone the
following parts may be cut : Anterior jugular vein ;
anterior belly of digastric ; mylo-hyoid, genio-hyoid,
genio-hyo-glossus, and hyo-glossus muscles ; the lingual
artery ; branches of the facial artery ; the hypoglossal
and gustatory nerves ; the submaxillary gland. The
substance of the tongue may be cut, and the floor of
tiie mouth freely opened. In any case, where the
attachments of the tongue are divided the organ is
apt to fall back upon the larynx and produce suffoca-
tion.

2. If the wound be across the thyro-hyoid space
the following may be the parts cut : Anterior jugular
vein ; sterno-hyoid, thyro-hyoid, omo-hyoid muscles ;
thyro-hyoid membrane ; inferior constrictor ; superior
laryngeal nerve ; superior thyroid artery ; and if
near hyoid bone the trunk of the lingual artery may
be cut. The pharynx would be opened in a deep
wound, and the epiglottis divided near its base.
Division of the epiglottis in wounds in this situation
is always a serious complication.

3. If the wound involve the trachea the following
may be the parts cut : Anterior jugular vein ; sterno-
hyoid, sterno-thyroid, and omo-hyoid muscles ; part of
sterno-mastoid ; thyroid gland ; superior and inferior
thyroid arteries ; superior, middle, and inferior thyroid
veins ; recurrent nerves and the gullet.

j

130 SURGICAL APPLIED ANATOMY. [Chap. ix.

In wounds of the neck the great vessels often
escape in a marvellous manner. They are protected
in part by the depth at which they are situated, and
in part by their great mobility, lying as they do in an
atmosphere of loose connective tissue. Dieffenbach
relates a case of cut throat in which both gullet and
trachea were divided without any damage to the
great vessels. In cut throat the vessels are greatly
protected by the projecting thyroid cartilage above,
and by the contracting of the sterno-mastoid muscles
below. Deep gashes made across the crico-thyroid
space, or through the upper part of the trachea,
reach the great vessels more easily than would wounds
made with equal force in any other part of the
neck.

In some cases of gunshot wound the vessels seem
to have been actually pushed aside, and to have owed
their safety to their mobility. Thus, in a case
reported by Longmore, the bullet passed entirely
through the neck from one side to the other. It
passed through the gullet, damaged the posterior part
of the larynx, but left the great vessels intact. In
another recorded case a boy fell upon the point of a
walking-stick. The end of the stick passed entirely
through the neck from side to side, entering in front
of one sterno-mastoid muscle, and emerging through
the substance of the opposite one. It probably passed
between the pharynx and the spine. The boy, who
left the hospital well in eighteen days, owed his safety
to the laxity of the cervical connective tissue, and to
the mobility of the main structures in the neck.

In connection with the subject of wounds of the
neck it must be remembered that the most important
part of the spinal cord can be reached from behind,
through the gap between the atlas and axis. In this
situation the cord has been divided by one stab of a
knife, the instrument entering between the two bones.

Chap, ix.] THE LARYNX AND TRACHEA. 131

Langier gives some ingenious cases of infanticide
where the lethal weapon was merely a long needle.
The needle was introduced into the spinal canal
between the atlas and axis, and the cord readily cut
across.

Wounds at the side of the neck have divided
considerable portions of the brachial plexus without
involving other structures.

The liyoid bone may be broken by direct
violence, as from blows, or in the act of throttling.
It is sometimes found broken in those who have been
hanged. The fracture may involve the body of the
bone, but more usually the greater cornu is found
broken off. In the New York Medical Record (1882)
is the report of the case of a man who felt something
snap under his chin while yawning. On examination
the hyoid bone was found to be fractured. The bone
was also found broken in a patient who threw her
head violently backwards to save herself from falling
(Hamilton). The fracture is associated with great
difficulty and pain in speaking, in moving the tongue,
in opening the mouth, and in swallowing, symptoms
that may be readily understood.

The larynx and trachea. — With the laryngo-
scope the following parts may be made out : The base
of the tongue and glosso-epiglottic ligaments ; the
superior aperture of the larynx, presenting in front
the epiglottis, at the sides the aryteno-epiglottidean
folds (in which are two rounded eminences corre-
sponding to the cornicula and cuneiform cartilages),
and at the back the arytenoid commissure of mucous
membrane. Deeply down can be seen the true and
false vocal cords, the ventricle, the anterior wall of
the larynx, a little of the cricoid cartilage, and more
or less of the anterior wall of the trachea. If the
glottis be very fully dilated the openings of the two
bronchi may be dimly seen.

132 SURGICAL APPLIED ANATOMY. [Chap. ix.

The thyroid and cricoid cartilages, and the greater
part of the arytenoid, are in structure hyaline, as are
the costal cartilages. Like the last-named, they are
liable to become more or less ossified as life ad-
vances, and when ossified are liable to be fractured
by violence ; the cartilage usually so fractured is the
thyroid.

The rim a. glottidis is the aperture between the
true vocal cords in front and the bases of the arytenoid
cartilages behind. It is the narrowest part of the
interior of the larynx, and it is well to be familiar
with its proportions in reference to the entrance of
foreign bodies, and the introduction of instruments.
In the adult male the rima measures nearly one inch
(23 millimetres) from before backwards ; from side
to side, at its widest part, it measures about 8 mm.,
and this diameter may be increased to 12 mm. in
extreme dilatation. In the female and the male before
puberty the antero-posterior diameter is about 17 mm.,
and the transverse about 4 mm.

The mucous membrane of the larynx varies
in thickness in different parts, and in the amount of
its submucous tissue. The membrane is thickest, and
the submucaus tissue most abundant, in the following
parts, taken in order of degree : The aryteno-
epiglottic(ean folds, the mucous membrane of the
ventricle, the fajse cords, and the laryngeal aspect of
the epiglottis. These are the parts that become
most congested and swollen in acute laryngitis ; and
the serious condition known as oedema of the glottis
depends mainly upon effusion into the lax submucous
tissue in the aryteno-epiglottidean folds. The affection
known as " clergyman's sore-throat " has an interesting
anatomical basis. The mucous membrane of the
larynx is well provided with mucous glands, whose
function it is to keep moist the parts concerned in
phonation. When an individual speaks aloud for a

chap, ix.] THE LARYNX AND TRACHEA. 133

long while the lining of the larynx tends to become
dry, on account of the large amount of cold air that
is drawn in directly through the mouth. To still keep
these parts moist the mucous glands have to exhibit
increased energy, and in those who speak much in
public the glands may in time become so over-worked
as to inflame. It is the inflammation of these glands
that constitutes the present affection. The glands are
not distributed equally over all parts of the larynx,
but are most numerous in the membrane covering
the arytenoid cartilages and parts immediately about
them, the base of the epiglottis, and the interior of
the ventricle. It is in these parts, therefore, that the
changes in chronic glandular laryngitis, or dysphonia
clericorum, are most marked.

The entire larynx has been removed for carcino-
matous disease, but the operation, although not imme-
diately fatal, has not been followed by very satisfactory
results. It is removed through an incision in the
middle line, and has to be freed from those muscles
that lie in front of it (sterno-hyoid, omo-hyoid), as well
as from those that are attached to it (sterno-thyroid,
thyro-hyoid, inferior constrictor and stylo-pharyngeus).
The larynx is then separated from the trachea, and
is dissected off from below up. The only vessels of
any magnitude divided are the superior and inferior
thyroid arteries and the thyroid veins. Both laryngeal
nerves are cut. In separating the gullet and pharynx
there is great risk of " button - holing " the former
tube.

Tracheotomy and laryngotomy. — The trachea
is about four and a half inches in length, and from
three-quarters to one inch in its extreme width.
It is surrounded by an atmosphere of very lax con-
nective tissue, which allows a considerable degree
of mobility to the tube. The mobility of the
trachea is greater in children than in adults, and

134 SURGICAL APPLIED ANATOMY. [Chap. ix.

adds much to the difficulties of tracheotomy. In
this procedure the windpipe is opened in the middle
line by cutting two or three of its rings above,
below, or through the isthmus of the thyroid gland.
Since the trachea, as it descends, lies farther from the
surface, and comes in relation with more and more
important structures, it is obvious that, other things
being equal, the higher in the neck the operation can
be done the better. The length of trachea in the
neck is not so considerable as may at first appear,
and, according to Holden, not more than some 7 or 8
of the tracheal rings (which number 16 to 20 in all)
are usually to be found above the sternum. The
distance between the cricoid cartilage and the sternal
notch varies greatly, and depends upon the length of
the neck, the age of the patient, and the position of
the head. If 2 inches of trachea are exposed above
the sternum when the head rests easily upon the
spine, then in full extension of the head some f of
an inch more of the windpipe will, as it were, be
drawn up into the neck. According to Tillaux, the
average full distance between the cricoid cartilage and
the sternum is, in the adult, about 2| inches (7 cm.).
The full distance in a child between three and five
years is about \\ inches (4 cm.), in a child between
six and seven about 2 inches (5 cm.), and in children
between eight and ten years about 2^ inches (6 cm.).
As may be imagined, the dimensions of the trachea
on section vary greatly at different ages, and even in
different individuals of the same age. This leads to
the question as to the proper diameter of tracheotomy
tubes. Guersant, who has paid much attention to
this matter, says that the diameter of the tubes should
run from 6 mm. to 15 mm.* The tubes with a
diameter of from 12 mm. to 15 mm. are for adults.

* The reader may be reminded that 12 mm. = about half an
inch, and 6 mm., therefore, = about a quarter of an inch.

chap, ix.] THE LARYNX AND TRACHEA. 135

The tubes below 12 mm. are for children, and are
divided into four sets.

No. 2. „ 8mm. „ 4 to 8 „

No. 3. 10mm. „ 8 to 12 „

No. 4. „ 12mm. „ 12 to 15

In children under eighteen months the diameter of
the tube should be about 4 mm.

In performing tracheotomy it is most impor-
tant that the head be thrown as far back as possible,
and that the chest be kept strictly in a line with
the sternal notch, so that the relations of the middle
line of the neck be preserved. Full extension of the
head not only gives the surgeon increased room for
the operation, but also brings the trachea nearer to
the surface, and by stretching the tube renders it
much less mobile.

In cutting down upon the trachea in the middle
line of the neck from the cricoid cartilage to the
'sternum the following parts are met with. Beneath
the integument lie the anterior jugular veins. As
a rule these veins lie some little way apart on either
side of the median line, and do not communicate
except by a large transverse branch which lies in the
iiiterfascial space at the upper border of the sternum.
Sometimes there are many communicating branches
right in front of the tracheotomy district, or the veins
may form almost a plexus in front of the trachea, or
there may be a single vein which will follow the
middle line. Then comes the cervical fascia, enclosing
the sterno-hyoid and sterno-thyroid muscles. The
gap between the muscles of opposite sides is lozenge-
shaped, and is such that the trachea can be exposed
without dividing muscle fibres. The isthmus of the
thyroid usually crosses the 2nd, 3rd, and 4th rings of
the trachea. Above it a transverse communicating

136 SURGICAL APPLIED ANATOMY. [Chap. ix.

branch between the superior thyroid veins is sometimes
found. Over the isthmus is a venous plexus, from
which the inferior thyroid veins arise, while below the
isthmus these veins lie in front of the trachea together
with the thyroidea ima artery (when it exists). The
inferior thyroid vein may be represented by a single
trunk occupying the middle line. In the infant before
the age of two years the thymus extends up for
a variable distance in front of the trachea. At
the very root of the neck the trachea is crossed by the
innominate and left carotid arteries and by the left in-
nominate vein ; and lastly, abnormal branches of the
superior thyroid artery may cross the upper rings
of the windpipe.*

The evil of wounding the thyroid isthmus is
greatly exaggerated. I have frequently divided this
structure in performing tracheotomy without any in-
convenience resulting. Like other median raphe, the
middle line of the thyroid isthmus has but a slight
vascularity, and it has been shown that one side of
the thyroid gland cannot be injected from the other
(i.e.,loj injection that would cross the isthmus). The
difficulty of tracheotomy in infants depends upon the
shortness of the neck, the amount of the subcutaneous
fat, the depth at which the trachea lies, its small size,
its great mobility, and the ease with which it can be
made to collapse on pressure. To the finger, roughly
introduced, the infant's trachea offers little resistance.
Its mobility is such that we hear of its being held aside
unknowingly by retractors, while the operator is
scoring the oesophagus (Durham). In the child also
the great vessels often cross the trachea higher up than
in the adult, and some inconvenience may also arise
from an unduly prominent thymus. In introducing

* See an excellent article on the anatomy of this region by Dr.
Pilcher, "Annals of Anatomy and Surgery." New York, April,
1881.

chap, ix.] THE LARYNX AND TRACPIEA. 137

the cannula, if the tracheal wound be missed, it is
easy to thrust the instrument into the lax tissue be-
neath the cervical fascia and imagine that it is within
the windpipe.

In laryngotomy the air passage is opened by a trans-
verse cut through the crico-thyroid membrane. The
crico- thyroid space only measures about half an inch
in vertical height in well-developed adult subjects,
while in children it is much too small to allow of a
cannula being introduced. The crico-thyroid arteries
cross the space, and can hardly escape division. They
are, as a rule, of very insignificant size, and give no
trouble. Occasionally, however, these vessels are
large, and " cases are recorded in which serious and
even fatal haemorrhage has occurred from these vessels "
(Durham). In introducing the cannula it may readily
slip between the crico-thyroid membrane and the
mucous lining instead of entering the trachea.

Foreign bodies often find their way into the
air passages, and have been represented by articles of
food, teeth, pills, buttons, small stones, and the like.
They are usually inspired during the act of respiration,
and may lodge in the superior aperture of the larynx,
or in the rima, or find their way into the ventricle,
or lodge in the trachea, or enter a bronchus. If a
foreign substance enters a bronchus it usually selects
the right, that bronchus having its aperture more im-
mediately under the centre of the trachea than has
the left tube. Quite recently, in a dissecting-room
subject, I found two threepenny pieces lying side by
side, in the right bronchus, so as to entirely block the
tube. The danger of inhaled foreign substances de-
pends not so much upon the mechanical obstruction
they offer, as upon the spasm of the glottis they excite
by reflex irritation. A body may, however, lodge in the
ventricle for some time without causing much trouble,
as in a case reported by Desault, where a cherry-stone

138 SURGICAL APPLIED ANATOMY. [Chap. ix.

lodged for two years in this cavity without much
inconvenience to its host. In one strange case a
bronchial gland found its way into the trachea by
producing ulceration of that tube, was coughed up,
and became impacted in the rima glottidis. The
patient was saved from immediate suffocation by
tracheotomy.

The thyroid body. — Each lobe should measure
about 2 inches in length, about 1J inches in breadth,
and | of an inch in thickness at its largest part.
When distinctly beyond these measurements the
thyroid may be considered to be enlarged. Its usual
weight is between one and two ounces. It is larger
in females than in males, and the right lobe is usually
larger than the left. In connection with these matters
it may be noted that thyroid enlargements (broncho-
cele, goitre) are more common in females than in males,
and in any case are more apt to be first noticed on the
right side. The body being closely adherent to
the trachea and larynx, it follows that it moves
up and down during deglutition, and this circum-
stance is of the utmost value in the diagnosis of
bronchocele from other cervical tumours. The thyroid
when enlarged may distort and narrow the trachea,
and this is all the more likely to be the case when the
enlargement occurs rapidly, since the body is held
down by the sterno-hyoid, sterno-thyroid, and omo-
hyoid muscles. In some cases, therefore, of dyspnoea
produced by rapidly growing bronchoceles, Bonnet
has proposed subcutaneous section of these muscles,
Since the isthmus must bind together the enlarging
lobes of a bronchocele, Sir Duncan Gibb, on the other
hand, proposed to divide the isthmus in cases where
dyspnoea resulted. This operation he performed
several times with great relief to the patient. The
thyroid body is very vascular, and is invested by
a thin capsule. In removing the gland (and many

Chap, ix.] THE GULLET 139

enlarged thyroids have been successfully removed
entire), great care should be taken not to tear
through this capsule before the vessels are secured.
If the capsule be torn, the gland tissue is ex-
posed and is apt to bleed profusely. Since the
superior thyroid arteries enter at the upper end of
each lobe, and the inferior thyroid vessels at the lower
end, it is essential, before the actual removal of the
mass is commenced, that the vessels be secured en
masse at each of the four corners of the body. The
posterior border of the thyroid body being in contact
with the sheath of the great vessels, it follows that
the gland when enlarged may readily receive pulsations
from those vessels. It generally touches also the lower
part of the pharynx, and the upper part of the gullet
behind, and enlargement in this direction may, in con-
nection with the interference with the movement of
the larynx in deglutition, serve to explain the difficulty
in swallowing often noticed in bronchocele.

The gullet commences opposite the sixth cervical
vertebra, and pierces the diaphragm opposite the
tenth or eleventh dorsal. It presents three curves :
one is antero- posterior, and corresponds to the curve
of the spinal column; the other two are lateral.
The gullet commencing at the middle line deviates
slightly to the left as far as the root of the neck ;
from thence, to the fifth dorsal vertebra, it gradually
returns to the middle line, and finally it turns again
to the left, at the same time passing forwards, to
pierce the diaphragm. Its length is from 9 to 10
inches. Its transverse diameter has been carefully
estimated by Dr. Mouton, by filling the gullet with
plaster of Paris in situ, and then measuring the cast
thus obtained. Dr. Mouton found that there were
three narrow parts in the gullet, one at its com-
mencement, one about 2| inches from that point, and
a third where the tube passed through the diaphragm.

140 SURGICAL APPLIED ANATOMY. [Chap. ix.

The diameter at each of these points was a little over
half an inch (14 mm.); the diameter elsewhere
was about f inch (17 mm. to 21 mm.). By for-
cible distension the two upper narrow parts could
be distended to a diameter of 18 to 19 mm., the
lower part to 25 mm., and the rest of the gullet to a
diameter of nearly 1| inches (35 mm.). It follows
that foreign bodies when swallowed are most apt to
lodge either at the commencement of the gullet or at
the spot where it passes the diaphragm. The same
parts also are those most apt to show the effects of
corrosives that have been swallowed.

Among the relations of the oesophagus, the follow-
ing may be noted as receiving illustration in surgical
practice. The gullet is in nearly all its course in
close relation with the front of the vertebral column.
In the neck the trachea is immediately in front of it.
In the thorax it is in close connection with the aorta,
and has the vena agygos behind it and on its right-
hand side. It is, moreover, partly in contact with
both pleurae, but more especially with the membrane
of the right side; and, lastly, the recurrent laryngeal
nerve ascends between it and the trachea. (See Figs.
33 and 35.)

Now, foreign bodies impacted in the gullet are
very apt to lead to ulcerations that may open adjacent
parts. Thus, in the Musee Dupuytren is a specimen
showing a five-franc piece that had stuck in the
gullet, and had produced an ulcer that had opened
the aorta. In another instance a " smasher" swallowed
a counterfeit half-crown piece. Eight months after
he died of haemorrhage. The coin had sloughed into
his aorta. In another case (Lancet, 1871), a fish-bone,
lodged in the gullet opposite the fourth dorsal vertebra,
had caused two perforating ulcers ; one on the right
side had caused plugging of the vena azygos major,
while the other on the left had made a hole in the aorta.

Chap, ix.] THE GULLET. 141

Less frequently impacted foreign substances have
found their way into the trachea and into the posterior
mediastinum. Dr. Ogle reports a case (Path. Soc.
Trans., vol. iv.) where a piece of bone impacted in
the gullet induced ulceration of an inter vertebral
disc and subsequent disease of the spinal cord.
Carcinoma of the gullet, also, when it spreads, is apt
to invade adjacent parts, and especially to open into
the trachea or bronchi. If it spreads to the pleura, it
will usully involve the right pleura, as being the
membrane more in relation with the gullet. Cancer
of the gullet has so spread as to invade the thyroid
body, the pericardium, and the lung, and has opened
up the first intercostal artery in one case, and the
right subclavian in another (Butlin's " Sarcoma and
Carcinoma," 1882).

The operation of cesopHag'otoiiiy consists in
incising the gullet for the purpose of removing an
impacted foreign body. The gullet is usually reached
from the left side, since it projects more on that
aspect. The incision is made between the sterno-
mastoid and the trachea, in the same direction as the
incision for ligaturing the common carotid. The cut
extends from the top of the thyroid cartilage to the
stern o-clavicular joint. The omo-hyoid muscle is
drawn outwards, or cut. The great vessels, larynx
and thyroid gland, are drawn aside, and care must
be taken not to wound these structures nor damage
the thyroid vessels or the recurrent nerve. The
gullet, when exposed, is opened by a vertical incision.

In cesophagostomy the opening is made into
the gullet through a like incision in cases of stricture
of the tube high up, the object being to feed the
patient through the opening made, in place of per-
forming gastrostomy. The risk, however, of setting
up severe diffuse inflammation in the loose planes of
connective tissue deep in the neck is very great, and

142 SURGICAL APPLIED ANATOMY. [Chap. ix.

in some twenty-six cases in which the operation has
been already performed death has, in nearly all
instances, supervened at the end of a few hours or
days.

Great vessels. — The course, relations, and ab-
normalities of the great cervical vessels, together with
the operations whereby they may be ligatured, and
the details pertaining to those procedures, are so fully
given, not only in works on operative surgery, but
also in the chief anatomical text-books, that nothing
need be said upon the matter in this place. The
bifurcation of the common carotid is a favourite
locality for aneurism, being a point where some resis-
tance is offered to the blood current. These tumours,
also, are common at the root of the neck, where they
are often due to extension of aneurismal disease from
the aorta, although in many cases they have an in-
dependent origin. It is in the neck that the treat-
ment of aneurism by the distal ligature is most often
carried out. There is 110 place in the body where
Brasdor's operation can be carried out with the
completeness with which it can be adopted in the
neck. In this procedure, a main trunk is ligatured
on the distal side of an aneurism, no branches inter-
vening between the sac and the ligature. The cure
by this measure depends upon the fact that blood
does not continue to go to parts when once the
need for blood in them is diminished. Thus, after
amputation at the hip joint, the femoral artery, having
no need to carry to the stump the amount of blood it
brought to the limb, often shrinks to a vessel no
larger than the radial. When an aneurism low down
in the carotid artery is treated by ligature of the
vessel near its bifurcation by Brasdor's method, the
blood, having now, as it were, no object in entering
the carotid trunk, soon ceases to fill the vessel entirely,
and the artery (and in successful cases the aneurism)

chap, ix.j THE NECK. 143

shrinks in coriseque^Kle. ; -"WArcirbp's operarioh, or1 -the
distal ligature' of large' branches tor" 'th6 relief of
aneurism ''of a! 'mair1 iftrrofc, is now, perhaps, quite
limited as* 't<> :its performance to the Ii^ai'i5re~ of the
carotid and subclaviaii arteries for innominate aneur-x
ism. Since in this procedure large branches come off
between the sac and the ligature, it is not easy to fully
understand how the operation acts beneficially. It is
assumed to owe its success to the same principle that
underlies Brasdor's operation. The right carotid and
subclavian have also been ligatured for aortic aneurism
with some success, and here also the reason for the
good effected by the operation is difficult to appreciate.
It has been pointed out that the innominate artery
lies more or less directly in the axis of the ascending
aorta, while the left carotid and subclaviaii arteries
arise at an angle to that axis, and it is upon this fact
that reasons have been founded for selecting the
vessels of the right side (Barwell). The matter is,
however, complicated by the knowledge that when
vegetations are swept off the aortic valves they enter
the left carotid with infinitely greater frequency than
they do the right. The whole subject, indeed, requires
investigation.

The cervical connective tissue being lax, aneurisms
in this part can grow and spread rapidly, and usually
soon produce " pressure symptoms." As examples of
these may be noted oedema and lividity of the face or
the upper limb from pressure upon the main veins
laryngeal symptoms from pressure upon the recurrent
nerve or trachea, spasm of the diaphragm from pres-
sure upon the phrenic nerve, damage to the sympa-
thetic, and giddiness and impaired vision from anaemia
of the brain. It must be remembered that the veins
of the neck are under the influence of the respira-
tory movements, and that when one of these vessels
is opened air may very readily be drawn into it by

144 SURGICAL APPLIED ANATOMY. [Chap. ix.

the inspiratory act, just t as ,, air is drawn. into the
:

The vertebral artery has beeji l^gat^rec] y/ith some
be'aefii; in cases t>'f 'epilepsy. The artery is reached
through a,n incision made along the posterior border
of the sterno-mastoid muscle just above the clavicle.
The " carotid tubercle" (see page 119) is then sought
for, and vertically below it the artery lies in the gap
between the scalenus anticus and longus colli muscles.
The procedure is surrounded by considerable diffi-
culties.

Dr. Bright and Dr. Eamskill have stated that
disease involving the vertebral artery just before it
enters the skull may lead to pain at the back of the
head. It is well known that the sub-occipital nerve lies
in close connection with the artery over the posterior
arch of the atlas, and that it gives a branch to the
great occipital nerve which is distributed to the back
of the head. The close connection of artery and
nerve and this communicating branch may serve to
explain the symptom noted. In some of Dr. Ram-
skill's cases there was difficulty of articulation. This
he ascribes to pressure upon the hypoglossal nerve,
which is also in close relation with the vertebral
artery.

The lymphatic glands in the neck are
very numerous, and are arranged in the following
sets: (1) Submaxillary (10 to 15), situate along the
base of the jaw beneath the cervical fascia ; (2) supra-
hyoid (1 or 2), situate about the middle line of the
neck between the chin and the hyoid bone ; (3) super-
ficial cervical (4 to 6), situate along the external
jugular vein beneath the platysma ; (4) deep cervical,
upper set (10 to 20), situate about the bifurcation of
common carotid, and along the upper part of the in-
ternal jugular vein ; (5) deep cervical, lower set (10 to
16), situate about the lower part of the internal

Chap, ix.] THE NECK. 145

jugular vein, extending outwards into the supra-
clavicular fossa, and becoming continuous with the
axillary and mediastinal glands.

These glands are very often enlarged and inflamed,
and it is in this part of the lymphatic system that the
changes in scrofula are most commonly met with.
The inflammatory affections in glands would appear
to be always of a secondary nature (if we exclude
some cases of inflammation excited by injury, and
perhaps by exposure to severe cold), and to follow
disturbances in those parts of the periphery whence
they respectively receive their lymph. It may be
convenient, therefore, to group the relations of certain
glands to certain parts of the periphery.

Scalp. — Posterior part = suboccipital and mas-
toid glands. Frontal and parietal portions = parotid
glands.

Vessels from the scalp also enter the superficial
cervical set of glands*

Skin of face and neck = submaxillary, parotid,
and superficial cervical glands.

External ear = superficial cervical glands.

Lower lip = submaxillary and suprahyoid glands.

Buccal cavity = submaxillary glands and deep
cervical glands (upper set).

Gums of lower jaw — submaxillary glands.

Tongue* — Anterior portion = suprahyoid and sub-
maxillary glands. Posterior portion = deep cervical
glands (upper set),

Tonsils and palate — ^.QQ^ cervical glands (upper
set).

Pharynx. — Upper part — parotid and retro-pha-
ryngeal glands. Lower part = deep cervical glands
(upper set).

Larynx, orbit, and roof of mouth = deep cervical
glands (upper set).

Nasal fossce = retro-pharyngeal glands, deep cervical

146 SURGICAL APPLIED ANATOMY. [Chap. ix.

glands (upper set). Some lymphatics from posterior
part of the fossae enter the parotid glands. *

Branchial fistulae. — Certain congenital fistulas
are sometimes met with in the neck, which are due to
partial persistence of one of the branchial clefts.
These clefts are placed in the fostus between the
branchial arches. The arches are usually described
as five in number. The first lays the foundation for
the lower jaw. From the second are developed the
incus, the styloid process, the stylo-hyoid ligament
and lesser cornu of the hyoid bone. From the third
is formed the body and greater cornu of the
hyoid bone, while the fourth and fifth take part
in the formation of the soft parts of the neck
below the hyoid bone. The first cleft is between
the first and second arches. " The cervical branchial
fistulas appear congenitally as very fine canals
opening into minute orifices in one or both sides
of the fore part of the neck, and leading backwards
and inwards or backwards and upwards towards
the pharynx or oasophagus " (Paget). Their length is
about 1J to 2^ inches, and their diameter varies from
that of a bristle to that of an ordinary probe. They
usually exist about the line of the third or fourth
cleft, and are most often met with just above the
sterno-clavicular joint. Others are found about the
level of the top of the thyroid cartilage at the anterior
edge of the sterno-mastoid muscle. It would appear
that certain poly cystic congenital tumours, occurring
as one form of " hydrocele of the neck," may be de-
veloped from an imperfectly closed cleft. I have
elsewhere detailed the dissection of one of these
tumours that appeared to be associated with a partially
closed second branchial cleft (Path. Soc. Trans., 1881).

* From " Scrofula, and its Gland Diseases," by the Author.

'47

part 5L

CHAPTER X.

THE THORAX.

1. THE thoracic walls. — The two sides of the
chest are seldom symmetrical, the circumference of
the right side being usually the greater, a fact that is
supposed to be explained by the unequal use of the
upper limbs. In Pott's disease, involving the dorsal
region, when the spine is much bent forwards, the
thorax becomes greatly deformed. Its antero-posterior
diameter is increased, the sternum protrudes, and may
even be bent by the bending of the spine, the ribs are
crushed together, and the body may be so shortened
that the lower ribs overlap the iliac crest.

In pigeon-breast deformity the sternum and
cartilages are rendered protuberant, so that the antero-
posterior measurement of the chest is much increased,
while a deep sulcus exists on either side along the
line of junction of the ribs and their cartilages. It is
by the sinking in of the parietes along this line that
the protuberance is produced. Shaw gives the following
explanation of this deformity : " When an inspira-
tion is taken, a threatened vacuum is created within
the chest, air rushes in by atmospheric pressure, and
at the end of the inspiration the balance of pressure
without the chest and within it are equalised. If in
inspiration there is an impediment to the entrance of
air, the atmospheric pressure upon the external wall
of the chest must produce some effect, being un-
balanced by a like pressure upon the inner chest wall.
In children, and especially in rickety children, the

148 SURGICAL APPLIED ANATOMY. [Chap. x.

thorax is very pliable and elastic, and if a constant
impediment exists to the entrance of air, as afforded,
for example, by greatly enlarged tonsils, the thoracic
walls may yield in time to the unbalanced pressure
brought to bear upon them at each inspiration. The
weakest part of the thorax is along the costo-chondral
line on either side, and it is here that the parietes
yield most conspicuously in such cases, and by this
yielding the deformity is produced."

The sternum. — The upper edge of the sternum
fin inspiration) corresponds to the disc between the
second and third dorsal vertebrse, and the sterno-
xiphoid joint to the lower part of the ninth dorsal.
A transverse ridge may be felt upon its anterior sur-
face that corresponds to the junction of the manu-
brium and gladiolus, and is in a line with the second
costal cartilages. The skin over the sternal region is
the part of the surface most frequently the seat of
keloid. The bone is rarely fractured, being soft
and spongy, and supported by the elastic ribs
and their cartilages, as by a series of springs. In
the old, when the cartilages are ossified and the chest
more rigid, the tendency to fracture is increased.
The sternum is most often found fractured in connec-
tion with injuries to the spine, although it may be
broken by simple direct violence. The bone may be
fractured by violent bending of the spine backwards,
and by abrupt bending of it forwards. In the former
instance the lesion is probably due to muscular
violence, to the abdominal muscles and the sterno-
mastoid pulling one against the other. In the latter
instance the lesion is commonly brought about
by the violent contact of the chin with the bone. In
all instances the fracture is usually transverse, and
most often occupies the line between the manubrium
and the gladiolus. As these two parts of the bone
are not entirely united until middle life, and are often

Chap, x.] THE THORAX. 149

not united at all, it follows that the lesion is in many
cases a dislocation rather than a fracture. The manu-
brium in these injuries 'generally remains in situ,
while the gladiolus with the ribs is displaced forwards
in front of it. Malgaigne cites the case of a youth
who, from constant bending at his work as a watch-
maker, caused the second piece of the sternum to
glide backwards behind the manubrium. Here, prob-
ably, the connection between the two bones was not
very substantial.

From its exposed position and cancellous structure,
the sternum is liable to many affections, such as caries
and gummatous periostitis. The comparative softness
also of the bone is such that it has been penetrated by
a knife in homicidal wounds. The shape and position
of the bone have also been altered by pressure, as
seen sometimes in artisans following employments re-
quiring instruments, etc., to be pressed against the
chest.

Certain holes may appear in the middle of the
sternum, and through them mediastinal abscesses may
escape, and surface abscess pass deeply into the thorax.
In the case of E. Groux, the bone was separated verti-
cally into two parts. The gap could be opened by
muscular effort, and the heart exposed covered only
by the soft parts. The sternum has been trephined
for mediastinal abscess, and for paracentesis in peri-
cardial effusion, and it has been proposed also to
ligature the innominate artery through a trephine hole
in the upper part of the bone.

The ribs are placed so obliquely that the anterior
end of one rib is on a level with the posterior end of
a rib some way below it in numerical order. Thus
* the first rib in front corresponds to the fourth rib
behind, the second to the sixth, the third to the
seventh, the fourth to the eighth, the fifth to the ninth,
the sixth to the tenth, and the seventh to the eleventh.

150 SURGICAL APPLIED ANATOMY. [Chap. x.

If a horizontal line be drawn round the body at the
level of the inferior angle of the scapula, while the
arms are at the side, the line would cut the sternum
in front between the attachments of the fourth and
fifth ribs, would cut the fifth rib at the nipple line,
and the ninth rib at the vertebral column. The
second rib is indicated by the transverse ridge on the
sternum already alluded to. The lower border of the
pectoralis major leads to the fifth rib, and the first
visible serration of the serratus magnus corresponds to
the sixth. The longest rib is the seventh, the shortest
the first. Tn breadth the bones decrease from the first
to the twelfth. The most oblique rib is the ninth.

The ribs are elastic and much curved, and being
attached by many ligaments behind to the column,
and in front to the yielding cartilages, resist injuries
tending to produce fracture with the qualities
possessed by a spring. A rib may be fractured by
indirect violence, as by a wheel passing over the body
when lying prostrate on the back. In such a case
the force tends to approximate the two ends of the
bone, and to increase its curve. When it breaks,
therefore, it breaks at the summit of its principal
curve, i.e., about the centre of the bone. The
fragments fracture outwards, and the pleura stands
no risk of being penetrated. When the rib is broken
by direct violence, the lesion occurs at the spot
encountered by the force, the bone fractures inwards,
the curve of the rib tends to be diminished rather than
increased, and there is much risk of the fragments
lacerating the pleura.

Those most often broken are the sixth, seventh,
and eighth, they being under ordinary circumstances
the most exposed. The rib least frequently fractured
is the first, which lies under cover of the clavicle.
Fractures are more common in the elderly than in
children, owing to the ossification of the cartilages

chap, x.] THE THORAX. 151

that takes place in advancing life. When a rib is
fractured, no shortening occurs, the bone being fixed
both in front and behind, while vertical displacement
is prevented by the attachments of the intercostal
muscles. Thus no obvious deformity is produced unless
a number of consecutive ribs are the subjects of frac-
ture. These bones have been broken by muscular
violence, as during coughing, and in violent expulsive
efforts such as are incident to labour. In such in-
stances the ribs are probably weakened by atrophy or
disease.

In many instances of gun-shot wound the curve
of the rib has saved the patient's life. In such cases
the bullet has entered behind near the dorsal spine,
has been conducted round the chest, along the curve
of a rib beneath the skin, and has escaped again near
the sternum. This property, however, of the ribs for
turning bullets refers rather to the days of round
bullets, and not to modern conical projectiles.

In rickets changes take place at the point of
junction of the ribs and cartilages leading to bony
elevations, which produce, when the ribs on both sides
are affected, the condition known as the " rickety
rosary."

The intercostal spaces are wider in front
than behind, and between the upper than the lower
ribs. The widest of the spaces is the third, then the
second, then the first. The narrowest spaces are the
last four. The first five spaces are wide enough to
admit the whole breadth of the index finger. The
spaces are widened in inspiration, narrowed in expira-
tion, and can be increased in width by bending the
body over to the opposite side.

Paraceiitesis is usually performed in the sixth
or seventh space, at a point midway between the
sternum and the spine, or midway between the
anterior and posterior axillary lines. If a lower

152 SURGICAL APPLIED ANATOMY. [Chap. x.

space be selected there is great danger of wounding
the diaphragm, especially upon the right side. The
trochar should be entered during inspiration, the space
being widened thereby, and should be kept as near as
possible to the lower border of the space, so as to
avoid the intercostal vessels. Tapping of the chest
through any space posterior to the angles of the ribs
is not practicable, owing to the thick covering of
muscles upon the thoracic wall in this place, and the
fact that the intercostal artery, having a more
horizontal course than the corresponding ribs, crosses
the middle of this part of the space obliquely. Beyond
the angle the intercostal vessels lie in a groove on the
inferior border of the rib forming the upper boundary
of the space. The vein lies immediately above the
artery, and the nerve immediately below it. In the
upper four or five spaces, however, the nerve is at
first higher than the artery.

Owing to the protection it derives from the ribs
and the intercostal muscles, it happens that the inter-
costal artery is seldom wounded, and when wounded
it will be understood that considerable difficulty is
experienced in securing the vessel without doing
damage to the pleura and adjacent parts.

Pus may readily be conducted along the loose
tissue between the two layers of intercostal muscles.
Thus, in suppuration following upon disease of the
transverse processes or bodies of the vertebrae, or of the
posterior parts of the ribs, the pus may be conducted
along the intercostal spaces to the sternum, and may
thus present at a considerable distance from the real
seat of the disease.

The internal mammary artery runs parallel
to the border of the sternum, and about half an inch
from it. It may give rise to rapidly fatal haemorrhage
if wounded. The vessel may readily be secured in the
first three intercostal spaces, and with some difficulty

Chap, x.] THE THORAX. 153

in the fourth or fifth space. It is most easily reached
through the second space, and cannot be secured
through any space below the fifth.

The female breast extends from the third to
the fifth rib. It is supported by the superficial
pectoral fascia, which divides into two layers to
enclose it. The organ is made up of an accumulation
of racemose glands, which open into ducts discharging
at the nipple. In cases where during lactation the
acini are engorged with milk, the outlines of the
several, lobules and lobes of the breast are rendered
very distinct. The size of the breast depends usually
rather upon a deposit of fat collected about the organ
and distributed among its lobules than upon a
development of true gland tissue. A considerable
and rapid development of the mammary gland tissue
takes place at puberty, and the breast remains in its
most perfect anatomical condition during the child-
bearing period of life. After the cessation of men-
struation, the glandular tissue atrophies, although the
ducts always persist. The breast is thinner at the
periphery than at the centre, and is thinnest about a
line extending from the nipple to the sterno- clavicular
joint. Abscesses situated beneath the breast not un-
frequently make their way through the gland at some
point along this line. The base of the gland is flat, and
is separated from the pectoral muscle by much loose
connective tissue. It is in this tissue that the sub-
mammary abscess forms. There is sometimes a kind
of bursa between the breast and the muscle which has
been found to form a definite hygroma or bursal cyst
(Yelpeau). Although the gland is but loosely con-
nected with the pectoralis major, yet it moves a little
with that muscle, and the position of the breast can
be slightly affected by the movement of the arm.
It is important, therefore, that the arm should be
kept at rest in inflammatory affections of the organ.

154 SURGICAL APPLIED ANATOMY. [Chap. x.

In cancer, the gland and the muscle may become
intimately adherent. The nipple is situated over the
fourth interspace, about three-quarters of an inch
from the junction of the ribs with their cartilages,
and some four inches from the middle line. It
contains muscular fibres, by means of which it can be
rendered prominent on stimulation. The skin about
the nipple is very thin and sensitive, and is often the
seat of painful fissures and excoriations. When any
contracting growth, such as scirrhus, drags upon the
ducts of the gland, the nipple becomes retracted.

Abscesses of the breast should be opened by in-
cisions radiating from the nipple, so as to avoid un-
necessary damage to the mammary ducts.

The breast is supplied by the anterior cutaneous
branches of the second, third, fourth, and fifth inter-
costal nerves, and by the lateral branches of the last
three of those nerves. The connections of these
trunks serve to explain the diffusion, of the pain
that is sometimes observed in painful affections of
the gland. Thus in abscess of the breast pain is
often felt round the side of the thorax to the back,
following the trunks of the above-named intercostal
nerves ; or it is distributed over the scapula by the
cutaneous branches of the posterior divisions of such
dorsal nerves as correspond to the intercostal trunks
that supply the breast ; or it runs down the arm
along the intercosto-humeral nerve (a branch of the
second intercostal), or shoots up the neck, probably,
along the supra-clavicular branch from the cervical
plexus, which communicates with the same intercostal
trunk.

The gland is supplied by the following arteries,
which are divided in excision of the organ : the
second, third, fourth, and fifth intercostal branches
of the internal mammary artery, some few branches
from the corresponding intercostal vessels, the long

Chap. x.i THE THORAX. 155

thoracic artery, and the external mammary. The
majority of the lymphatics from the breast proceed to
the axilla. Some few follow the mammary branches
of the internal mammary artery, and enter the
anterior mediastinal glands, which are consequently
often found enlarged in cancer of the organ.

As the chief blood- supply of the breast comes
from the axilla, and as the main lymph vessels pro-
ceed to that region, it follows that malignant growths
of the gland tend to spread towards the axilla rather
than towards the middle line.

2. The thoracic viscera.

The lung*. — The apex of the lung rises in the neck
from one to one arid a half inches above the clavicle.
The anterior edges of the two lungs lie behind the
sterno-clavicular articulations, pass obliquely behind
the manubrium, and meet in the middle line at the
junction of the manubrium with the gladiolus. The
edge of the right lung then continues vertically down-
wards behind the middle line of the sternum to the
sixth chondro-sternal articulation, where it slopes off
along the line of the sixth rib. The edge of the left
lung keeps close to that of the right as far as the fourth
chondro-sternal articulation, where it turns off to the
left, following a line drawn from the fourth cartilage
to the apex of the heart. The lower border of the
lung corresponds to a slightly convex line drawn round
the chest from the sixth chondro-sternal articulation
in front to the tenth dorsal spine behind. In the
mammary line this line would correspond to the sixth
rib, opposite the posterior fold of the axilla with the
eighth rib, and in a line continued vertically down-
wards from the inferior angle of the scapula with the
tenth rib. The pleura extends further down than
the lung, reaching in front to the level of the seventh
chondro-sternal union, behind to the eleventh dorsal
spine, and at the sides to a point some two and a half

156 SURGICAL APPLIED ANATOMY. [Chap. x.

inches above the lower margin of the thorax. Thus
it will be seen that the pleura and diaphragm may
be wounded in many places without the lungs being
involved.

In penetrating wounds involving the pleura, air
may enter the pleural cavity, producing pneumo-
thorax, and this air may be subsequently pressed by
the respiratory movements into the subcutaneous
tissues through the wound in the parietal pleura, and
lead to surgical emphysema. The two layers of the
pleura are so intimately in contact with one another
in the normal thorax that it is questionable whether
the parietal pleura can be wounded without injury to
the visceral layer. In wounds of the lung without
external wound, as when that organ is torn by a
fractured rib, the air escapes from the lung into the
pleura, and may thence pass into the subcutaneous
tissues through the pleural wound, thus producing both
pneumo-thorax and emphysema.

It is well to note that emphysema may occur
about certain non-penetrating wounds of the thorax
when they are of a valvular nature. In such cases
the air is drawn into the subcutaneous tissues during
one respiratory movement, and is forced by another
into the cellular tissue, the valvular nature of the
wound preventing its escape externally. When the
pleural " cavity " is opened, the lungs become more
or less collapsed ; yet a few cases have been recorded
where the lung has protruded at the time of the acci-
dent through the wound in the parietes. In such in-
stances the glottis must have been closed, and the lung
fully distended at the time of the injury ; and it must
be further assumed that the viscus was practically pro-
truded before air could enter the pleural space. It is
noticeable that these recent hernise are most common
at the anterior part of the chest where the lungs are
the most movable, and the injuries that bring them

Chap, x.] THE THORAX. 157

about are often associated with violent respiratory
efforts at the time of the accident. In wounds of the
lung the blood may escape in three directions : into
the tissue of the organ (pulmonary apoplexy), into the
bronchi (causing haemoptysis), and into the pleura
(causing hsemothorax). In some instances the lung
has been ruptured without wound and without frac-
ture of the ribs. These cases are difficult to interpret,
and probably the best explanation suggested is that
put forward by M. Gosselin. This surgeon believes
that at the time of the injury the lungs are suddenly
filled and distended with air by a full inspiration,
and that the air, prevented from escaping by occlusion
of the larynx, thus becomes pent up in the pulmonary
tissue, and the lung not being able to recede from
the superincumbent pressure, its structure necessarily
gives way.

Owing to the fineness of its capillaries, and to the
fact that all venous blood returned to the heart must
pass through the lungs before it can reach other parts
of the body, it follows that pysemic and other secondary
deposits are more commonly met with in the lung
than in any other of the viscera.

The trachea divides opposite the junction of the
manubrium and gladiolus in front, and the interval
between the third and fourth dorsal spines behind
(Fig. 33).

Certain foreign substances that have been drawn
into the air passages have shown a remarkable facility
for escaping through the parietes. Thus Mr. Godlee
records the case of a child, from an abscess in whose
back a head of rye-grass esca-ped, that had found its
way into the air passages forty -three days previously.

The heart. — The relations of the heart to the
surface are as follows. Its upper limit corresponds
to a horizontal line crossing the sternum about the
upper border of the third cartilages. Its right border

158

SURGICAL APPLIED ANATOMY. [Chap. x.

to a curved line arching from the third right cartilage
at the sternum to the seventh right chondro-sternal
articulation, and reaching about 1^ inches from the
middle line. Its lower border follows a line from the

Fig. 16. — Diagram to show the relations of the Heart to the Surface.
(4/ter Eiidinger.)

a, Left innominate vein ; 6, right innominate vein : c, superior vena cava ; d, right
auricle ; e, inferior vena cava ; /, aorta ; g, pulmonary artery ; h, right ven-
tricle ; i, left ventricle ; j, left auricle.

seventh right chondro-sternal articulation to the apex.
Its apex is opposite the fifth interspace, 3^ inches to
the left of the middle line. Its left border is repre-
sented by ail arched line drawn from the apex to the
third left cartilage at the sternum.

The orifice of the pulmonary artery is behind the
upper edge of the third left cartilage close to the

Chap, x.] THE THORAX. 159

sternum. The vessel proceeds upwards under cover
of the second left cartilage. The aortic orifice is behind
the left border of the sternum close to the lower edge
of the third cartilage. The trunk ascends behind the
second cartilage of the right side, and would be
wounded by a stab through that cartilage close to
the sternum. The concavity of the aortic arch corre-
sponds to the point between the first and second pieces
of the sternum. The auriculo-ventrieular orifices are
behind the sternum, the right being opposite the fourth
spaces, and the left on a level with the fourth carti-
lages. The innominate and left carotid arteries come
off at a spot corresponding to the middle of the maim-
brium, and run behind the right and left sterno-cla-
vicular joints respectively. The superior vena cava
would be wounded by a knife entering either the first
or the second right interspace close to the sternum.
The left innominate vein lies transversely just below
the upper border of that bone. The right auricle
would be wounded in stabs passing through the sternal
ends of the third, fourth, and fifth cartilages on the
right side, or through the corresponding intercostal
spaces if the knife be kept fairly near to the sternum.
(See Fig. 16, which shows the relations of the heart
and great vessels as given by Riidinger, and which
differ somewhat from the above account.)

A circle with a diameter of two inches, and
with its centre midway between the nipple and the
end of the gladiolus, would approximately define
that part of the heart which lies immediately behind
the chest wall,, and is uncovered by lung or pleura
(Latham).

Wounds of the heart most frequently involve the

right ventricle, that segment of the heart being the

' part most exposed anteriorly. Next in frequency is

the left ventricle wounded, and then the right auricle.

Other things being equal, a wound of the ventricle is

160 SURGICAL APPLIED ANATOMY. [Chap. x.

less rapidly fatal than is a wound of the auricle, owing
to the thickness of the ventricular wall, and to its
capacity for contracting and preventing the escape of
blood. Death in cases of wound of the heart would
appear in a great number of cases to be due to an
impression upon the nervous centres rather than upon
actual hsemorrhage. Many instances have been
recorded to show that the heart may be very tolerant
of foreign bodies in its substance. Thus a man lived
for twenty days with a skewer traversing the heart
from side to side (Ferrus). In another case a lunatic
pushed an iron rod, over six inches in length, into his
chest, until it disappeared from view, although it
could be felt beneath the skin receiving pulsation
from the heart. He died a year following, and the
metal was found to have pierced not only the lungs,
but also the ventricular cavities (Tillaux). A propos
of chest wounds, Yelpeau cites the case of a man in
whose thorax was found a part of a foil that entirely
transfixed the chest from ribs to spine, and that had
been introduced fifteen years before death. In the
museum of the Royal College of Surgeons is the
shaft of a cart that had been forced through the ribs
on the left side, had passed entirely through the chest,
and had come out through the ribs on the right side.
The patient had lived ten years.

Paracentesis of the pericardium has been
performed through the fourth or fifth spaces on the
left side close to the sternum, care being taken to
avoid the internal mammary artery. The operation
has also been performed through a trephine hole
made in the middle line of the sternum.

The mediastina. — Abscess in the anterior
mediastinum may have developed in situ, or may
have spread down from the neck. In like manner
posterior mediastinal abscesses may arise from diseases
of the adjacent spine, or lymphatic glands, or may be

Chap, x.] THE THORAX. 161

due to the spreading downwards of a retro-pharyngeal
or retro-cesophageal collection of matter.

The azygos veins, commencing as they do below
in the lumbar veins, and having more or less direct
communications with the common iliac, renal, and
other tributaries to the vena cava, are able to a great
extent to carry on the venous circulation in cases of
obstruction of the main trunk.

These veins are apt to be pressed upon by tumours
(such as enlarged gland masses) developed in the
posterior mediastinum, and to produce in consequence
some oedema of the chest walls by engorgement of
those intercostal veins that they receive. Tumours
growing in the posterior mediastinum may cause
trouble by pressing upon the trachea or gullet, or by
disturbing the vagus nerve or the cord of the sym-
pathetic (Figs. 33 and 35).

162

f art

THE UPPER EXTREMITY

CHAPTER XL

THE REGION OF THE SHOULDER.

A STUDY of the region of the shoulder comprises
the clavicle, the scapula, the upper end of the humerus,
and the soft parts that surround them, together with
the shoulder joint and axilla.

Surface anatomy. — The clavicle, acromion pro-
cess, and scapular spine are all subcutaneous, and can
be readily felt. In the upright position, when the
arm hangs by the side, the clavicle is, as a rule, not
quite horizontal. In well-developed subjects it inclines
a little upwards at its outer end.* In the recumbent
posture, the weight of the limb being taken off, the
outer end rises still higher above the sternal extremity.
The degree of the elevation can be best estimated by
a study of frozen sections. Thus, in making horizontal
sections of the body, layer by layer, from above down-
wards, Braune found that by the time the sterno-
clavicular articulation was reached, the head of the
humerus would be cut across in the lateral part of
the section (Fig. 17).

The deltoid tubercle of the clavicle may, if large,
be felt through the skin, and be mistaken for an
exostosis. The acromio-clavicular joint lies in the
plane of a vertical line passing up the middle of the

* In some women, in the feeble, and in some narrow-shoul-
dered men, the clavicle may be horizontal, or its outer end may
incline downwards.

Chap, xi.] REGION OF THE SHOULDER. 163

front of the arm. A prominence is sometimes felt
about this joint in place of the level surface that it
should present. This is due to an enlargement of the
end of the clavicle, or to a thickening of the fibro-
cartilage sometimes found in the joint. In many
cases it has appeared to me to be due to a trifling
luxation upwards of the clavicle depending upon some
stretching of the ligaments. It is certain that the
dry bone seldom shows such an enlargement as to
account for this very common prominence at the
acromial articulation. The sternal end of the clavicle
is also, in muscular subjects, often large and unduly
prominent, and sufficiently conspicuous to suggest a
lesion of the bone or joint when none exists.

The roundness and prominence of the point of the
shoulder depend upon the development of the deltoid
and the position of the upper end of the humerus.
The deltoid hangs like a curtain from the shoulder
girdle, and is bulged out, as it were, "by the bone
that it covers. If the head of the humerus, there-
fore, be diminished in bulk, as in some impacted
fractures about the anatomical neck, or be removed
from the glenoid cavity, as in dislocations, the
deltoid becomes more or less flattened, and the acro-
mion proportionately prominent. The part of the
humerus felt beneath the deltoid is not the head,
but the tuberosities, the greater tuberosity externally,
the lesser in front. A considerable portion of the
head of the bone can be felt by the fingers placed
high up in the axilla, the arm being forcibly abducted
so as to bring the head in contact with the lower
part of the capsule. The head of the humerus faces
very much in the direction of the internal condyle.
As this relation, of course, holds good in every
position of the bone, it is of value in examining
injuries about the shoulder, and in reducing disloca-
tions by manipulation, the condyle being used as

164 SURGICAL APPLIED ANATOMY. [Chap. xi.

an index to the position of the upper end of the
bone.

In thin subjects the outline and borders of the
scapula can be more or less distinctly made out, but
in fat and muscular subjects all parts of the bone,
except the spine and acromion, are difficult of access
in the ordinary positions of the limb. To bring out
the superior angle and vertebral border of the bone,
the hand of the subject should be carried as far as pos-
sible over the opposite shoulder. To bring out the
inferior angle and axillary border, the fore-arm should
be placed behind the back. The angle formed at
the point of junction of the spine of the scapula
and the acromion, is the best point from which to
take measurement of the arm, the tape being carried
down to the external condyle of the humerus.

When the arm hangs from the side with the palm
of the hand directed forwards, the acromion, external
condyle, and styloid process of the radius, all lie in the
same line. The groove between the pectoralis major
arid deltoid muscles is usually to be made out. In it
run the cephalic vein and a large branch of the ac. romio-
thoracic artery. Near the groove, and a little below
the clavicle, the coracoid process may be felt. The
process, however, does not actually present in the
interval between the two muscles, but is covered by the
innermost fibres of the deltoid. The position of the
coraco-acromial ligament may be defined, and a knife,
thrust through the middle of it, should strike the
biceps tendon and open the shoulder joint.

When the arm hangs at the side with the palm
forwards, the bicipital groove may possibly be defined.
It looks directly forwards.

Just below the clavicle is a depression, the sub-
clavicular fossa, which varies considerably in depth
in different subjects. It is obliterated in subcoracoid
dislocations of the hurnerus, in fractures of the clavicle

Chap. XL] REGION OF THE SHOULDER. 165

with displacement, by many axillary growths, and by
some inflammations of the upper part of the thoracic
wall. In subclavicular, or intracoracoid dislocation,
the fossa is replaced by an eminence. In this region,
at a spot to the inner side of the coracoid process,
and corresponding nearly to the middle of the clavicle,
the pulsations of the axillary artery can be felt on
deep pressure, and the vessel be compressed against the
second rib. Just below the clavicle the interspace
between the sternal and clavicular portions of the
pectoralis major can often be made out.

The anterior and posterior borders of the axilla
are very distinct. The anterior border formed by the
lower edge of the pectoralis major follows the line of
the fifth rib. The depression of the armpit varies,
other things being equal, with the position of the
upper limb. Jt is most deep when the arm is raised
from the side at about an angle of 45°, and when the
muscles forming the borders of the space are in a
state of contraction. As the arm is raised above the
horizontal line the depression becomes shallower, the
head of the bone projects into the space and more
or less obliterates it, while the width of the fossa is
encroached upon by the approximation of the anterior
and posterior, folds. The coraco-brachialis muscle
itself forms a distinct projection along the humeral
side of the axilla when the arm is raised to a right
angle with the body. If the arm be brought nearly
close to the side, the surgeon's hand can be thrust
well up into the axilla, and the thoracic wall explored
as high up as the third rib.

The axillary glands cannot be felt when they are
in a normal condition.

The direction of the axillary artery, when the arm
is raised from the side, is represented by a line drawn
from about the middle of the clavicle to the humerus
at the inner side of the coraco-brachialis. A line

1 66 SURGICAL APPLIED ANATOMY. [Chap. xi.

drawn from the third rib near its cartilage to the tip
of the coracoid process indicates the upper border of
the pectoralis minor, and the spot where this line
crosses the line of the axillary artery points out the
position of the acromio-thoracic artery. A line drawn
from the fifth rib near its cartilage to the tip of the
coracoid process indicates the lower border of the
pectoralis minor, and the position of the long thoracic
artery which runs along that border. The line of the
subscapular artery corresponds to the lower border of
the subscapularis muscle along which it runs, but 'the
position of this border can only be approximately
indicated on the living or undissected subject.

The circumflex nerve and posterior circumflex
artery cross the humerus in a horizontal line that is
about a finger's breadth above the centre of the vertical
axis of the deltoid muscle. This point is of importance
in cases of supposed contusion of the nerve. The
dorsalis scapulae artery crosses the axillary border of
the scapula at a point corresponding to the centre of
the vertical axis of the deltoid muscle. These various
indications of the positions of the main branches of
the axillary artery are made while the arm hangs in
its natural position at the side.

The clavicle. — The skin over the clavicle is
loosely attached, and is easily displaced about the
bone. This circumstance may serve to explain why
the skin so often escapes actual wound in contusions
of the clavicular region, and in part explains the
infrequency of penetration of the integument in
fractures of the clavicle. The position of the supra-
clavicular nerves in front of the bone renders them
very liable to contusion, and accounts for the unusual
amount of pain that is said to sometimes follow
blows over the collar bone. Tillaux believes that the
severe pain that in rare cases persists after fracture of
the clavicle is due to the implication of these nerves

Chap, xi.] THE CLAVICLE. 167

in the callus formed. The three nerves that cross the
clavicle are branches of the third and fourth cervical
nerves, and it is well to note that pain over the collar
bone is sometimes a marked feature in disease of the
upper cervical spine. This symptom is then due
to irritation of these nerves at their points of exit
from the spinal canal.

Beneath the clavicle the great vessels and the
great nerve-cords lie upon the tirst rib. The vein is
the most internal, and occupies the acute angle
between the collar bone and the first rib. It will be
seen that growths from the bone may readily press
upon these important structures, and that the vein,
from its position, as well as from the slighter resis-
tance that it offers, is likely to be the first to be
compressed. These structures have also been wounded
by fragments of bone in. fracture of the clavicle. Fortu-
nately, between the clavicle and these large nerves
and vessels the subclavius muscle is interposed. This
muscle is closely attached to the under surface of the
bone, is enveloped in a dense fascia, and forms one of
the chief protections to the vessels in cases of fracture.
This interposing pad of muscle is also of great service
in resection operations, as can be well understood.
Braune states that by pressing the clavicle against the
first rib in the dead body a stream of injection in the
thoracic duct can, in some cases, be entirely arrested.
Behind the clavicle the following structures may be
noted : The brachio-cephalic, subclavian, and external
jugular veins, the subclavian, suprascapular, and in-
ternal mammary arteries, the cords of the brachial
plexus, the phrenic nerve and nerve of Bell, the thoracic
duct, the omo-hyoicl, scalene, sterno-hyoid and sterno-
thyroid muscles, the apex of the lung. The sternal
end of the bone is not far removed from the innominate,
or left carotid artery, the vagus and recurrent nerves,
the trachea, and the oesophagus.

i68

SURGICAL APPLIED ANATOMY. [Chap. xi.

These relations of the clavicle are given to show
the dangers in the way of partial or complete
resections of the bone. The difficulties and risks
of the operation increase as one progresses from the

Fig. 17. — Horizontal Section of the Body just below the Upper Border
of the Manubrium (Brat'Jie).

a, Manubrium ; b, head of humerus ; c, clavicle ; d, first rib : e, second rib ; /, third
dorsal vertebra; g, spine of second dorsal; h. pectoralis major; i, deltoid;
j, inf raspinatus ; k, subscapnlaris : I, coraco-braehialis and biceps: m, pec-
toralis minor ; n, serratus magnus ; o, intercostals ; p, semispinalis and
multifidus spina3 ; q, biventer cervicis and complexus; r, longissimus dorsi ;
s, splenius colli ; t, rhomboideus ; u, trapezius ; v. sterno-thyroid ; w, sterno-
hyoid ; T, thymus ; L, lung ; 1, left innominate vein ; 2, left carotid artery ;
8, left subclavian artery : 4, vertebral artery ; 5, left stibelavian vein ;
6, cephalic vein ; 7, phrenic nerve ; 8, vagus ; 9, transverse scapular artery.

acromial to the sternal end. Resection of the acromial
third of the bone is comparatively easy, but resection
of the sternal portion is most difficult and dangerous.
The entire clavicle has been removed with success,
and the operation has been followed by less impair-
ment of the arm movements than would be imagined.
The clavicle forms the sole direct bony connection
between the upper limb and the trunk, and in severe

Chap, xi.] THE CLAVICLE. 169

accidents, this connection being broken through, it is
possible for the extremity to be torn off entire. Thus
Billroth reports the case of a boy aged fourteen,
whose right arm, with the scapula and clavicle, was so
torn from the trunk by a machine accident, that it was
only attached by a strip of skin two inches wide. Other
like cases of avulsion of the limb have been reported.

Fractures of clavicle. — The clavicle is more
frequently broken than is any other single bone in
the body. This frequency is explained by the fact
that the bone is very superficial, is in a part exposed
to injury, is slender and contains much compact
tissue, is ossified at a very early period of life, and
above all receives a large part of all shocks communi-
cated to the upper extremity. The common fracture,
that due to indirect violence, is oblique, and very
constant in its position, viz., at the outer end of the
middle third of the bone. Tho bone breaks at this
spot for the following reasons. It is here that the
clavicle is the most slender ; it is here that the
two curves of the bone meet ; it is here that a very
fixed part of the bone, viz., the outer third, joins
with a more movable portion. The displacement that
occurs is as follows. The inner fragment remains
unchanged in position, or, its outer end is drawn
a little upwards by the sterno-mastoid. It will be
seen that any action of this muscle would be resisted
by the pectoralis major, and the rhomboid ligament.
The outer fragment undergoes a threefold displace-
ment. (1) It is carried directly downwards. This
is effected mainly by the weight of the limb aided by
the pectoralis minor, the lower fibres of the pectoralis
major, and the latissimus dorsi. (2) It is carried
directly inwards by the muscles tha.t pass from the
trunk to the shoulder, viz., the trapezius, the levator
anguli scapulae, the rhomboids, the latissimus dorsi, and
especially by the pectorals. To these may be added

1 70 SURGICAL APPLIED ANATOMY. [Chap. xi.

the subclavius. (3) The fragment is rotated in such a
way that the outer end projects forwards and the
inner end back. This rotation is brought about
mainly by the two pectorals assisted prominently by
the serratus magnus. The normal action of this latter
muscle is to carry the scapula forwards, and the
clavicle, acting as a kind of outrigger to keep the
upper limb at a proper distance from the trunk, moves
forwards at the same time and keeps the scapula
direct. When this outrigger is broken the serratus
can no longer carry the scapula directly forwards.
The bone tends to turn towards the trunk, and the
point of the shoulder is therefore seen to move inwards
as well as forwards. The fragments in this fracture
must consequently overlap, and as the displacement is
difficult to remedy, it follows that in no bone save the
femur is shortening so uniformly left as after an
oblique fracture of the clavicle. The degree of
shortening very seldom exceeds one inch. The
deformity associated with this fracture is well
remedied when the patient assumes the recumbent
position. In this posture, the weight of the limb
being taken off, the downward displacement is at
once remedied. The point of the shoulder falling
back also tends to relieve in part the inward displace-
ment, and the rotation of the outer fragment forwards.
It is through the scapula, however, that these two
latter displacements are in the main removed. In
the recumbent posture the scapula is pressed closely
against the thorax, with the result that its outer
extremity (and with it, of course, the outer fragment
of the clavicle) is dragged outwards and backwards.
Some surgeons, recognising this important action of the
scapula in remedying the displacement in these cases,
strap the scapula firmly against the trunk, while at
the same time they elevate the arm.

Fractures due to direct violence are usually

Chap. XL] THE CLAVICLE. 171

transverse, and may be at any part of the bone.
When about the middle third they present the
displacement just described. When the fracture is
between the conoid and trapezoid ligaments no dis-
placement is possible. When beyond these ligaments
the outer end of the outer fragment is carried forwards
by the pectorals and serratus, and its inner end is
a little drawn up by the trapezius. In this fracture
there is no general displacement downwards of the
outer fragment, since it cannot move in that direction
unless the scapula go with it, and the scapula remains
fixed by the coraco-clavicular ligaments to the inner
fragment of the clavicle.

The clavicle may be broken by muscular violence
alone. Polaillon, from a careful analysis of the
reported cases, concludes that the muscles that break
the bone are the deltoid and clavicular part of the
great pectoral. In no case does the fracture appear
to have been produced by the sterno-mastoid muscle.
The commonest movements producing fracture appear
to be violent movements of the limb forwards and
inwards, or upwards. These fractures are usually
about the middle of the bone, and show no displacement
other than that of both fragments forwards, i.e., in the
direction of the fibres of the two muscles first named.

The clavicle is more frequently the seat of
green -stick fracture than is any other bone in
the body. Indeed, one half of the cases of broken
collar bone occur before the age of five years. This
is explained by the fact that the bone is ossified
at a very early period, and is in a breakable condi-
tion at a time when most of the other long bones
still present much unossified cartilage in their parts.
Moreover, the periosteum of the clavicle is unduly
thick, and not very closely attached to the bone, cir-
cumstances that greatly favour subperiosteal fracture.

A reference to the relations of the bone will

172 SURGICAL APPLIED ANATOMY. [Chap. xi.

si low that important structures may be wounded in
severe fractures associated with much displacement
and with sharp fragments. Several cases are reported
of paralysis of the upper limb (as a rule incomplete)
following upon fracture of this bone. In some cases
this symptom was due to actual compression, or
tearing of some of the great nerve-cords by the
displaced fragments. In other cases the nerve in-
jury, while due to "the original accident, was yet
independent of the broken clavicle. Cases are reported
of wound of the subclavian artery, of the subclavian
vein, of the internal jugular vein, and of the acromio-
thoracic artery. In several instances the fracture has
been associated with wound of the lung, with or with-
out a fracture of the upper ribs.

The clavicle begins to ossify before any bone in
the body. At birth the entire shaft is bony, the two
ends being still cartilaginous. The bone has one
epiphysis for its sternal end that appears between the
eighteenth and twentieth year, and joins the shaft
about twenty-five. It is a mere shell, is closely
surrounded by the ligaments of the sternal joint, and
cannot, therefore, be well separated by accident.*

Sterno-clavicular joint. — Although this is
the only articulation that directly connects the upper
limb with the trunk, yet it is possessed of such
considerable strength that luxation at the joint is
comparatively rare. The amount of movement in the
joint depends to a great extent upon the lack of
adaptability between the facet on the sternum and
the sternal end of the clavicle. The disproportion
between these parts is maintained by the inter-
articular cartilage, which reproduces only the outline

* Mr. Heath (Lancet, Nov. 18, 1882) reports a case which
is probably unique. It concerns a lad, aged 14, who, when in the
act of bowling at cricket, tore the clavicle away from its epiphyseal
cartilage, which remained in situ. The muscle producing the
accident was apparently tfye pectoralis major.

chap. xi.] STERNO-CLAVICULAR /OINT. 173

of the clavicular surface. Extensive muscular exercise
appears to increase the dissimilarity between the two
joint surfaces by producing enlargement of the sternal
end of the collar bone. The facet on the sternum
looks upwards, outwards, and a little backwards.
This obliquity has important relations to respiration,
for " by this backward slope of the facet the sternum
is able to advance a little upon the end of the clavicle
during its elevation in inspiration " (Henry Morris).
The cavity of the joint is V-shaped, since the clavicle
only touches the socket at its inferior angle when the
arm hangs by the side. When the arm is elevated,
however, the two bones are brought in more imme-
diate contact, and the joint cavity becomes a mere slit.
Thus, in disease of this articulation it will be found
that of all movements of the joint the movement of the
limb upwards is the most constant in producing pain.
The movements permitted at this joint are
limited, owing to the anterior and posterior sterno-
clavicular ligaments being moderately tense in all
positions of the clavicle. Movement forwards of the
clavicle on the sternum is checked by the posterior
ligament, and resisted by the anterior ligament.
This latter ligament is more lax and less sub-
stantial than is the posterior band, and would be
comparatively weak were it not strengthened by the
tendon of the sterno-mastoicl. Its weakness serves in
part to explain the frequency of the dislocation
forwards. Movement of the clavicle backwards on the
sternum is checked by the anterior ligament, while
the passage of the head of the bone is resisted by the
powerful posterior band. The movement is also
opposed by the rhomboid ligament. To produce,
therefore, a dislocation backwards considerable force
must be used. Movement of the clavicle upwards on
the sternum is checked by the rhomboid ligament, the
interclavicular ligament, the interarticular cartilage,

174 SURGICAL APPLIED ANATOMY. [Chap. XL

and in a less direct manner by the two remaining
ligaments of the joint. Thus it happens that dis-
location upwards is the least common of the luxations
at this articulation.

Disease of the sterno-clavicular joint. —
This articulation is really divided into two joints by
the interarticular cartilage, each being provided with
a distinct synovial membrane.

These joints are liable to the ordinary maladies
of joints, and it would appear that the disease may
commence in, and be for some time limited to, one only
of the synovial sacs. In time the whole articulation
usually becomes involved, but even in advanced cases
the mischief is sometimes restricted to the synovial
cavity on one side of the cartilage. According to
some authors, this joint is more frequently involved
in pyaemia than is any other. When effusion has taken
place into the sterno-clavicular joint, and especially
after suppuration has ensued, the swelling usually
makes itself evident in front, owing to the fact that
the anterior sterno-clavicular ligament is the thinnest
and least resisting of the ligamentous structures about
the articulation. For the same reason the pus usually
escapes from the anterior surface, when it discharges
itself spontaneously. It may, however, make an
opening for escape through the posterior ligament,
and under these circumstances has found its way into
the mediastinum. The relations of this joint to the
great vessels at the root of the neck should be borne
in mind. In one case reported by Hilton a large
abscess formed in the articulation, and the collection,
receiving pulsations from the subjacent artery (the
innominate or right subclavian), was supposed at one
time to be an aneurism. It is remarkable that disease
of this joint never leads to anchylosis. This cir-
cumstance may be explained (1) by the constant
slight movement in the part which prevents the

Chap. XL ] STERNO- CLA VICULA R JOINT. 175

diseased structures from being kept at rest, (2) by the
occasional persistence of the interarticular cartilage,
and (3) by the utter lack of adaptability of the two
bony surfaces involved.

Dislocations of the sterno-clavicular joint.
—The clavicle may be dislocated from the sternum in
one of three directions, which, given in order of fre-
quency, are : (1) forwards, (2) backwards, (3) upwards.
The relative frequency of these dislocations can be
understood from what has been already said as to the
action of the ligaments in restricting movements.
The displacement forwards involves entire rupture
of the capsule, and more or less damage to the
rhomboid ligament. The head of the bone carry-
ing with it the sterno-mastoid, rests on the front
of the manubrium. The dislocation backwards
may be due to direct or indirect violence, and
has occurred spontaneously in connection with the
chest deformity in Pott's disease. The capsule is
entirely torn, as is also the rhomboid ligament. The
head is found in the connective tissue behind the
sterno-hyoid and sterno-thyroid muscles. In this
position it may cause severe dyspnosa, or dysphagia,
by pressure upon the trachea or gullet. It may so
compress the subclavian artery as to arrest the pulse
at the wrist, or so occlude the brachio-cephalic vein as
to produce semi-coma (Fig. 17). In one case the head
of the bone had to be excised to relieve a troublesome
dysphagia. In the luxation upwards, due usually to
indirect violence, the head rests on the upper border
of the sternum between the sterno-mastoid and sterno-
hyoid muscles. It involves more or less complete
tearing of all the ligaments of the joint, together with
avulsion of the interarticular fibro-cartilage.

The non-adaptability of the joint surfaces in this
part serves to explain the ease with which these
luxations are usually reduced, and the difficulty

1 76 SURGICAL APPLIED ANATOMY. [Chap. XL

of retaining the clavicle in position after it is re-
placed.

Acromio-clavicular joint. — This articulation
is shallow, and the outlines of the two bones that
enter into its formation are such that no obstacle
is offered to the displacement of the clavicle from the
acromion. The joint, indeed, depends for its strength
almost entirely upon its ligaments. The plane of the
joint would be represented by a line drawn from above
downwards and inwards between the two bones. This
inclination of the joint surfaces serves to explain the
fact that the usual luxation of this part takes the form
of a displacement of the clavicle upwards on to the
acromion. The capsule that surrounds the joint is ]ax
and feeblej and it is partly from its comparative
thinness that effusion into this joint, when it is the
seat of disease, makes itself so soon visible. The
joint, however, depends mainly for its strength upon
the powerful conoid and trapezoid ligaments.

As the movements permitted in this joint may
be impaired by accident or disease, it is well to
note the part the articulation takes in the move-
ments of the extremity. The scapula (and with it,
of course, the arm), as it glides forwards and back-
wards upon the thorax, moves in the arc of a circle
whose centre is at the sterno-clavicular joint, and
whose radius is the clavicle. As the bone moves
forwards it is important, for reasons to be imme-
diately given, that the glenoid cavity should also be
directed obliquely forwards. This latter desirable
condition is brought about by means of the acromio-
clavicular joint. Without this joint the whole
scapula as it passed forwards with the outer end
of the clavicle would precisely follow the line of
the circle aboVe mentioned, and the glenoid cavity-
would look in an increasingly inward direction. It
is essential that the surface of the glenoid cavity

Chap. XL] ACROMIO- CLA VICULAR JOINT. 177

should be maintained as far as possible at right
angles to the long axis of the humerus. When
these relations are satisfied, the humerus has the
support behind of a stout surface of bone, and it is
partly to obtain the value of this support that the
boxer strikes out from the side, i.e., with his humerus
well backed up by the scapula. If there were no
acromio-clavicular joint the glenoid fossa would offer
little support to the humerus when the limb
was stretched forwards, and a blow given with the
limb in that position, or a fall upon the hand under
like conditions, would tend to throw the humerus
against the capsule of the shoulder joint, and so
produce dislocation. Normally, therefore, as the
scapula and arm advance, the angle between the
posterior border of the acromion and the adjacent
portion of the clavicle becomes more and more acute,
and the glenoid fossa is maintained with a sufficiently
forward direction to give substantial support to the
humerus.* It will thus be seen that rigidity of this
little joint may be a cause of insecurity in the articu-
lation of the shoulder, and of weakness in certain
movements in the limb.

Dislocations of ttie acromio - clavicular
joint. — The clavicle may be displaced upwards
on to the acromion or downwards beneath it. Pol-
laillon has collected thirty-eight cases of the former
luxation, and six only of the latter. This dis-
proportion is, in the main, explained by the direc-
tion of the articulating surfaces of the joint.
Both luxations are usually due to direct violence.
The dislocation upwards is very commonly only par-
tial, and is associated only with stretching and some
irining rupture of ligaments. In the complete form,
where the end of the clavicle rests entirely upon the

* For an excellent account of the mechanism of these joints
see Morris's " Anatomy of the Joints," p. 202, el seq. 1879.
M

178 SURGICAL APPLIED ANATOMY. [Chap. XL

acromion, there is rupture, not only of the capsule, but
also to a greater or less extent of the coraco-clavicular
ligaments. In the complete dislocation downwards,
also, there is a rupture of the capsule, with extensive
tearing of the conoid and trapezoid ligaments. These
luxations are usually easily reduced, but it will be
understood, from the direction of the articular surfaces,
that in the displacement upwards it is very difficult
to retain the clavicle in situ when once reduced.

Scapula. — At the posterior aspect of the bone
the muscles immediately above and below the spine
are somewhat precisely bound down by the deep
fascia. Thus, the supraspinatus muscle is enclosed in
a fascia, that, being attached to the bone all round
the origin of the muscle, forms a cavity open only
towards the insertion of the muscle.

The inf raspinatus and teres minor muscles are also
enclosed in a distinct, but much denser, fascia that is
attached to the bone beyond these muscles, and blends
in front with the deltoid sheath so as to form a second
enclosed space. The arrangement of these fasciae
serves to explain the trifling amount of ecchymosis that
usually follows upon fractures of the scapular blade.
The extravasation of blood about the fracture is
bound down by the fasciae over these muscles, and is
unable, therefore, to reach the surface.

Thus also pus, in the supra- and infraspinous fossse,
tends to be pent up, and to come forward in the one
case at the insertion of the subscapular muscle, and in
the other instance about the insertion of the teres
minor.' Owing to the rigidity of the fascia over the
inf raspinatus and teres minor muscles, it happens that
dense tumours growing from this fascia may readily
be mistaken for growths from the bone itself.

The inferior angle of the scapula is crossed by a
part of the latissimus dorsi, and by means of this muscle
is retained in contact with the thorax. In certain

Chap, xi.] THE SCAPULA. 179

injuries the angle may slip from beneath the muscle
and appear as a marked projection. This lesion is pro-
ductive of some loss of power in the limb. In many
cases where this accident is supposed to have occurred,
it is probable that the symptoms present are due
rather to paralysis of the nerve of Bell.

Fractures of the scapula, and especially of
the body of the bone, are not common, owing to the
mobility of the part and the thick muscles that cover
in and protect its thinner portions. It rests also
upon a soft muscular pad, and derives, no doubt,
additional security from the elasticity of the ribs.

The most common lesion is a fracture of the
acromion process. This is often but a separation of the
epiphysis. There are two, sometimes three, epiphy-
seal centres for the acromion. Ossification appears in
them about puberty, and the entire epiphysis joins
with the rest of the bone from the twenty-second to the
twenty-fifth year. Several cases of supposed fracture
of the acromion united by fibrous tissue are probably but
instances of an imperfectly-united epiphysis, and may
have been independent of injury. In fractures of the
process much displacement is quite uncommon, owing
to the dense fibrous covering the bone derives from the
two muscles attached to it. This dense periosteum also
explains the circumstance that many fractures are
incomplete and crepitus often absent. When the
fracture is in front of the clavicular joint, displace-
ment of the arm is impossible. When it involves the
joint, a dislocation of the collar-bone is common.
When behind the joint, the arm, having lost its
support from the thorax, is displaced in somewhat the
same way as obtains in the common fracture of the
clavicle. The coracoid process may present a genuine
fracture, or may be separated as an epiphysis. As an
epiphysis, it joins the main bone about the age of
seventeen. In spite of the powerful muscles attached

180 SURGICAL APPLIED ANATOMY. [Chap. xi.

to it, the displacement is usually slight, inasmuch as
the coraco - clavicular ligaments are seldom torn.
These ligaments, it may be noted, are attached to the
base of the process. In some few cases the process
has been torn off by muscular violence.

Among the more usual fractures of the body of the
scapula is a transverse or oblique fracture of its blade
below the spine. Owing to the infraspinatus, sub-
scapularis, and other muscles being attached to both
fragments, none but a trifling displacement is usual.
A fracture may occur through the surgical neck. The
surgical neck is represented by a narrowed part
of the bone behind the glenoid fossa, and in the
line of the suprascapular notch. The smaller frag-
ment will, therefore, include the coracoid process,
the larger, the acromion. The amount of deformity
in these cases depends upon whether the coraco-
clavicular and acromio-clavicular ligaments are entire
or torn. If they be torn, the small fragments and
the entire limb are displaced downwards, and the
injury somewhat resembles a subglenoid dislocation.
From this, however, it is distinguished by the
crepitus, by the ease with which the deformity is
removed and the equal ease with which it returns,
by the position of the head of the humerus in regard
to the glenoid fossa, and by the conspicuous fact that
the coracoid process is displaced downwards with the
limb.

Tumours of various kinds grow from the scapula
and mainly from the spongv parts of the bone, viz.,
the spine, the neck, the inferior angle. The bone
may be removed entire, with or without amputa-
tion of the upper limb. The main vessels to be noted
in connection with this operation are the supra-
scapular at the superior border of the bone, the
posterior scapular about the vertebral border, the
subscapular running along the lower border of the

Chap. XL]

THE AXILLA.

181

subscapularis muscle, the dorsalis scapulae crossing the
axillary edge of the bone, and the acromial branches
of the acromio-thoracic artery.

The axilla. — The axilla may be regarded sur-
gically as a passage between the neck and the upper
limb. Axillary tumours and abscesses may spread up
into the neck, and in like manner cervical growths and
purulent collections
may extend to the a -
arm-pit. The skin
forming the base of
the axilla is pro-
vided with many
short hairs and with
numerous sebaceous ,
and sudoriferous
glands. In this in-
tegument small su-
perficial abscesses
are often met with,
that arise usually
from suppuration
of these glandular
structures, and that
are brought about
by the friction of

the Skin against the Fig. 18.-Vertical Section throug-li the Axilla
, , . ® . and Shoulder-joint (Rudinger).

clothing. Owing to 3> Scapula . ?f humerus .

the tendency of the

axillary integument

to become chafed

and inflamed under

friction, the axilla is not a good locality to select for

the use of the mercurial inunction as applied in

syphilis. Beneath the skin and superficial fasciae is

the axillary fascia, and beyond this dense membrane

is the axillary space. The connective tissue with

, clavicle ; 4, acroraion ;
a, trapezius; 6, supraspinatus ; c, subacromial
bursa and deltoid; d, circumflex artery and

,

nerve ; e.latissimusdorsi ; /, coraco-brachialis
g, subscapularis; h, serratus
illary artery ; j, axillary vein.

and biceps ;
magnus ; i, a:

1 82 SURGICAL APPLIED ANATOMY. [Chap. xi.

which the axillary space is mainly occupied is very
loose, and, while this laxity favours greatly the free
movement of the arm, it at the same time permits of
the formation of large purulent collections and im-
mense extravasations of blood.

It is important to remember the disposition of
the fasciae about this region. There are three layers
principally concerned. (1) The deep pectoral fascia
that covers in and encloses the pectoralis major.
(2) The clavi-pectoral fascia that, adherent above to
the clavicle, fills in the space between that bone and
the pectoralis minor, then splits to invest this muscle,
and joins the deep pectoral layer at the anterior fold
of the axilla to form with it the axillary fascia. The
upper part of this fascia is generally known as the
costo-coracoid membrane. The whole membrane is
sometimes known also as " the suspensory ligament of
the axilla," since it draws up the axillary fascia towards
the clavicle, and is mainly instrumental in producing
the " hollow " of the armpit. (3) The axillary fascia,
that is formed by the union of the two preceding
fasciae, and stretches across the base of the axilla from
its anterior to its posterior fold.

Abscess about the axillary region may be
considered (1) when it is beneath the pectoralis major,
or between the two pectoral muscles, and (2) when it is
beneath the pectoralis minor and clavi-pectoral fascia,
and therefore in the axillary space. (1) An abscess
in this situation is placed between the deep pectoral
and the clavi-pectoral fasciae, the latter separating
it from the axillary space. Such an abscess under-
mines the great pectoral, and tends to present either
at the anterior margin of the axilla, or in the groove
between the great pectoral and deltoid muscles, being
guided thither by the attachment of the fasciae.
(2) A purulent collection in the axilla may soon fill
that space and distend it entirely. Its progress

Chap, xi.] THE AXILLA. 183

towards the skin is arrested by the axillary fascia, its
progress backwards by the serratus magnus muscle,
which, by its attachment to the scapula, hermetically
closes the axillary space behind. In front the
advance of the abscess is prevented by the pectoral
muscles and clavi-pectoral fascia, while on the inner
side is the unyielding thorax, and on the outer side
the upper limb. The abscess, therefore, as it fills the
axilla pushes forwards the pectoralis major, more or
less obliterates the hollow of the armpit, thrusts back
the scapula, and widens the angle between the serratus
rnagnus and the subscapularis muscles. There is a
great tendency, therefore, for unrelieved abscesses to
extend upwards into the neck, that being the direction
in which the least amount of resistance is encountered.
From the neck the purulent collection may extend
into the mediastinum. In one case an axillary
abscess, set up by shoulder-joint disease, perforated
the first intercostal space, and set up fatal pleurisy.

In opening an axillary abscess, and, indeed, in
most incisions into this space, the knife should be
entered at the centre of the floor of the axilla, i.e.,
midway between the anterior and posterior margins,
and near to the inner or thoracic side of the space.
The vessels most likely to be damaged by an
indiscreet incision are the subscapular, running along
the lower border of the subscapularis muscle ; the
long thoracic, following the lower border of the small
pectoral ; and the main vessels lying close to the
hnmerus. The knife, if properly entered, should be
midway between the two first-named vessels, and
quite away from the main trunks. There is an
artery (the external mammary) that sometimes comes
off as the lowest branch of the axillary trunk, and
crosses the middle of the axilla, to be distributed to
the thorax below the long thoracic. This vessel would
p 'obably be wounded in the incision above named.

184 SURGICAL APPLIED ANATOMY. [Chap. xi.

The artery is, however, very inconstant, is small, and
is not far below the surface. It is usually met with
in female subjects.

Lymphatic glands.— The axillary glands are
numerous, and of much surgical importance. They
may be arranged in three sets. (1) The greater
number are placed along the axillary vessels, and
reach up into the neck along those vessels so as
to form a chain continuous with the cervical
glands. They receive mainly the lymphatics of the
upper limb, and are enlarged in inflammatory and
other affections of that part. (2) Other glands lie
upon the serratus magnus muscle on the thoracic side
of the axilla, and just behind the lower border of the
pectoral muscles. They receive the lymphatics from
the front of the chest, the principal lymph vessels
of the breast, and the superficial lymphatics of the
abdomen as low down as the umbilicus. Their
efferent vessels for the most part pass on to join the
chief axillary glands. These glands will be the
first to be enlarged in certain breast affections, and
after blistering and other superficial inflammations,
etc., of the chest and upper abdomen. Paulet has
seen them affected in inflammation of the hand.
(3) The remaining glands are situated at the back of
the axilla, along the subscapular vessels. They are
joined by the lymphatics from the back.

It may here be convenient to note that one or
two glands are commonly found in the groove between
the deltoid and pectoralis major muscles. They
receive some vessels from the outer side of the
arm and a part of the shoulder. The superficial
lymphatics over the upper part of the deltoid go
to the cervical glands (Tillaux), over the lower half
to the axilla. The lymphatics from the supraspinous
fossa follow the suprascapular artery, and join the
lowest cervical glands. The superficial lymphatics of

Chap, xi.] THE AXILLA. 185

the back that converge to the axilla are derived from
the neck over the trapezius muscle, and from the
whole dorsal and lumbar regions as far down as the
iliac crest.

The removal of axillary glands is an operation
frequently undertaken. It will be understood from
their position that these bodies, when diseased, are
very apt to become adherent to the axillary vessels,
and especially to the vein. The latter vessel has
frequently been wounded during the removal of
gland tumours, and in one case at least the artery
was accidentally cut (Holmes).

The axillary vessels. — The axillary vein is
formed by the union of the basilic with the two vense
coruites of the brachial artery. This union commonly
takes place at the lower border of the subscapular
muscle, and the vein is therefore shorter than the
artery. Sometimes the vein does not exist as a single
trunk until just below the clavicle. This condition,
when it exists, is very unfavourable to operations
upon the artery, as many transverse branches cross
that vessel to unite the veins that lie on either side of
it. The axillary vein, being comparatively near the
heart, is readily influenced as regards its contained
blood by the inspiratory movement. Thus it happens
that in many instances of wound of the vessel, or of
its larger tributaries, air has been drawn into the
venous canal and death has ensued. The entrance
of air into the main vein is perhaps aided by
the circumstance that the costo-coracoid membrane
(upper part of clavi-pectoral fascia) is adherent
to the vessel, and thus tends to maintain it in a
patent condition when wounded. This connection
with the fascia is supposed by some to in part ac-
count for the furious bleeding that occurs from this
vein when it is divided.

The vein is more often wounded than is the artery, it

1 86 SURGICAL APPLIED ANATOMY. [Chap. xi.

being larger, more superficial, and so placed as to more
or less overlap the arterial trunk. On the other hand,
in injury to the vessels by traction, as, for example, in
reducing dislocations, the artery suffers more frequently
than the vein. In all positions of the upper limb the
artery keeps to the outer angle of the axillary
space. The relation of the vein, however, to the first
part of the axillary artery, the parfc above the
pectoralis minor, is modified by the position of the
limb. Thus, when the arm hangs by the side the
vein is to the inner side of the artery, and a little in
front of it, but when the limb is at a right angle with
the trunk the vein is drawn so far in front of the
artery as to almost entirely conceal that vessel.

Aneurism is very frequent in the axillary artery, a
fact to be explained by the nearness of the vessel to the
heart, by the abrupt curve it presents, by its suscepti-
bility to frequent and extensive movements, and by its
liability to share in the many lesions of the upper
limb. In violent and extreme movements of the limb
the artery may be more or less torn, especially if its
walls are already diseased.

In ligaturing the first part of the axillary artery
it is well to note that the pectoralis major has some-
times a cellular interval between two planes of
muscle fibre, and this may be mistaken for the space
beneath it (Heath). If the pectoralis minor has
an origin from the second rib, it may more or
less entirely cover the artery and require division.
The cord of the brachial plexus nearest to the artery
may be mistaken for that vessel, or easily included in
a ligature intended for it. A ready guide to the
axillary vessels in this operation is to follow the
cephalic vein.

In applying a ligature to the third part of the
artery, it should be borne in mind that a muscular
slip sometimes crosses the vessels obliquely, passing

Chap, xi.] THE DELTOID. 187

from the latissimus dorsi to join the pectoralis major,
coraco-brachialis, or biceps muscles. This slip may
give rise to confusion during the operation, and may
be mistaken for the coraco-brachialis.

The axillary nerves. — Any of the axillary
nerves may be injured by a wound, the median
being the most frequently damaged, and the musculo-
spiral the least frequently. The comparative im-
munity of the latter is explained by its deep
position, its situation at the inner and posterior
aspect of the limb, and its large size. The nerves are
very seldom torn by a traction on the limb short of
more or less complete avulsion. Indeed, if forcibly
stretched, they are disposed rather to become torn
away from their attachments to the spinal cord than to
give way in the axilla. Thus, Flaubert records a case
where the last four cervical nerves were torn away
from the cord during a violent attempt to reduce a
dislocated shoulder.

The deltoid region. — This region, comprising
as it does the " point " of the shoulder, is limited
in all parts by the deltoid muscle. The deltoid
covers the upper end of the humerus and the
shoulder joint. Between the joint and the surface,
therefore, are only the skin and superficial fascia, the
deltoid in its sheath, and some loose connective tissue
(the subdeltoid tissue) in which is found the great
subacromial bursa. This subdeltoid tissue sometimes
assumes the form of a distinct thick membrane, and
may have an important influence upon the locali-
sation of purulent collections proceeding from the
joint. The fatty tissue over the deltoid is a favourite
seat for lipomata, and it is in this situation that the
tendency of these growths to change their position
is sometimes seen. Thus, Erichsen records a case
where the tumour slid downwards from the shoulder
to the breast.

1 88 SURGICAL APPLIED ANATOMY. [Chap. xi.

Emerging from the interval between the two teres
muscles, and winding horizontally round the shaft of
the humerus, quite close to the bone, and about the
line of the surgical neck, are the circumflex nerve and
posterior circumflex artery. This nerve affords an
example of an arrangement pointed out by Mr. Hilton,
viz., that a principal nerve to a joint not only supplies
the articular surfaces, but also some of the main
muscles that move that joint and the skin over those
muscles. This nerve supplies the shoulder joint,
the deltoid and teres minor muscles, and the skin over
the lower two-thirds of the shoulder and upper part
of the triceps. "The object of such a distribution of
nerves to the muscular and articular structures of a
joint, in accurate association, is to ensure mechanical
and physiological consent between the external
muscular or moving force and the vital endurance of
the parts moved, viz., of the joints, thus securing in
health the true balance of force and friction until
deterioration occurs" (Hilton). This nerve is frequently
damaged in injuries to the shoulder. It may be
severely bruised by a simple contusion of the part,
and this bruising may be followed by paralysis of the
deltoid. It would appear, however, that damage to
the circumflex is much less frequent after contusions
of the shoulder than was formerly maintained. It
will also be readily understood that the nerve is often
torn in fractures of the surgical neck of the humerus,
in dislocations of that bone (especially the luxation
backwards), and in violent attempts at reducing such
dislocations. The nerve, from its position, is very apt
to be seriously pressed upon by growths springing
from the upper end of the humerus. From its con-
nection with the joint, it follows that in chronic
inflammation of that part the inflammation may extend
along the nerve, producing a neuritis that may lead to
paralysis of the deltoid (Erb).

chap, xi.j THE SHOULDER-JOINT. 189

The shoulder-joint. — From one surgical point
of view, joints may be divided into (1) those that
depend for their strength mainly upon ligaments ;
(2) those that are mechanically strong, and that
derive their stability to a great extent from the
arrangement of their component bones ; and (3) those
that rely for their support principally upon muscles.
As an example of the first kind may be cited the
sterno-clavicular joint, of the second form the elbow-
joint, and of the third the shoulder-joint. The articu-
lation the least prone to dislocation is the one that
derives its strength from tough unyielding ligaments,
while the one most often luxated belongs to the third
variety, its strength being greatly dependent upon
muscles that may be taken by surprise, and that may
themselves, from disordered action, prove sources of
weakness. These are, of course, not the only features
in the etiology of dislocation. A great deal depends
upon the amount of movement permitted in a given
joint, and the degree of leverage that can be brought
to bear upon its parts.

The arch formed by the coracoid and acromion
processes and the ligament between them forms an
essential support to the head of the humerus, and is
an important constituent of the articulation. With
this arch the humeral head is in immediate relation,
although not in actual contact (Fig. 18). In paralysis
of the deltoid the head may be separated by some
distance from the coracoid process, and Nannoni
records the case of a child with old standing paralysis
of the deltoid, between whose humeral head and acro-
mial vault four fingers could be lodged. It is well to
note that at least two-thirds of the head of the bone
are not in contact with the glenoid cavity when the
arm hangs by the side, and Anger points out that in
this position three-fourths of the circumference of the
humeral head are in front of a vertical line drawn

190 SURGICAL APPLIED ANATOMY. [Chap. xi.

from the anterior border of the acromion process. In
this posture, also, the head is wholly to the outer side
of the coracoid process. The margin of the glenoid
cavity is more prominent on the inner than on the
outer side, while the strongest part of the margin and
the broadest part of the fossa are below. This is sig-
nificant, since it points to an attempt to strengthen a
part of the joint that practice shows to be the weakest
in the articulation, viz., the lower and inner portion
of the capsule. It is at this place that the head of the
bone leaves the joint in dislocation of the shoulder.

The capsule of the shoulder-joint is very lax, and
would lodge a bone-head twice as large as that of the
humerus. According to Henry Morris, no one part
of the capsule is constantly thicker than the rest, as is
the case in the hip-joint. The inner surface of the
capsule looks into the axilla, and is there free between
the two tuberosities, between the lesser one in front
and the posterior part of the greater process behind.
It is between these two projections that the humeral
head can be felt through the axilla.

Of the Imrsse about the joint, the subacromial
bursa is the one most frequently the seat of disease,
and this sac, when distended with fluid, may be mis-
taken for the results of chronic inflammation, of the
joint (Fig. 18).

Experiment shows that the walls of this bursa may
be actually torn in twists of the arm, especially when
either flexed or extended (Nancrede). When the sac
is distended most pain is elicited in the position of
abduction, for in this posture the bur sal walls are
normally folded up, so as to form a sort of collar in
advance of the greater tuberosity. When the walls
are thickened and distended by inflammation, abduc-
tion must press the bursa very forcibly under the
acromion, and so cause pain. In elderly people the
sac sometimes communicates with the joint.

Chap, xi.] THE SHOULDER-JOINT. 191

The biceps tendon strengthens the upper part
of the joint, keeps the humerus against the glenoid
cavity in the various positions of the limb, and pre-
vents the head of the bone from being pulled too
closely upwards under the acromion. The tendon
may be ruptured, and in such a case, in addition to
the general weakening of the limb and the peculiar
projection formed by the contraction of the muscle,
the head of the humerus is usually drawn upwards
and forwards until arrested by the coraco-acromial
arch. Thus, a kind of slight false dislocation may
be produced. In certain violent wrenches of the limb
the tendon may slip from its groove and be displaced
to one or other side, usually to the inner side. In
these cases also the head is drawn up under the
acromion, and is prominent in front, while abduction
is rendered less free than is normal owing to the great
tuberosity being sooner brought in contact with the
acromion.

Joint disease. — This articulation is liable to all
forms of joint disease. The capsule, as just stated, is
very lax, but the humerus is kept in contact with the
glenoid cavity by atmospheric pressure. In joint
disease, however, the effusion may effect a considerable
separation of the two bones. Braune, having pierced
the glenoid cavity through the supraspinous fossa,
injected tallow at considerable pressure into the joint.
When fully distended the humerus was found to be
separated from the scapula by more than half an inch,
and this may serve to explain the lengthening of the
limb often noted in joint disease of this part with
much effusion. When the greatest degree of disten-
sion of the capsule was reached the humerus became
slightly extended and rotated in. It is significant that
in shoulder-joint disease it is common for the arm to
be found close to the side, the elbow carried a little
back (extension), and the limb rotated inwards. This

192 SURGICAL APPLIED ANATOMY. [Chap. xi.

position may also be due to the rigid contraction of
the muscles about the joint that is usually observed.
When such contractions exist it may be inferred that
the powerful latissimus dorsi has a little advantage
over its opponents, and may be answerable for the rota-
tion in and slight projection backwards of the arm.

There may be three diverticula from the synovial
membrane: (1) One that runs some way down the
bicipital groove with the tendon ; (2) a cul-de-sac
beneath the subscapularis, formed by a communication
between the synovial cavity and the bursa under that
muscle ; and (3) a cul-de-sac of like nature beneath
the infraspinatus muscle. The first-named is constant ;
the second is frequently present ; the third is rare.
When the joint is filled with effusion, the capsule is
evenly distended and the shoulder evenly rounded.
Special projections usually occur at the seats of the
diverticula. Thus a swelling often appears early in
the course of a synovitis in the groove between the
pectoralis major and the deltoid muscles, and this
swelling may appear bilobed, being cut in two by the
unyielding biceps tendon (Paulet). Fluctuation can
best be felt by examining the uncovered part of the
capsule in the axilla beyond the subscapular muscle.
When the joint suppurates pus usually escapes at one
of the cul-de-sacs just mentioned, most often through
the one that follows the biceps tendon. Pus may thus
extend for some way along the bicipital groove. Pus
escaping through the subscapular cul-de-sac is apt to
spread between the muscle and the venter of the
scapula, and to present at the lower and back part of
the axilla. Purulent collections beneath the deltoid
are nearly always conducted towards the anterior
aspect of the limb, being unable to proceed backwards
owing to the denseness of the fascia covering in the
deltoid and infraspinous muscles. In one recorded
case, pus that had escaped from the shoulder-joint

chap. XL] THE SHOULDER-JOINT. 193

followed the course of the musculo-spiral nerve, and
opened on the outer side of the elbow.

The various forms of anchylosis are common at the
shoulder-joint, and to afford a freer range of move-
ment to the limb in the more intractable of these
cases, Tillaux proposes to divide the clavicle.

Dislocations. — Dislocations at this joint are
more common than at any other joint in the body.
This is explained by the shallowness of the glenoid
fossa, the large size and globular shape of the head of
the humerus, the extensive movements of the arm,
the long leverage it affords, and the dependence of the
articulation for its strength mainly upon muscles.
The upper limb and shoulder are also peculiarly ex-
posed to injury.

The principal forms of luxation of the humerus at
the shoulder are : 1. Subcoracoid, forwards and a
little downwards ; the usual form. 2. Subglenoid,
downwards and a little forwards ; rare. 3. Subspinous,
backwards ; rare.

In all complete dislocations, the head of the bone
leaves the joint cavity through a rent in the capsule.
In so-called "false luxations" the capsule is not torn.
For example, in the cadaver, if the deltoid be divided
the humeral head can be displaced under the coracoid
process without rupture of the capsule, and the same
thing may occur during life, in cases where the muscle
has long been paralysed.

In all cases of dislocation at this joint the primary
displacement is always downwards into the axilla. It
is well known that dislocations at the shoulder are
usually due to violence applied to the limb while
the arm is abducted, or to severe direct violence
forcing the bone downwards. Now when the limb is
abducted the head of the humerus projects below the
glenoid fossa, and rests upon the inferior and least
protected part of the capsule. The fibres of this

N

,94 SURGICAL APPLIED ANATOMY. [Chap. xi.

portion of the capsule being tightly stretched in this
position, it requires no extraordinary force to tear the
ligament and drive the bone into the axilla.

Thus it happens that in luxations at this joint the
rent in the capsule is at its inferior and inner aspect.
The head of the bone being thus driven downwards
into the axilla, may, for certain reasons, remain there
(subglenoid form), or more usually it will be drawn
forwards and inwards by the powerful pectoralis
major, aided by other muscles whose action is now
less resisted (subcoracoid form) ; and lastly, the direc-
tion of the violence being applied markedly from in
front, the head of the bone may be thrust backwards
under the acromion or spinous processes (subspinous
form). The overwhelming frequency of the subcora-
coid variety is explained by the greater advantage at
which those muscles act that draw the bone forwards,
in comparison with those that would draw it back-
wards, and by the very trifling opposition offered to the
passage of the head forwards when compared with the
substantial obstacles in the way of its passage back-
wards under the scapular spine.

Features common to all dislocations at
the shoulder. — As the roundness of the deltoid
depends to a great extent upon the presence beneath
it of the humeral head, and as in all these luxations
(save perhaps in the slighter grades of the subspinous
form) the head is removed practically from its
connection with the deltoid, that muscle is always
more or less flattened. This flattening is augmented
by the stretching of the muscle, which in some degree
is constantly present. Stretching of the deltoid in-
volves abduction of the arm, and this symptom is
fairly constant in all the luxations. The biceps being
also more or less unduly tense, the elbow is found
flexed and the fore-arm supinated. In every form
there is some increase in the vertical circumference of

chap, xi.] THE SHOULDER-JOINT. 195

the axilla, since the head, having left the glenoid fossa,
must occupy some part comprised within that cir-
cumference. Again, Dr. Dugas has pointed out that
" if the fingers of the injured limb can be placed by
the patient, or by the surgeon, upon the sound
shoulder while the elbow touches the thorax (a con-
dition that obtains in the normal condition of the
joint), there can be no dislocation ; and if this
cannot be done there must be one, for no other injury
than a dislocation can induce this physical impossi-
bility." This depends upon the fact that in con-
sequence of the rotundity of the thorax it is impossible
for both ends of the humerus to touch it at the same
time, and in luxation at the shoulder the upper end
of the bone is practically touching the trunk. Lastly,
from the position of the great vessels and nerves it
will be seen that in the subcoracoid and subglenoid
luxations the head of the bone may press injuriously
upon those structures. Thus may result oedema of
the limb from pressure on the veins, and severe pain
or loss of muscular power from pressure on the
nerves. The artery is usually saved by its greater
elasticity ; but Berard reports a case of displacement
forwards where the axillary artery was so compressed
by the humeral head as to induce gangrene of the
limb.

The close connection of the circumflex nerve with
the humerus renders it very liable to injury, especi-
ally in the subglenoid and subspinous forms of dis-
location.

Special anatomy of each form. — 1. Sub-
coracoid.— The articular head of the humerus lies on
the anterior surface of the neck of the scapula, and the
anatomical neck rests on the anterior lip of the glenoid
fossa. The head is thus placed immediately below the
coracoid process, and is in front of, internal to, and
a little below, its normal site. The great tuberosity

196

SURGICAL APPLIED ANATOMY. [Chap. xi.

faces the empty glenoid cavity (Fig. 19). The sub-
scapularis muscle is stretched over the head of the
humerus, and is usually in some part torn. The supra-
spinatus, infraspinatus, and teres minor are stretched

or torn, or the
great tuberosity
may even be
wrenched off. The
c o r a c o - brachialis
and short head of
the biceps are
tense, and are
immediately in
front of the head
of the humerus
instead of to its
inner side. The
long tendon of the
biceps is deflected
downwards and
outwards. It is
sometimes, al-
though rarely,
torn from its
groove. The del-
toid is put upon the stretch. The prominence
formed by the humeral head in the front of the
axilla depends to some degree upon the amount of
rotation. If the bone be rotated out the projec-
tion is most distinct; but if rotated in, its head
sinks into the axilla and is brought more in contact
with the scapula than with the skin. The head of
the bone being always carried a little downwards some
lengthening must in all cases really exist; but with
the ordinary method of measuring the limb this
lengthening may be replaced by a normal measure-
ment, or even by apparent shortening, if the head of

Fig. 19. — Subcoracoid Dislocation of the
Humerus.

chap, xi.] THE SHOULDER-JOINT. 197

the bone be carried a good deal forwards and inwards,
and the limb be abducted. When the head has left
the glenoid cavity abduction tends to bring the
external condyle nearer to the acromion, and these
are the two points between which the measurement is
usually taken. Thus the apparent length of the arm
depends mainly upon the degree of abduction of the
humerus, or the obliquity of the axis of the bone.

2. Sufoglenoid. — The head is below, and a
little in front of and internal to, its normal position.
It cannot go directly downwards, owing to the situa-
tion of the long head of the triceps, but escapes in
the interval between that muscle and the subscapularis.
The articular head rests on the anterior aspect of the
triangular surface just below the glenoid fossa that
gives origin to the triceps. The upper border of the
great tuberosity is in close relation with the lower
margin of the joint. It is generally stated, on the
authority of Malle, that the circumstance which pre-
vents the head of the bone from being drawn upwards
is the entirety of the anterior part of the capsule, the
rent being in the lower part only of that ligament.
The subscapularis muscle is much stretched or torn,
and the head usually lies beneath its tendon, and
upon some fibres of the disturbed muscle. The supra-
spinatus will be torn. The infraspinatus will be
stretched or torn, and the two teres muscles will not
be much affected unless there be considerable abduc-
tion of the arm. The coraco-brachialis and biceps will
be stretched, but owing to the amount of abduction
usually present the biceps tendon is but little deflected
from a straight line. The deltoid is greatly stretched,
and its tension serves to produce the extreme flatten-
ing of the shoulder, and the great abduction common
in this injury. Some lengthening is seldom absent,
although it is always modified by the abduction that
exists.

198

SURGICAL APPLIED ANATOMY. [Chap. xi.

3. Subspinous. — The head usually rests on
the - posterior surface of the neck of the scapula, the
groove of the anatomical neck of the humerus corre-
sponding to the posterior lip of the gleiioid fossa.
The head is thus placed beneath the acromion ; but it

may be displaced still
farther back, and may
rest on the dorsum
scapulae, and beneath
the scapular spine
(Fig. 20). The sub-
scapularis tendon is
drawn right across the
glenoid fossa, and is
often torn from its
attachment. The head
pushes back the hinder
part of the deltoid, the
infraspinatus, and teres
minor muscles. These
latter cover the bone,
and are stretched over

Fig. 20.— Subspinous Dislocation of & Tne Supraspiliatus

Humerus. js tense, as is also the

biceps, while the teres

major and latissimus dorsi are relaxed. The great
pectoral is rendered unduly tense, and this serves
in part to explain the rotation inwards of the
humerus, and the adduction forwards, that are usually
observed, those movements being more or less un-
opposed. The circumflex nerve is often torn.

In reducing dislocations, especially such as are of
long standing, serious damage may be inflicted on the
axillary structures. The axillary artery suffers most
frequently, the vein rarely , and the nerves still less
often. The artery, being placed externally, is apt to
contract adhesions to the soft parts covering the head

Chap. XL] UPPER END OF HUMERUS. 19^

of the displaced bone, and to be, therefore, torn when
those parts are disturbed.

Fractures of the upper end of the hu-
merus. — 1. Anatomical neck. The upper part
of the capsule is exactly attached to the anatomical
neck, and in this situation the fracture may run
beyond the ligament and be partly extracapsular.
The lower part of the capsule is inserted some little'
way below the anatomical neck, and in this position,
therefore, the lesion must be intracapsular. From
the line of attachment of the lower part of the capsule
to the humerus, fibres are reflected upwards to the
margin of the articular cartilage on -the head of the
bone. These fibres, if unruptured, may serve to con-
nect the fragments. If entirely separated, the head of
the bone must necrose, having no such source of blood
supply as the head of the femur derives from the
round ligament. It is easy for the small and com-
paratively dense upper fragment to be driven into the
wide surface of cancellous bone exposed on the upper
surface of the lower fragment. When impaction
occurs, there may be some flattening of the. deltoid,
since the head is rendered of less dimensions by that
impaction, and consequently causes a less projection of
the deltoid. I may be possible to detect the impac-
tion by examination through the axilla when the arm
is fully abducted. The difficulty of obtaining crepitus
in non-impacted fractures will be obvious when the
small size of the upper fragment is considered, together
with its great mobility, and the obstacles in the way
of so fixing it that one broken end may be rubbed
against the other.

The amount of displacement is to be measured by
the laxity of the capsule. The usual deviation is a
projection of the upper end of the lower fragment
towards the anterior and inner side of the articulation,
brought about mainly by the muscles attached to the

200 SURGICAL APPLIED ANATOMY. [Chap. xi.

bicipital groove. In no case could the two bone-ends
overlap.

2. Separation of the upper epipliysis. — The

lower border of this epiphysis is represented by a
horizontal line crossing the bone at the base of the
great tuberosity, and placed between the anatomical
and surgical necks. It would be fairly indicated by a
transverse saw-cut through the widest part of the bone.
The three component nuclei of this epiphysis (head,
greater and lesser tuberosities) fuse together about the
fifth year, and the entire mass joins the shaft about
the twentieth year. The upper fragment may be
carried and rotated a little outwards by the muscles
attached to the great tuberosity, while the lower frag-
ment is drawn inwards and forwards by the muscles
inserted into the bicipital groove. Thus, a part of the
smooth upper end of the lower fragment commonly
forms a distinct projection below the coracoid process.
In such case the axis of the limb would be altered, and
the elbow carried a little from the side. Often, how-
ever, the displacement is solely in the antero-posterior
direction, the lower fragment projecting forwards.
So wide are the two bone surfaces at the seat of
injury that it is scarcely possible for them to overlap
one another.

3. Surgical neck. — The surgical neck is situated
between the bases of the tuberosities and the insertions
of the latissimus dorsi and teres major muscles. A
common displacement of parts is the following. The
upper fragment is carried out and rotated out by the
supra- and infraspmatus and teres minor. The upper
end of the lower fragment is drawn upwards by the
deltoid, biceps, coraco-brachialis, and triceps, inwards
by the muscles attached to the bicipital groove, and
forwards by the great pectoral. Thus, it forms a
projection in the axilla, and the axis of the limb is
altered so that the elbow projects from the side. This

Chap. XL]

UPPER END OF HUMERUS.

201

displacement, however, is by no means constant.
Pean, Anger, and others maintain that the usual
deformity is a projection of the upper end of the lower
fragment forwards, and that this deviation is due to
the nature and direction of the violence, and not to
muscular action. In some cases there is no displace-
ment, the broken ends being retained in situ, pro-
bably, by the biceps tendon and the long head of the
triceps. In at least one instance (Jarjavay) the lower
fragment was so drawn upwards and outwards,
apparently by the deltoid, as to nearly pierce the skin
of the shoulder. Hamilton comes to the general con-
clusion " that com-
plete or sensible
displacement is
less common at
this fracture than
in most other frac-
tures," and in this
conclusion many
surgeons agree.

Amputation
at the shoulder
joiut. — "Flap
method ; " " del-
toid flap." In the
outer flap are only
the deltoid and a
few small vessels
derived from the
acromio - thoracic
and the two cir-
cumflex arteries.
The cephalic vein
and descending
branch of the acromio - thoracic artery are in the
inner flap. The anterior and posterior borders of the

Fig. 21.— Amputation at Shoulder-joint (flap

method) (Agatz).
a, Glenoid cavity ; 6, deltoid ; c, long head of

biceps ; d, pectoralis major ; e, biceps and coraco-

brachialis ; /, latissimus dorsi and teres major ;

g, triceps ; 1, axillary vessels ; 2, circumflex

vessels ; 3, brachial plexus.

2O2 SURGICAL APPLIED ANATOMY. [Chap. xn.

inner flap show portions of the deltoid muscle.
Along its lower border from before backwards are
sections of the pectoralis major, the short head
of the biceps and coraco-brachialis, the axillary
vessels and nerves, the latissimus dorsi and teres
major, the triceps, and the posterior portion of the
deltoid. The trunks of the posterior circumflex
artery and nerve are found divided on the posterior
part of the surface of the flap, between the sections of
the triceps and deltoid, and not far from the axigle
between the two flaps.

Oval method (Spence). The parts cut and the
order of their division are practically the same as
obtain in the anterior and inferior borders of the two
flaps made in the previous method. The anterior
incision being a little more vertical than is the gap
between the two flaps, divides more of the pectoralis
major and cuts the cephalic vein higher up. The
posterior circumflex vessels and nerve are separated
from the bone by the finger and are retained, one
advantage of the procedure being that only a few of
the terminal branches of that artery are divided.

CHAPTER XII.

THE ARM.

THE arm, upper arm, or brachial region is con-
sidered to extend from the axilla above to the region
of the elbow below.

Surface anatomy. — In women, and in those
who are fat, the outline of the arm is rounded and fairly
regular. It is less regular in the muscular, in whom
it may be represented by a cylinder, somewhat

Chap, xii.] THE ARM. 203

flattened on either side and unduly prominent in front
(biceps muscle). The outline of the biceps muscle is
distinct, and on either side of it is a groove. The
inner of the two grooves is by far the more con-
spicuous. It runs from the bend of the elbow to the
axilla, and indicates generally the position of the
basilic vein and brachial artery. The outer groove
is shallow, and ends above at the insertion of the
deltoid muscle. So far as it goes it marks the position
of the cephalic vein.

The insertion of the deltoid can be well made out,
and is an important landmark. It indicates very
precisely the middle of the shaft of the humerus, is
on the same level with the insertion of the coraco-
brachialis muscle, and marks the upper limit of the
brachialis anticus. It corresponds also to the spot
where the cylindrical part of the humeral shaft joins
the prismatic portion.

When the arm is extended and supinated, the
brachial artery corresponds to a line drawn along the
inner border of the biceps, from the outlet of the
axilla (at the junction of its middle and anterior
thirds) to the middle of the bend of the elbow. The
artery is superficial, and can be felt in its entire
extent. In its upper two-thirds it lies on the inner
aspect of the shaft of the humerus, and can be com-
pressed against the bone by pressure in a direction
outwards and slightly backwards. In its lower third
the humerus lies behind it, and compression, to be
effectual, should be directed backwards.

The superior profunda artery and musculo-spiral
nerve cross the posterior surface of the humerus
obliquely at a spot on a level with the insertion of
the deltoid.

The inferior profunda would be represented by a
line drawn from the inner side of the humeral shaft
at its middle to the back part of the internal condyle.

204 SURGICAL APPLIED ANATOMY. [Chap. xn.

The nutrient artery enters the bone at its inner aspect,
opposite the deltoid insertion, and the anastomotic
vessel comes off about two inches above the bend of
the elbow.

The ulnar nerve follows first the brachial artery,
and then a line drawn from the inner side of that
vessel, about the level of the insertion of the coraco-
brachialis to the gap between the inner condyle and
the olecranon. The main part of the internal cuta-
neous nerve is beneath the inner bicipital groove,
while the superficial portion of the musculo-cutaneous
corresponds to the lower termination of the outer
groove.

The arm. — The skin of the arm is thin and
smooth, especially in front and at the sides. It is
very mobile, being but loosely attached to the deeper
parts by a lax subcutaneous fascia. In circular am-
putations of the arm this looseness of the integument
allows it to be sufficiently drawn up by traction with
the hand only. It is from the integument covering
the anterior surface of the biceps that the flap is
fashioned in Tagliacozzi's operation for the restoration
of the nose. The fineness of the skin of this part, and
its freedom from hairs, render it very suitable for this
procedure. The scanty attachments of the skin of the
arm allow it to be readily torn or stripped away in
lacerated and contused wounds. Sometimes in these
lesions large flaps of integument are violently dis-
sected up. The looseness of the subcutaneous tissues
favours greatly the spread of inflammatory processes,
while its comparative thinness allows of the early
manifestation of ecchymoses.

The limb is completely invested by a deep fascia,
the brachial aponeurosis, as by a sleeve. The fascia
is held down at the sides by the two intermuscular
septa which are attached along the outer and inner
margins of the humerus, running from the deltoid

chap, xii.] THE ARM, 205

insertion to the outer condyle on the one side, and
from the coraco-hrachialis insertion to the inner condyle
on the other. By means of this aponeurosis and its
septa the arm is divided into two compartments, that
can be well seen in transverse sections of the limb.
These compartments serve to confine inflammatory
and hsemorrhagic effusions. The anterior of the two
spaces has the less substantial boundaries, owing to
the thinness of the brachial fascia as it covers the
biceps. Effusions can readily pass from one compart-
ment to the other by following the course of those
structures that, by piercing the intermuscular septa,
are common to both spaces. These are the musculo-
ppiral and ulnar nerves, the superior and inferior
profunda, and anastomotic arteries. The principal
structures that pierce the brachial aponeurosis itself
are the basilic vein, a little below the middle of the
arm, the internal cutaneous nerve, about the middle,
and the external cutaneous nerve, just above the
elbow. The two first named are in the inner bicipital
groove, and the last named in the outer.

The skin over the point of insertion of the deltoid
was commonly selected as a suitable place for an issue
at a time when that remedy was popular. The reasons
for such selection were the absence of blood-vessels of
any size in the parts beneath, and the freedom of the
spot from muscular movement. The brachialis anticus
is closely adherent to the bone, while the biceps is
free. It follows, therefore, that in section of these
muscles, as in amputation, the latter muscle retracts
more considerably than does the former. It is well,
therefore, in performing a circular amputation, to
divide the biceps muscle first, and then after it has
retracted to cut the brachialis anticus.

The foracliial artery. — The line of this vessel
has already been given. It is well to note that in the
very muscular the artery may be overlapped to a

206 SURGICAL APPLIED ANATOMY. [Chap. xn.

considerable extent by the biceps muscle. Compression
of the brachial, unless performed carefully with the
fingers, can hardly avoid at the same time compression
of the median nerve. Thus no doubt arises the severe
pain that is often complained of when tourniquets, or
circular indiarubber bands, are applied to the limb.
It must also be remembered that the internal
cutaneous nerve lies in front of the vessel, or close to
its inner side, until it pierces the fascia ; that the ulnar
nerve lies along the inner side of the artery as far as
the coraco-brachialis insertion, and that behind the
commencement of the vessel is the musculo-spiral
nerve. The venae comites are placed one on either
side of the artery, and communicate frequently with
one another by short transverse branches which
directly cross the vessel, and which may give trouble
in operations upon the artery. If in ligaturing the
artery at its middle third the arm rests upon any
support the triceps may be pushed up and mistaken
for the biceps. If the incisions be too much to the
inner side the basilic vein may be cut, or the ulnar
nerve exposed and mistaken for the median. Tillaux
states that in the operation a large inferior profunda
artery has been taken for the brachial. Inasmuch
as the median nerve often derives distinct pulsation
from the subjacent vessel, it happens that in the
living subject it has been confused with the main
artery itself.

The Hiusculo-spiral nerve, from its close
contact with the bone, which it crosses at the level
of the deltoid insertion, is frequently injured and
torn. Thus it has been damaged in severe contusions,
in kicks, in stabs, in bites from horses, and very
frequently in fractures of the humeral shaft ; or the
nerve may be sound at the time of fracture, and
become subsequently so involved in the callus formed
as to lead to paralysis of the parts it supplies. In a

chap, xii.] THE ARM. 207

case reported by Tillaux, where paralysis followed
some time after a fracture, the nerve was found
embedded in callus, and on cutting some of the
redundant mass away a good recovery followed. In
several instances the nerve has been paralysed by the
pressure of the head when a man has slept with his
head resting on the arm in the position of full
supination and abduction. It is said to be often
paralysed in Russian coachmen who fall asleep with
the reins wound round the upper arm. It has also
been frequently damaged by the pressure of badly
constructed crutches, especially those that afford no
proper support for the hand. Indeed, it is the nerve
most often affected in " crutch paralysis," the ulnar
being the trunk that suffers next in frequency.

Fracture of the shaft of the humeriis is
usually due to direct violence. The shaft may, how-
ever be broken by indirect violence, and of all bones
the humerus is said to be the one most frequently
fractured by muscular action. As examples of the
latter may be noted the throwing of a ball, the
clutching at a support to prevent a fall, and the so-
called trial of strength known as "wrist turning."
When the bone is broken above the deltoid insertion
the lower fragment may be drawn upwards by the
biceps, triceps, and deltoid, and outwards by the last-
named muscle ; while the upper fragment is drawn
inwards by the muscles attached to the bicipital
groove. When the fracture is below the deltoid
insertion, the lower end of the upper fragment may
be carried outwards by that muscle, while the lower
fragment is drawn upwards to its inner side by the
biceps and triceps. The deformity, however, as a
rule depends much more upon the nature and direction
of the force that breaks the bone than upon any
muscular action. The displacements just noted may
be met with, but usually they are quite independent

2o8 SURGICAL APPLIED ANATOMY. [Chap. xn.

of the relation of the deltoid insertion to the seat of
fracture, and cannot be tabulated. The weight of the
arm seldom allows of more than three-quarters of an
inch of shortening.

The humerus is more frequently the seat of
non-union after fracture than is any other bone.
This result is quite independent of the position
of the fracture in relation to the nutrient artery.
Hamilton's explanation is briefly this : the fracture is
usually so adjusted that the elbow is flexed ; this
joint soon becomes fixed by muscular rigidity, and
when any movement is made as if to flex or extend
the fore-arm on the arm, that movement no longer
occurs at the elbow joint, but at the seat of fracture.
Thus, if the arm be in a sling, and the patient allows
the hand to drop by relaxing that sling, it is main-
tained that the bulk of that movement will take place
about the fracture line. There are many objections
to this theory. If true, the tendency to movement
about the fragments would be the greater the farther
the fracture is from the elbow joint, but non-union is
more common at the middle than at the upper third
of the shaft. Probably many causes conspire to
bring about non-union of fractures of this bone,
among which may be mentioned the imperfect fixing
of the joint above the fracture, and the inadequate
support afforded to the elbow, whereby the weight
of the arm and of the splints tends to drag the
lower fragment out of the proper line it should form
with the upper fragment. The most effective cause
would appear to be due to the entanglement of
muscular tissue between the broken ends, for it
must be remembered that the shaft of the bone is
closely surrounded by muscular fibres that are directly
adherent to its surfaces. Thus, in an oblique fracture
the end of one fragment may be driven into the
brachialis anticus, while the other end projects into

Chap. XII.]

THE ARM.

209

the substance of the triceps, and immediate contact
of the bones be consequently prevented.

Amputation through the middle of the
arm. — Circular method : The parts divided in this
amputation are fully shown in Fig. 22. Flap
method : Two flaps of about equal size and shape
may be cut antero-posteriorly by double transfixion,
the arm being well
rotated outwards.
In the anterior flap
would be the biceps
and the greater part
of the brachialis
anticus, with the
musculo - cutaneous
nerve between them,
and a small piece
of the triceps from
the inner side of
the limb. The

brachial vessels, the
median and ulnar

nerves, and possibly Fig. 22.-A Transverse Section through the
the inferior profunda middle of the Arm (Braune).

nr+pvtr afp nlcm a> Biceps ; 6, coraco-brachialis: c, brachialis

;C1 J ) anticus ; d, triceps : 1, brachial artery ; 2, me-

fouild ill this flap, dian nerve ; 3' ulnar nerve »' 4' musculo-spiral

jr ' ner > e.

about the inner

angle of the stump. The basilic vein and internal
cutaneous nerve lie cut about the inner border of
the anterior flap, and the cephalic vein about its
outer border. In the posterior flap would be the
triceps, any small part of the outer portion of the
brachialis not divided in the anterior flap, the superior
profunda artery, and the musculo-spiral nerve. If
the amputation be lower down in the arm, the ulnar
nerve and inferior profunda artery may be found in
the posterior instead of the anterior flap. Since the
o

210 SURGICAL APPLIED ANATOMY. [Chap. xm.

nutrient artery enters the bone about the insertion
of the coraco-brachialis and runs towards the elbow,
it would be divided in these amputations, and might
give trouble.

CHAPTER XIII.

THE REGION OF THE ELBOW.

Surface anatomy. — On the anterior aspect of the
elbow are seen three muscular elevations. One, above
and in the centre, corresponds to the biceps and its
tendon ; while, of the two below and at the sides, the
outer corresponds to the supinator longus and the
common extensor mass, and the inner to the pronator
radii teres and the common set of flexor muscles.
The arrangement of these elevations is such that two
grooves are formed, one on either side of the biceps
and its tendon. The grooves diverge above, and join
the outer and inner bicipital grooves, while below
they meet over the most prominent part of the
tendon, and thus form together a V-shaped depression.
The distinctness of these details depends upon the
thinness and muscular development of the individual.
In the inner of the two grooves are to be found the
median nerve and the brachial artery and its veins ;
while deeply placed below the outer groove are the
terminations of the musculo-spiral nerve and superior
profunda artery, with the small radial recurrent
vessel. The biceps tendon can generally be very
distinctly felt. Its outer border is more evident than
is its inner edge, owing to the connection of the
bicipital fascia with the latter side of the tendon.
Extending transversely across the front of this region
is a crease in the integument, the " fold of the elbow."

Chap, xui.] REGION OF ELBOW. 211

This fold is not a straight line, but is convex below.
It is placed some little way above the line of the
articulation, and its lateral terminations correspond to
the tips of the two condylar eminences. In backward
dislocations of the elbow the lower end of the humerus
appears about one inch below this fold, whereas in a
fracture of the humerus just above the condyles the
fold is either opposite to the prominence formed by
the lower end of the upper fragment, or is below it.
This crease is obliterated on extension.

At the apex of the Y-shaped depression, about the
spot where the biceps tendon ceases to be distinctly
felt, and at the outer side of that tendon, the median
vein divides into the median basilic and the median
cephalic. At the same spot also the deep median vein
joins the superficial vessels. The median basilic vein
can be seen to cross the biceps tendon, to follow more
or less closely the groove along the inner border of the
muscle, and to join, a little above the internal condyle,
with the posterior ulnar vein to form the basilic trunk.
The median cephalic following the groove at the outer
margin of the biceps joins, about the level of the
external condyle, with the radial vein to form the
cephalic vein. The brachial artery bifurcates about
a finger's breadth below the centre of the bend of the
elbow. " The cororioid process of the ulna can be
indistinctly felt, if firm pressure is made in the
triangular space in front of the joint " (Chiene). The
points of the two condyles can always be felt. The
internal condyle is the more prominent and the less
rounded of the two. The humero-radial articulation
forms a horizontal line, but the humero-ulnar joint is
oblique, the joint surfaces sloping downwards and in-
wards. Thus it happens that while the external condyle
is only f of an inch (18 mm.) above the articular
line, the point of the internal condyle is more than
1 inch (28 mm.) above that part (Paulet). From the

212 SURGICAL APPLIED ANATOMY. [Chap. xni.

obliquity of the joint surfaces between the ulna and
humerus, it follows that the fore-arm, when in ex-
tension, is not in a straight line with the upper arm,
but forms with it an angle that opens outwards.
Thus, when traction is made upon the entire upper
limb from the wrist, some of the extending force is
necessarily lost, and such traction, therefore, should
be applied from the elbow, as is the usual practice in
reducing a dislocation of the shoulder by manipulation.
A line drawn through the two condyles will be at
right angles with the axis of the upper arm, while it
will form an angle with the axis of the fore-arm.
Thus if we look at the upper arm, the two condyles
are on the same level, whereas, when viewed from the
fore-arm, the inner condyle lies at a higher level than
does the external process.

The joint line of the elbow is equivalent only to
about two -thirds of the width of the entire line
between the points of the two condyles. The promi-
nence of the condyles forms an excellent point
d'appui for traction by encircling bands applied
to the limb above the elbow joint. At the back of
the elbow the prominence of the olecranon is always
to be distinctly felt. It lies nearer the internal
than the external condyle. In extreme extension
the summit of the olecranon is a little above the line
joining the two condyles. When the fore-arm is at
right angles with the arm, the tip of the process is
below the line of the condyles, and in extreme flexion
it lies wholly in front of that line. Between the
olecranon and the inner condyle is a depression that
lodges the ulnar nerve and the posterior ulnar
recurrent artery.

To the outer side of the olecranon, and just below
the external condyle, there is a depression in the skin
which is very obvious when the limb is extended.
This pit is to be seen even in those who are fat, and

Chap, xiii.] REGION OF ELBOW. 213

also in young children. In it the head of the radius
can be felt, and can be well distinguished when the
bone is rotated in pronation and supination. The pit
corresponds to the hollow between the outer border
of the anconeus and the muscular eminence formed
by the two radial extensors of the carpus and the
supinator longus. The highest point of the bone that
can be felt moving on rotation will correspond to the
radius immediately below the line of the elbow joint,
and is a valuable guide to that articulation. The
upper limit of the elbow joint reaches a line drawn
between the points of the two condyles. The. tubercle
of the radius can be felt just below the head of the
bone when the limb is in the position of extreme
pronation.

The region of the elbow. — The skin in front
of the elbow is thin and fine, and is readily excoriated
by tight bandaging and by improperly applied splints.
The thinness of the skin allows the subjacent veins to
be easily seen through the integuments, but the
distinctness with which these veins appear depends
mainly upon the amount of subcutaneous fat. In
the very stout they may be quite invisible, and it
may be difficult or impossible to render them evident
by the usual means adopted in venesection. Tillaux
points out that if such people are bled a pellet of fat
will often project into the wound and prevent the
flow of blood.

The arrangement of the superficial veins in
front of the elbow, so as to form an M-shaped figure,
is familiar, but it must be confessed that it is by no
means constant (Fig. 23). So far as I have seen,
it would appear that the precise M-like arrangement
figured in most books is only present in about two-
thirds, and perhaps in only one-half, of all cases.

The median vein breaks up into the median
cephalic and median basilic, just to the outer side

214

SURGICAL APPLIED ANATOMY. [Chap xm.

of the biceps tendon, and, therefore, the latter vein
passes in front of the tendon, of the brachial artery
and its veins, and of the median nerve. From
these structures it is separated by the bicipital fascia.
The median basilic vein may
cross the brachial artery ab-
ruptly, and be comparatively
free of it, except at the point
of crossing, or it may run for
some distance quite in front
of the artery, or, crossing it
early, it may lie parallel with
the vessel, although at a diffe-
rent level, for the greater part
of its course. As regards size,
the median basilic is usually
the largest of these veins, the
median cephalic coming next,
and the median itself third,
while the ulnar and radial veins
are the smallest of the series.
These veins are liable to many
abnormalities, some of the most
conspicuous being in cases where
the main arteries of the part are
Fig. 23.— The Left Elbow aiso abnormal. The deviation

from in front. . .

a, Basilic vein; 6, -cephalic is more usual in the veins on

jSia&^SK^ffi the radial than in those on the

Se°dian e ^Sir^ein; ulnar side of the limb. Thus

^^,»UbrmSSS it is common for the radial or

the median cephalic veins, or

both, to be either very defective or entirely absent.
In spite of the relation the median basilic vein
bears to the brachial artery, it is nevertheless
the vein usually selected in venesection. The
reasons for its selection are these : it is usually
the largest and most prominent of the veins, and

chap, xiii.] REGION OF ELBOW. 215

the one the nearest to the surface ; it is also the
least movable vein, and the one the least subject
to variation. The bicipital fascia forms an excel-
lent protection to the brachial artery during
phlebotomy. The density of that membrane varies,
arid depends mainly upon the degree of muscular
development. In thin subjects the median basilic
vein may receive pulsations from the subjacent
artery. According to one observer, the walls of
this vein are often as thick as those of the popliteal
vein. The ulnar, radial, and median veins seldom
yield enough blood on venesection, since they are
below the point of junction of the deep median
vein, and thus do not receive blood from the deep
veins of the limb. The brachial artery has, as may
be supposed, been frequently injured in bleeding ; and
at the period when venesection was very commonly
practised, arterio-venous aneurisms at the bend of
the elbow were not infrequent. Since the principal
superficial lymphatic vessels run with these veins,
and since some of them can scarcely escape injury in
phlebotomy, it follows that an acute lymphangitis
is not uncommon after the operation, 'especially when,
the point of the lancet being unclean, septic matter is
introduced into the wound.

The internal cutaneous nerve, which usually runs
in front of the median basilic vein, may be wounded
in bleeding from that vessel. The injury to the
nerve, according to Tillaux, may lead to " traumatic
neuralgia of extreme intensity, and very chronic."
A "bent arm " may follow after venesection, and
Mr. Hilton believes this to be often due to injury
to the filaments of the musculo-cutaneous nerve,
especially to the inclusion of those filaments in a
scar left by the operation. These peripheral fibres
being irritated, the muscles supplied by the nerve
(biceps and brachialis anticus) are caused to contract

216 SURGICAL APPLIED ANATOMY. [Chap. xm.

by reflex action. Hence the bent arm. In one case
he cured a bent arm following bleeding by simply
resecting the old cicatrix, which on removal wras
found to have included within its substance some nerve
filaments.

There is a lymphatic gland situated over the
internal intermuscular septum of the arm, and just
above the internal condyle. It receives some of the
surface lymphatics from the inner side of the fore-arm,
and two or three inner fingers. In position, it is the
lowest gland in the fore-arm.

The foracnial artery • — In forcible flexion of the
limb the artery is compressed between the muscular
masses in front of the joint, and the radial pulse is
much diminished or even checked. Aneurisms at the
bend of the elbow have been treated by flexion of the
limb, that position bringing more or less direct pressure
to bear upon the sac. In full extension of the joint
the artery becomes flattened out, and the radial pulse
diminished. In the over extension possible with
fractured olecranon the pulse may be stopped at the
wrist. Forcible extension of an elbow that has be-
come rigid in the bent position has caused rupture of
the brachial artery.

The ulnar nerve is, from its position at the
elbow, very liable to be injured, although it is to some
extent protected by the prominences of the olecranon
and inner condyle. In some cases the nerve passes in
front of. the internal condyle, and an instance is
reported where the nerve slipped forward over that
eminence whenever the elbow was bent (Quain). In
cases where an abnormal brachial passes beneath a
supracondyloid process the median nerve goes with
the artery.

The elbow joint. — The strength of this joint
depends not so much upon either ligaments or muscles
as upon the coaptation of the bony surfaces. The

chap, xiii.] REGION OF ELBOW. 217

relations of the olecranon and coronoid process to the
humerus are such that in certain positions the strength
of the joint is very considerable.

The elbow, being a pure hinge-joint, permits only of
flexion and extension. These movements are oblique,
so that in flexion the fore-arm inclines inwards, carrying
the hand towards the middle third of the clavicle. If
it were not for the obliquity of the joint line it would
be possible for the hand to be placed flat upon the
shoulder of the same side, but this movement is only
possible after some excisions of the joint, for in this
operation the oblique direction of the articular surfaces
is not reproduced. In extreme extension the ulna is
nearly in a straight line with the humerus as regards
their lateral planes, while in extreme flexion the two
bones form an angle of from 30° to 40°.

Bursse. — Of the bursse about the joint the large
subcutaneous bursa over the olecranon is very
commonly found enlarged and inflamed ; and when
inflamed may lead to extensive mischief in the limb.
Its enlargement is favoured by certain employments
involving pressure on the elbow ; thus, the disease
known as " miner's elbow " is merely an enlargement
of this sac. There is a bursa between the biceps
tendon at its insertion and the bone, the relations of
which to the nerves of the fore-arm are worth noting.
A case, for instance, is reported where this bursa
became chronically enlarged, and by pressing upon the
median and posterior interosseous nerves produced
loss of power in the fore-arm (Agnew).

Of the ligaments of the elbow joint the anterior
and posterior are comparatively thin, and the latter
especially soon yields to the pressure of fluid within
the joint in disease of the articulation. The internal
lateral is the strongest and most extensive of the
ligaments of the part. From its rigidity, its extended
attachment, and the fact that it serves to limit not

2i8 SURGICAL APPLIED ANATOMY. [Chap. xin.

only flexion and extension, but also any attempt
to wrench the fore-arm laterally from the arm, it
happens that it is the ligament that suffers the most
often in " sprains " of the elbow. As this ligament
is attached to the whole length of the inner border
of the olecranon it may assist in preventing separa-
tion of the fragments when that process has been
fractured.

Joint disease. — In disease of this joint the
effusion first, and most distinctly, shows itself by a
swelling around the margins of the olecranon. This
is explained by the facts that the synovial cavity is
here nearest to the surface, and the posterior ligament is
lax and thin. Some swelling is also very soon noticed
about the line of the radio-humeral joint, and fluctua-
tion in this situation serves to distinguish joint effusion
from simple enlargement of thebursa beneath the triceps
tendon. Deep-seating swelling may be noted about
the front of the joint beneath the brachialis anticus,
owing to the thinness of the anterior ligament ; and
lastly, about the external condyle. The density of
the internal ligament prevents a bulging of the
synovial membrane on the inner side. When the
joint suppurates the pus will most easily reach the
surface by travelling upwards and backwards between
the humerus and the triceps, and the abscess points,
therefore, very commonly at one or other border
of that muscle. The pus may escape beneath the
brachialis anticus in front, and discharge itself near
the insertion of the muscle. When the bone is
diseased the sinuses form usually directly over the
part attacked. The diseased elbow tends to assume
the posture of semi-flexion, and it is interesting to
observe that that is the position assumed by the joint
when forcible injections are made into its cavity
(Braune). The joint, in fact, holds the greatest amount
of fluid when it is semi-flexed. As regards muscular

Chap, xiii.] REGION OF ELBOW. 219

rigidity of the elbow, due to reflex irritation from
disease, it is well to note that all the nerves of the
articulation supply muscles acting upon the joint,
notably, the musculo-spiral and musculo-cutaneous.
The relation of the ulnar nerve to the joint serves to
explain cases where severe pain has been felt along
the fore-arm and in the fingers, in parts corresponding
to the distribution of that nerve.

Dislocations of the elbow. — These are many,
and may be thus arranged. (1) Dislocations of both
radius and ulna either backwards, outwards, inwards,
or forwards (in order of frequency). (2) Dislocations
of the radius alone either forwards, backwards, or
outwards (in order of frequency). (3) Luxation of
the ulna alone backwards.

As a preliminary it may be convenient to note
some general anatomical considerations in connection
with these various displacements.

(a) Antero-posterior luxations are much more
common than are lateral luxations. — Displacements
in the antero-posterior direction are more common,
because the movements of the joint take place in that
direction, and the width of the articular surface of the
humerus from before backwards is comparatively small.
On the other hand, there is normally no lateral move-
ment of the elbow, and the width of the articulation
from side to side is considerable. The antero-posterior
ligaments are feeble, while the lateral ligaments are
strong, and the joint, moreover, receives more muscular
support at its sides than it does either behind or 'in
front. The mutual support afforded by the bones to
one another is weakened in the antero-posterior
direction 'during certain movements. Thus in full
flexion the olecranon has but a feeble hold upon
the humerus, while in extension the hold of the
coronoid process upon that bone is even less. In a
lateral direction, however, movement has but a very

220 SURGICAL APPLIED ANATOMY. [Chap. xm.

slight effect upon the support the bones mutually
derive from one another.

(b) Both bones of the fore-arm are more often
luxated together than is either the radius alone or the
ulna alone. This depends upon the powerful liga-
mentous connection between the radius and ulna on
the one hand, and the absence of such connection
between the humerus and the radius on the other.
In the dead subject it is not difficult to dislocate the
two bones of the fore-arm, but it is extremely difficult
to separate the radius from the ulna without great
breaking and tearing of parts.

(c) The commonest dislocation of the two bones
together is backwards, the rarest is forwards. — In
the former instance the movement is resisted by
the small coronoid process, in the latter by the
large and curved olecranon. For like reasons the
luxation outwards is less rare than is the displace-
ment inwards, since the articular surface of the
humerus inclines downwards and inwards on the
inner side, and thus affords a greater obstacle in
that quarter.

(d) If a single bone be dislocated it will usually be
the radius. — This follows from the absence of reliable
union between that bone and the humerus, from the
greater exposure of the radius ("the handle of the
hand") to indirect violence, and from its greater
mobility. The luxation is usually forwards, due
to the fact that the forms of violence that tend
most often to displace the bone tend also to draw
it forwards. Paulet asserts that the posterior part
of the annular ligament is " much more resistant "
than is the anterior part. The luxation of the ulna
alone occurs in the backward direction, for reasons
that will be obvious.

Dislocations of the elbow of all kinds may be
partial or complete. More usually they are complete

chap, xiii.] REGION OF ELBOW. 221

when in the antero-posterior direction, and partial
when the luxation is lateral.

Some more detailed notice may now be taken
of the only two forms of dislocation at the elbow that
are at all common.

(1) Displacement of* both bones back-
ward s. — This may be effected during forced exten-
sion. Here the point of the olecranon pressed against
the humerus acts as the fulcrum of a lever of the
second kind, and tends to tear the ulna from the
latter bone. The addition of violence to the fore-arm
in a backward or upward direction would effect the
actual displacement. This condition may be illustrated
by a fall, as in running, upon the fully extended
hand. The lesion may also be produced by certain
violent wrenchings of the limb. Malgaigne maintained
that the particular kind of wrench most effectual in
producing luxation was a twisting inwards of the
fore-arm while the elbow was semi-flexed. In this
way the internal lateral ligament was ruptured, and
the coronoid process twisted inwards and downwards
under the humerus, and the bones thus displaced back.
This lesion would be difficult to effect while the joint
was fully flexed. In the complete form the coronoid
process is opposite to the olecranon fossa. It can
hardly occupy that hollow (as sometimes described),
since the connection of the ulna to the radius, and the
projection of the latter bone behind the outer condyle,
would prevent it from actually falling into the fossa.
The anterior and the two lateral ligaments are usually
more or less entirely torn, while the posterior and the
orbicular ligaments escape. The biceps is drawn over
the lower end of the humerus, and is rendered
moderately tense. The brachialis anticus is much
stretched and often torn. The anconeus is made very
tense. Both the median and ulnar nerves may be
severely stretched.

222 SURGICAL APPLIED ANATOMY. [Chap. xin.

Dislocation of the radius forwards. — Tins
may be due to direct violence to the bone from behind,
or to extreme pronation, or to falls upon the extended
and pronated hand. The anterior, external, and
annular ligaments are torn. There would seem to be
a lack of evidence in support of Hamilton's statement
that " sometimes the anterior and external lateral
are alone broken, the annular ligament being then
sufficiently stretched to allow of the complete disloca-
tion." The biceps being relaxed, the pronators act,
and the limb is either pronated, or assumes a position
midway between pronation and supination. Some
stretching of the supinator brevis would probably
modify the amount of pronation. A difficulty in the
reduction is often due to the torn annular ligament
coming between the head of the radius and the
humeral condyle.

Fractures of the lower end of the humerus.
— These are : (1) A fracture just above the condyles ;

(2) "the T-shaped fracture" involving the joint;

(3) fractures of the internal, and (4) of the external
condyle ; (5) fracture of the internal epicondyle ; and
(6) separation of the lower epiphysis.

All these fractures are more common in the
young.

1. The fracture "at the base of the condyles," as
it is sometimes called, is usually situate a little above
the olecranon fossa, where the humeral shaft begins
to expand. It is commonly transverse from side to
side, and oblique from behind downwards and forwards.
It is generally the result of a blow inflicted upon
the extremity of the elbow. Probably the tip of
the olecranon driven sharply against the bone acts
Like the point of a wedge, and takes an important
share in the production of the fracture. The lower
fragment, together with the bones of the fore-arm, is
generally carried backwards by the triceps, and

Chap, xiii.] REGION OF ELBOW. 223

upwards by that muscle, the biceps, and the brachialis
anticus. The median, or ulnar nerves, especially the
latter, may be severely damaged.

2. The " T-shaped fracture " is but a variety of the
lesion just noted. In addition to the transverse
fracture above the condyles, there is also a vertical
fracture running between the two condyles into the
joint. The lower fragment is thus divided into two
parts. The displacement is the same. The fracture
is very usually due to a fall upon the bent elbow, and
here possibly also the tip of the olecranon acts as
a wedge, producing the transverse fracture, while the
prominent ridge along the middle of the greater
sigmoid cavity, acting as a second wedge, produces
the vertical fracture into the joint.

3, 4, and 5, For surgical purposes it is well to
limit the term " condyle " to such parts of the
extremity of the humerus as are within the capsule,
and the term " epicondyle " to such parts of the lower
projections of the bone as are without the joint.

In the so-called fracture of the inner condyle
the line of separation generally commences about half
an inch above the tip of the epicondyle (and, therefore,
outside the joint), and running obliquely outwards
through the olecranon and coronoid fossae, enters the
articulation through the centre of the trochlear surface
(Hamilton). The fragment is often displaced a little
upwards, backwards, and inwards, the ulna going
with it.

In the fracture of the external condyle the line
commences also above the epicondyle and outside
the joint, and running downwards enters the joint
usually between the trochlear surface and the surface
for the radius. The displacement is trifling and
inconstant.

On account of its insignificant size, a fracture
of the external epicondyle is scarcely possible.

224 SURGICAL APPLIED ANATOMY. [Chap. XIIL

Fractures of the inner epicondyle are, however, quite
common, the joint remaining free. This epicondyle
exists as a distinct epiphysis, which unites at the age
of eighteen, and which at any time before that age
may be separated from the bone by direct injury or
muscular violence. Owing to the dense aponeurotic
fibres that cover the part, much displacement of the
fragment is uncommon. When displacement exists,
it is in the general line of the common flexor muscles
that arise from the tip of the process.

6. The lower epiphysis. The line of this epiphysis
is nearly horizontal, running across the bone just
above the tips of the two condyles. It presents
several ossific nuclei, which, with the exception of the
nucleus for the inner epicondyle, unite with the
main bone about the sixteenth year. Thus, after the age
of sixteen the growth of the bone must depend upon
the activity of the upper epiphysis, which does not unite
until twenty. Excision of the elbow, therefore, after
the sixteenth or seventeenth year, will not be followed
by arrest of development in the limb, even if the
epiphyseal line has been transgressed by the saw.
Several cases are, however, reported of marked arrest
of growth in the limb following upon injuries to the
lower epiphysis before the sixteenth year, and to the
upper epiphysis before twenty. Since the epiphyseal
line is almost wholly within the capsule, it follows
that but little displacement, other than a slight
movement backwards, is consequent upon the separa-
tion of the mass.

Fractures of the olecranon are commonly due
to direct violence, and in a few cases to severe indirect
violence applied to the lower end of the humerus or
upper end of the ulna. Instances of fracture by
muscular action are few, and open to some question.
The fracture is most commonly met with about the
middle of the process, just where it begins to be

chap, xiii.] REGION OF ELBOW. 225

constricted, and is transverse, following often the
line of the olecranon epiphysis. The amount of
displacement effected by the triceps varies, and de-
pends upon the extent to which the dense perios-
teum about the process and the ligaments that are
attached to it are torn.

Fracture of the coroiioid process is an
extremely rare accident. It is impossible to under-
stand how the process can be torn off by the action
of the brachialis anticus, as some maintain, since that
muscle is inserted rather into the ulna at the base of
the projection, than into the process itself. Nor can
it be separated as an epiphysis, as supposed by others,
since it does not exist as such.

Fractures of the head or neck of the radius
are rare, and occur usually with dislocation or other
severe injury. The head is commonly found split or
starred, and the lesion, if limited to the head, could
hardly be diagnosed. The upper epiphysis of the
radius is entirely within the limits of the annular
ligament, and could scarcely be separated in a simple
lesion. When the neck is broken (a very rare occur-
rence) the upper end of the lower fragment is drawn
well forwards by the biceps muscle.

Resection of the elbow may be performed in
many different ways. In all procedures there is
danger of inflicting damage upon the ulnar nerve, and
some little difficulty often in clearing the prominent
internal condyle. If the knife be kept close to the
bone throughout the operation, no vessel of any
magnitude should be divided. The muscles most
disturbed during the resection are the triceps,
anconeus, supinator brevis, extensor carpi ulnaris,
extensor carpi radialis br^vior, and brachialis anticus.
It is most important to preserve the periosteum over
the olecranon, so that the triceps may still have some
attachments to the fore-arm after the joint is excised,
p

226 SURGICAL APPLIED ANATOMY. [Chap. XIIL

The connection also of this muscle with the ulna
through the anconeus should be as little disturbed as
possible. It is never necessary to divide the insertion
of the brachialis anticus, still less of the biceps,
although some few fibres of the former muscle may be
separated in removing the upper surface of the ulna.
As regards the future usefulness of the new joint, it
is most desirable that the cut surface of the humerus
should be as broad as possible. By the subperiosteal
method of Oilier and others the periosteum is care-
fully peeled off from all the parts to be resected, and
is preserved. By this means the triceps retains a
good hold upon the ulna, and the restoration of the
joint is more complete. The functions of the joint
may be remarkably restored after resection, especially
when performed by the sub-periosteal method, but it
would appear that after no method are the anatomical
details of the articulation reproduced. Thus, in a
successful case, the new joint will assume the bi-
malleolar form, and will resemble the tibio-tarsal
rather than the normal elbow joint. The humerus
throws out two malleoli on the sites of the normal
condyles, and in the concavity between these pro-
cesses the ulna and radius are received. The ends of
these latter bones are smoothed and rounded, and
between the ulna and the humerus new ligaments
form. A new annular ligament for the radius is also
developed.

227

CHAPTER XIV.

THE FORE-ARM.

Surface anatomy. — At its upper half, and
especially in its upper third, the limb is much wider
in its transverse than in its antero-posterior diameter.
A horizontal section through this part will show a
cut surface that is somewhat oval in outline, and
is at the same time flattened in front and more
convex behind. This outline is best seen in muscular
subjects, and depends chiefly upon the development of
the lateral masses of muscle that descend from the
condyles. In the non-muscular, the limb, even in its
highest parts, tends to assume a rounded rather than
an oval outline. In women and children, also, the limb
is round, owing to the comparatively slight develop-
ment of the lateral muscular masses, and to the
accumulation of fat on the front and back of the limb.
The posterior surface of the fore-arm in a vigorous
subject presents along its outer border a prominence
formed by the supinator longus and the two radial
extensors, which become tendinous below the centre
of that border. On the lower third of this edge is a
slight eminence, directed obliquely downwards, out-
wards, and forwards, and due to the crossing of the
extensors of the thumb. In the middle of the pos-
terior surface is another elevation, running down
from the outer condyle, and formed mainly by
the extensor communis. To the inner side of this
eminence is a groove, well seen in the very muscular,
that indicates the posterior border of the ulna. The
ulna is subcutaneous throughout its entire extent, and

228 SURGICAL APPLIED ANATOMY. [Chap. xiV;

can be readily examined. The upper half of the radius
is too deeply placed to be well made out, but the1
lower half of the bone can be easily felt beneath the
skin. The course of the radial artery is represented
by a line drawn from the outer border of the biceps
tendon at the bend of the elbow to the narrow
interval between the scaphoid bone and the extensor
tendons of the thumb. The middle and lower thirds
of the ulnar artery follow a line from the inner con-
dyle to the radial side of the pisiform bone. The
upper third would be represented by a line drawn from
the middle of the bend of the elbow to meet the first
line at the junction of the upper and middle thirds of
the inner border of the fore-arm. Such a line would
be slightly curved, with its concavity outwards. The
tendons, etc., that can be demonstrated at the lower
extremity of the fore-arm will be considered in the
description of the wrist.

Vessels. — It is well to note the very free anasto^
moses that exist along the greater part of the limb
between the ulnar and radial arteries. This fact was
illustrated by a case under my care, some time ago, in
the London Hospital. A seaman had inflicted upon
his left fore-arm three deep transverse wounds across
the front of the limb with a sharp knife. The wounds
were about \\ inches apart. The radial artery was
divided in each of the wounds, and that vessel, there-
fore, presented six cut ends. It would appear to be
sufficient to ligature the proximal and distal ends of
the wounded vessel, and to leave the two isolated
portions of the artery, each about 1| inches in length,
alone. I applied ligatures to five of the divided ends,
leaving the lower end of the upper isolated piece of
the artery untied, and watched the effect. During the
course of the day, when the man had rallied from the
profound faintness due to the great loss of blood he
had experienced, copious bleeding took place from this

Chap. XIV.]

THE FORE-ARM.

229

single unsecured end of the vessel, and it, of course,
had also to be tied.

There is a singular absence of large blood-vessels
or nerves along the posterior aspect of the fore-arm,
and it is significant that this is the aspect of the limb
most exposed to injury. For a hand's-breadth below
the olecranon there is almost an entire absence of
superficial veins.

The median nerve passes between the two
heads of the pronator teres, and may possibly be com-
pressed by that muscle
when in vigorous ac-
tion. In this way
may be, perhaps, ex-
plained the cramp on
the flexor side of the
limb that sometimes
occurs after, certain
violent exercises. The
amount of muscular
tissue in the deep
head of the muscle
varies considerably.

The bones of the
fore-arm. — Trans-
verse sections of the
limb at various levels
show that the radius
and ulna are in all
parts nearer to the
posterior than the an-
terior aspect of the
extremity (Figs. 24
and 25). This relation is the more marked the higher
up the section. The two bones are nearest to the centre
of the limb, about the lower end of the middle third.
At the upper part of the fore-arm the muscles are

Fig1. 24. — A Transverse Section through
the middle of the Forerarm (Braune).

a, Radius; &, ulna; c, supinator Ipngus ; d,
flexor longus pollicis : e, flexor carpi radi- •
alis ; /, palmaris longus ; g, flexor publimis i
digitorum ; h, flexor carpi ulnaris ; i, flexor
profundus digitorum ; k, extensor carpi
ulnaris ; I, extensor indicis ; m, extensor
minimi digiti ; % extensor coinmunis digi-
torum ; o, extensor ossis and extensor
secundi internodii pollicis ; q, extenso^
carpi radialis brevier ; r, extensor carpi
radialis longior : s, pronator radii teres ;
1, radial vessels and nerve ; 2, ulnar vessels'
and nerve.

230 SURGICAL APPLIED ANATOMY. [Chap. xiv.

found mainly at the sides and in front. The lower the
section proceeds down the limb, the less will the bones
be covered at the sides, and the more equally will the
soft parts be found distributed about the anterior
and posterior aspects of the limb. It will be noticed
that where one bone is the most substantial the other
is the most slender, as near the elbow and wrist ; and
that it is about the centre of the limb that the twp
are most nearly of equal strength. The proximity
pf the two bones, and especially of the ulna, to the
posterior aspect of the limb permits them to be easily
examined from that surface, while it is from the
same aspect that resections and other operations upon
the bones are most readily performed. It will be
understood, moreover, that in compound fractures,
flue to penetration of fragments, the wound is more
usually on the posterior aspect of the limb.

The important movements of pronation and supi-
nation take place between these bones, and round an
axis corresponding to a line drawn through the head
of the radius, the lower end of #ie ulna, and the
metacarpal bone of the ring-finger. Pronation is
mainly checked by the lower and middle parts of the
interosseous membrane, the posterior radio-ulnar liga-
ment, the inner part of the posterior ligament of the
wrist, and the opposition of the bones. Supina-
tion is chiefly limited by the lowest fibres of
the interosseous membrane, the anterior radio-ulnar
ligament, and the internal lateral ligament of the
wrist. "The chief influence in checking supination
is not to be found in ligament at all, but in the con-
tact of the posterior edge of the sigmoid cavity of the
radius with the tendon of the extensor carpi ulnaris,
as it lies in the groove between the styloid process and
the round head of the ulna " (H. Morris). Of the two
movements, supination is the more powerful. This
is illustrated in many ways. Jn using a screw-driver

chap, xiv.] THE FORE-ARM. 231

or a gimlet the movements of pronation and supination
are conspicuously involved, but the main force is
applied during supination. It is significant that the
thread of a corkscrew is so turned that it shall be in-
serted by supination rather than by prona,tion.

The only position in which the two bones are
parallel to one another is in the mid-position between
pronation and supination. It is in this posture only
that the interosseous membrane is uncoiled throughout.
Hence the selection of this position in the adjustment
of most fractures of the fore-arm. The interosseous
space is an irregular ellipse, a little larger below than
above. It is narrowest in full pronation, widest in
supination, and nearly as wide in the mid-position.

It may be noted that the oblique ligament tends
to resist forces that would drag the radius away from
the humerus, and takes the place and the function of
a direct ligament, passing from the humerus to the
radius, while the interosseous membrane, from the
obliquity of its fibres, makes the ulna take a share in
the strain put upon the radius when that bone is
forced upwards, as in resting on, or pushing with, the
palm.

Fractures of the fore-arm. — The two bones
are more often broken together than is either the
radius or the ulna alone. The radius, when broken
alone, is usually fractured by indirect violence, since
it receives more or less entirely all shocks transmitted
from the hand. The ulna, on the contrary, is more
often broken by direct violence, it being the more super-
ficial and exposed of the two bones. For example, in
raising the arm to ward off a blow from the head, the
ulna becomes uppermost. When the two bones are
broken together, the violence may be direct or indirect.
Malgaigiie reports a case where both bones were broken
by muscular violence in a patient while shovelling
earth. Here the bones probably were broken between

232 SURGICAL APPLIED ANATOMY. [Chap. xiv.

the two opposed forces represented by the biceps and
brachialis anticus above and the weight of the loaded
shovel in the hand below. When both bones are
broken and the fractures are oblique, shortening may
be produced by the united action of the flexors and
extensors. The displacement varies greatly, and de-
pends rather upon the direction of the violence than
upon muscular action. Thus Hamilton says : " I have
seen the fragments deviate slightly in almost every
direction." If union be delayed, the delay is usually
in the radius, since it is the more mobile of the two
bones. When the radius alone is broken (1) between
the insertions of the biceps and pronator teres, the
upper fragment is flexed by the biceps and fully
supinated by that muscle and the small supinator.
The lower fragment will be pronated by the two pro-
nators, and drawn in towards the ulna by means
of those muscles. If such a fracture be put up
with the hand midway between the prone and supine
position, the following evils result : the upper frag-
ment is fully supinated by the muscles ; the lower
fragment is placed in the mid-position by the splints.
It follows that the proper axis of the bone is not repro-
duced, and the use of the biceps and supinator brevis
as supinators is entirely lost. Thus patients so treated
usually recover with great loss in the power of
supination ; and to avoid this ill result, it is advised
to put the limb up in full supination, so that the two
fragments may unite in their proper axis, the upper
fragment being supinated by the muscles, the lower
by the splints. (2) When the fracture is between the
insertions of the two pronators, the upper fragment
may be carried a little forwards by the biceps and pro-
nator teres, and drawn towards the ulna by the latter
muscle. The bone will probably be in the mid-position,
the two supinators (biceps and supinator brevis)
attached to the fragment being more or less

chap, xiv.] THE FORE- ARM. 233

neutralised by the pronator that is also connected
with it. The lower fragment will be adducted to
the ulna by the pronator quadratus, and its upper
end will be still further tilted towards that bone
by the action of the supinator longus upon the
styloid process. When the ulna is broken alone,
as, for example, about its middle, the upper frag-
ment may be drawn a little forwards by the
brachialis anticus, while the lower fragment will be
carried towards the radius by the pronator quad-
ratus.

The displacement, however, in all cases is in-
fluenced as much by the direction of the violence as
by the action of muscles. When the fragments,
after fracture of one or of both bones, fall in towards
one another, so as to meet across the interosseous
space, attempts are sometimes made to separate the
broken ends and to preserve the integrity of the space
by the use of graduated pads. These pads, however,
if supplied with sufficient force to separate the frag-
ments, will probably compress one or both of the
arteries of the limb, and cause great distress by
pressure upon the median nerve.

The fact that the bulk of the venous blood of the
fore-arm is returned by surface veins may explain the
ready occurrence of severe oedema in the limb when
fractures are treated with improperly-applied splints
or bandages. Since the arteries also can be readily
affected by pressure, it follows that gangrene of the
limb, as a result of improper treatment, is more com-
mon after fracture of the fore-arm than after fracture
in any other part.

Amputation of tlie fore-arm. — In amputa-
tion of the fore-arm by double transfixion flaps, at
about the upper part of .the middle third the parts
would be cut in the following manner : On the face of
the anterior flap would be seen from without inwards

234

SURGICAL APPLIED ANATOMY. [Chap. xiv.

the supinator longus (cut the whole length of the flap),
then the flexor sublimis (cut to a like extent), and,

lastly, the flexor carpi ul-
naris. Between the supi-
nator longus and the flexor
sublimis the divided end of
the pronator teres is seen ;
and between the flexor sub-
limis and the skin would
lie the flexor carpi radialis
and the palmaris longus.
The latter would appear as

-

ji o ri

Fig. 25. — A Transverse Section & tendon at the inner
through the lower third of the border of the flap. In the

Fore-arm. (Braune). *"

between the two

wrmlrl hp> fniinH in
WOU1Q C

^f +>>A varliiic a lifflp>
OI tne raCilUS a ilttl€

flo^ryi* lrmrrn« Tinlli
neXOr lOllgUS pOJ

QTir] in fWvnt nf tTiA nlno
> ancl m l^Ont OI Uie I na,

a, Radius; 6, ulna ; c, supinator longus;
d, flexor longus pollicis ; e, flexor
carpi radialis ; /, palmaris longus ;
g, flexor sublimis digitorum ; h,
flexor carpi ulnaris ; i, flexor pro-

,

fundus digitorum;^, pronator quad-
ratus; fc, extensor carpi ulnaris;
I, extensor indicis ; m, extensor
minimi digiti ; n, extensor com-
munis digitorum; o, extensor
cundiinternodii pollicis;

n n rl n «
imailS,

In-f+oY* nut Yrmr»V» fVia lr»riffpT*
latter CUt mucn tne longer.

or se- 4-"Uo -flavr»v

s; p, exten- tne n6XOr
sor primi internodii pollicis; q,
extensor carpi radialis brevior ; r,

extensor carpi radialis longior.witli, Oni-f-o /->lr»afi

in front of it, the extensor ossis SJ^lte CLOS6

metacarpi pollicis; 1, radial vessels; o1ir] fnvtViArn

2, ulnar vessels ; 3, median nerve. ^IICI tor tne m

it, would be the lowest part

of the small supinator, while behind the ulna would
be the cut fibres of the upper end of the extensor
ossis. On the face of the posterior flap would be
seen from without inwards the extensor carpi radialis
longior and brevior, the extensor communis, the ex-
tensor of the little finger, and the extensor carpi
ulnaris. The radial artery will run the whole length
of the anterior flap, and be cut near its outer border
to the inner side of the supinator longus. The ulnar
artery will be cut shorter, will be in front of the bone,
and between the flexor sublimis and flexor profundus.
The anterior interosseous vessels will be divided im-
mediately in front of the interosseous membrane.

chap, xv.i THE WRIST AND HAND. 235

The posterior interosseous vessels will be cut long,
and will be fqimd between the superficial and deep
muscles.

Fig. 25 shows the relation of the parts as they
would be cut in a circular amputation of the limb
through the lower third.

CHAPTER XV.

THE WRIST AND HAND.

Surface anatomy* — The following structures
can be made put about the wrist: Commencing at
the outer side, the lower extremity and styloid process
of the radius can be well defined. The bone is here
superficial in front and behind. The styloid process
lies more anteriorly than does the corresponding
process of the ulna, and also descends about half an
inch lower down the limb. The outer surface of the
radius at the wrist is crossed by the tendons of the
extensor ossis metacarpi and extensor primi inter-
nodii pollicis. These are very distinct when the
thumb is abducted, and the slit-like interval between
ohe two can be felt. About the centre of the front of
the wrist is the palmaris longus tendon, which is usually
the most conspicuous of the tendons on this aspect
of the joint. It is rendered most prominent when the
wrist is a little flexed, the fingers and thumbs ex-
tended, and the thenar and hypothenar eminences as
much approximated as possible. A little to its outer
side is the larger but less prominent tendon of the
flexor carpi radialis. In the narrow groove between
these two tendons lies the median nerve, and on the
radial side of the flexor carpi radialis is the radial

236 SURGICAL APPLIED ANATOMY. [Chap. xv.

artery.* Towards the inner border of the wrist the
flexor carpi ulnaris tendon is evident, descending to
the pisiform bone. It is rendered most distinct when
the wrist is slightly flexed, and the little finger pressed
forcibly into the palm. In the hollow which this
posture produces between the last-named tendon and
the palmaris longus lie the flexor sublimis tendons, and
just to the radial side of the flexor carpi ulnaris the
pulsations of the ulnar artery can be felt. Beneath
the thin skin in front of the wrist a part of the plexus
of veins can be seen that end in the median and
anterior ulnar trunks.

At the back of the wrist the following tendons can
be readily distinguished from without inwards : the
extensor secundi internodii, the extensor communis,
and the extensor carpi ulnaris. Of these, the most
prominent is the first-named. It is rendered most
distinct when the thumb is forcibly abducted and
extended. The tendon leads up to a small but promi-
nent bony elevation on the back of the radius that
marks the outer border of the osseous groove for its.
reception. This tendon, when it reaches the radius,
points to the centre of the posterior surface of that
bone, and indicates also roughly the position of the
interval between the scaphoid and semilunar bones.
The lower end of the ulna is very distinct. When
the hand is supine, its styloid process is exposed at
the inner and posterior aspect of the wrist to the
inner side of the extensor carpi ulnaris. In prona-
tion, however, the process is rendered less distinct,
while the head projects prominently on the posterior
part of the wrist, and is found to lie between the
tendons of the extensor carpi ulnaris and extensor
minimi digiti.

* Sometimes the superficialis volse arises higher and is larger
than usual. It then runs by the side of the radial in front of the
wrist, and, giving additional volume to the pulse, has been the
foundation of the so-called "double pulse."

Chap. xv. j THE WRIST AND HAND. 237

The wrist joint. — The tip of the styloid process
of the ulna corresponds to the line of the wrist joint,
and a knife entered below that point would enter the
articulation. A knife entered horizontally just below
the tip of the styloid process of the radius would
hit the scaphoid bone. A line drawn between the
two styloid processes would slope downwards and
Outwards, its two extremities would represent the
extreme inferior limits of the radio-carpal joint, and
would fairly correspond to the chord of the arc
formed by the line of that joint. The line between
the styloid processes would be nearly half an inch
below the summit of the arch of the wrist joint.

There are several folds in the skin on the front of
the wrist ; of these, the lowest is the most distinct^
It is a little convex downwards, precisely crosses the"
heck of the os magnum in the line of the third m eta-
carpal bone (Tillaux), and is not quite three-quarters
of an inch below the arch of the wrist joint. It is
about half an inch above the carpo-metacarpal joint
line, and indicates very fairly the upper border of the
anterior annular ligament.

The palmar surface of hand. — The palm is con-
cave in the centre where the skin is adherent to the
palmar fascia. This " hollow of the hand " is of some-
what triangular outline, with the apex upwards. On
either side are the thenar and hypothenar eminences.
At the upper end of the former eminence, a bony pro-
jection is felt, just below and internal to the radial
styloid process, that is formed by the tubercle of the
scaphoid and ridge on the trapezium. The interval
separating these two processes of bone cannot always
be made out. At the upper extremity of the hypothenar
eminence is the projection of the pisiform bone, and
just below it the unciform process can be identified.
Below the hollow of the palm, and opposite the clefts
between the four fingers, three little elevations are

238

SURGICAL APPLIED ANATOMY. [Chap. xv.

seen, especially when the first phalanges are extended,
and the second and third are flexed. These corre-

Fig. 26.— Surface Markings on the Palm of the Hand.
The thick black lines represent the chief creases on the skin.

spond to the fatty tissue between the flexor tendons
and the digital slips of the palmar fascia. The

chap, xv.] THE WRIST AND HAND. 239

grooves that may be seen to separate the elevations
correspond to those slips.

Of the many creases in the skin of the palm
three require especial notice. The first starts
at the wrist, between the thenar and hypothenar
eminences, and marking off the former eminence
from the palm ends at the outer border of the
hand at the base of the index finger. The second
fold is slightly marked. It starts from the outer
border of the hand, where the first fold ends, It runs
obliquely inwards across the palm with a marked
inclination towards the wrist, and ends at the outer
limit of the hypothenar eminence. The third, lowest,
and best-marked of the folds starts from the little
elevation opposite the cleft between the index and
middle fingers, and runs nearly transversely to the
ulnar border of the hand, crossing the hypothenar
eminence at the upper end of its lower fourth. An
unimportant crease running obliquely from the third
to the second fold give's to these markings the outline
of the letter M. The first fold is produced by the
opposition of the thumb, the second mainly by the
bending simultaneously of the metacarpo-phalangeal
joints of the first and second fingers, and the third by
the flexion of the three inner fingers. The second
fold, as it crosses the third metacarpal bone, about
corresponds to the lowest point of the superficial
palmar arch. The third fold crosses the necks of the
metacarpal bones, and indicates pretty nearly the
upper limits of the synovial sheaths for the flexor
tendons of the three outer fingers. A little way
below this fold the palmar fascia breaks up into its
four slips, and midway between the fold and the webs
of the fingers lie the metacarpo-phalangeal joints.
Of the transverse folds across the fronts of the fingers
corresponding to the metacarpo-phalangeal and phalan-
geal joints, the highest is single for the index and

240 SURGICAL APPLIED ANATOMY. .[Chap. xv.

little finger, and double for the other two. It is
placed nearly three-quarters of an inch below the
corresponding joint. The middle folds are double for
all the fingers, and are exactly opposite the first inter-
phalangeal joints. The lowest creases are single, and
are placed a little above the corresponding joints (1 to
2 mm., according to Paulet). There are two single
creases on the thumb corresponding to the two joints,
the higher crossing the metacarpo-phalangeal articula-
tion obliquely. The free edge of the web of the fingers,
as measured from the palmar surface, is about three-
quarters of an inch from the metacarpo-phalangeal
joints. The superficial palmar arch may be repre-
sented by a curved line across the palm starting from
the pisiform bone and running in a line with the
palmar border of the thumb when outstretched at
right angles with the index finger. The deep arch is
between a quarter and half an inch nearer the wrist.
The digital arteries bifurcate about half an inch above
the clefts between the fingers.

The dorsal surface of hand. — On the outer side
of the wrist, when the thumb is extended, a hollow is
obvious between the extensores ossis metacarpi and
primi internodii pollicis and the extensor secundi.
French writers have termed this hollow "tabatiere
anatomique." Across this hollow and beneath the
tendons just named runs the radial artery. Under the
skin over the space can usually be seen a large vein,
the cephalic vein of the thumb. Across the space
also run those branches of the radial nerve that go to
the dorsum of the thumb. In the floor of the ll smifF-
box " are the scaphoid bone and the trapezium. The
extensor secundi internodii crosses the apex of the
first interosseous space. The sesamoid bones of
the thumb and the joint between the trapezium
and the first metacarpal bone can be well made out.
The latter articulation is situate on the floor of the

chap, xv.] THE WRIST AND HAND. 241

" tabatiere." On the back of the hand the various
tendons and the surface veins can all be well made
out. Between the first and second metacarpal bones
is the first dorsal interosseous muscle, which forms a
conspicuous prominence when the thumb is pressed
against the side of the index finger. The three rows
of knuckles are formed by the proximal bones of the
several joints.

The wrist and Irand. — The skin of the palm
and of the front of the fingers is thick and dense,
while that on the back of the hand is much finer.
The palm, the fronts, and sides of the fingers, and the
dorsal aspects of the last phalanges, all show an entire
absence of hair, and of sebaceous glands. These parts
are, therefore, exempt from the maladies that attack
hair follicles and their gland appendages. On the
dorsum of the hand, and of the first and second rows
of phalanges, there are numerous hairs and sebaceous
follicles. Sweat glands are more numerous in the
skin of the palm than in any other part. According
to Sappey they are four times more numerous here than
they are elsewhere. Krause has estimated that nearly
2,800 of these glands open upon a square inch of the
palm. Only about half the number are found upon
the dorsum of the hand. The profuseness with which
the palm may perspire is well known, and is very
marked in certain conditions. The cutaneous nerve-
supply of the hand is very free. The nerves present
Pacinian bodies, which are far more numerous in the
hand than in any other part, and in no portion of
the surface are tactile corpuscles more numerous or
more highly developed. With the exception of the
tip of the tongue, a more acute degree of tactile
sensibility is met with in the hand than in any
other part. The most sensitive district is the
palmar surface of the third phalanx of the
index finger, while the least sensitive to tactile
Q

242 SURGICAL APPLIED ANATOMY, [chap. xv.

impressions is the dorsum of the hand. It may be
said that the tips of the fingers are about thirty times
more acute to the sense of touch than is the skin of
the middle of the fore-arm, which is among the least
sensitive portions of the integument as regards tactile
influences.

The subcutaneous tissue of the front of the hand,
and especially of the palm, is scanty and dense, and
somewhat resembles the subcutaneous tissue of the
scalp in that the skin is closely adherent to it, and the
fat it contains is arranged in minute lobules lodged
in lacunse. The subcutaneous tissue on the dorsum
is, on the other hand, lax, and has but a frail
association with the skin. Thus it follows that
subcutaneous extravasations of blood are practically
impossible in the palm, and on the anterior aspect
of the fingers, while they may be very extensive on
the dorsum. In like manner rederna of the extremity
is conspicuously marked upon the dorsal surface, while
the, palm remains comparatively free even in severe
cases. Surface inflammations also of the dorsum are
attended with considerable swelling, while those of
the front of the hand show no such feature. At the
same time the adhesion of the palmar integument to
the deeper parts is so close that surface wounds do not
gape, and are in a position to encourage ready healing.
The denseness of the integuments of the palm renders
inflammation of the part extremely painful, owing
to the tension that is so readily produced, whereas
inflammation in the lax tissues on the dorsum may
reach some magnitude without causing great pain.
The palm of the hand is well adapted to meet the
effects of pressure and friction. The cuticle is thick,
the skin is adherent, and immediately beneath it lies
the dense palmar fascia. This fascia efficiently
protects the palmar nerves and the main vessels, while
it must be noted that the front of the hand, and

Chap, xv.] THE WRIST AND HAND. 243

especially the p'alm, i<5 singularly1 free from* surface
veins. Indeed, the great bulk of the' blood ^frtfrn the
hand i? te^unied • by- tl»e "superficial* veins on the
dorsum -of «tJfia nng^rs and -hand. *v» ' " *" ;

The lymphatics of the palm are, moreover, Scanty,
and very minute, whereas on the dorsuin they are
large and profusely distributed. The ulnar border of
the palmar part of the hand is much used in pressure
and in "hammering" movements, and it is significant
that this surface is well protected by soft parts, and
presents a singular absence of large nerves, that, if
present, would be liable to sustain damage from such
movements.

The form of the nail varies somewhat in individuals,
and, according to certain authors, there are special
types of nail to be met with in some constitutional
diseases. Thus are described the tubercular, the
rachitic, the arthritic nail. By the Hippocratic hand
is meant a hand the tips of the fingers of which are
clubbed, and the nails of which are much curved.
This condition would appear to be due to impeded
circulation, to retardation in the return of venous
blood, and perhaps also to imperfect oxygenation of
that blood. It is most often met with in congenital
heart disease, in phthisis, empyema, chronic lung
affections, certain thoracic aneurisms, and some forms
of scrofula.* There are several forms of inflammation
affecting the matrix of the nail and the soft parts
immediately around it (onychia, paronychia). Such
inflammations lead to great deformity of the structure
itself. When a nail is thrown off by suppuration or
violence a new nail is produced, provided any of the
deeper epithelial cells are left. During convalescence
from certain illnesses (e.g., scarlet fever), a transverse
groove will appear across all the nails. This groove

* See " Scrofula and its Gland Diseases," p. 99. By the
Author. London. 1882.

244 SURGICAL APPLIED ANATOMY. [Chap. xv.

indicates the 'portion of nail formed during the illness,
and loty iwatchirrg its movement the rate of growth of
the nail can be 'estimated. • I * n'ave mace Jhan once
foui^d t'hfese 'grooves useful in. tecting. the 'truth of a
patrerUrs Account of his more recent ailments. The
nail grows at the average rate of ^nd of an inch per
week. It may be noted that each digital nerve gives
a special branch of large size to the pulp beneath the
nail, and this serves to account for the intense pain
felt when a foreign body is accidentally thrust under
the nail.

The fasciae. — Beneath the skin of the palm is the
dense palmar fascia. This fascia gives almost as much
strength to the hand as would so much bone, while its
unyielding character, its comparative freedom from
vessels and nerves, and its superficial position, render
it admirably suited to withstand the effects of pressure.
In certain circumstances this fascia, in part or in
whole, contracts, and the disease known as Dupuytren's
contraction is produced. In this affection the skin
and subcutaneous tissue become also involved, and the
fingers become flexed. Apropos of this flexion,
experiment shows that by dragging upon the fascia
the first phalanx can be readily bent, and also, but with
less ease, the second phalanx (Goyrand).

The structures of the palm are divided into three
spaces by the fasciae of the part (Fig. 27). Thus the
muscles of the thenar and hypothenar eminences
are both enclosed in a thin fascia proper to each
eminence. The two spaces formed by these membranes
are enclosed in all directions, and are capable, though
only in a feeble way, of limiting suppuration when it
commences in them. Between these two spaces
(loges) is a third space, which is roofed in by the
palmar fascia. This cavity is closed in at the sides,
but is open above and below. Above there is a
free opening beneath the annular ligament and along

chap, xv.] THE WRIST AND HAND. 245

the flexor tendons into the fore-arm, while below
there are the seven passages provided for by the
division of the palmar fascia. Of these seven
passages, four, situate at the roots of the several
lingers, give passage to the flexor tendons, while the
remaining three correspond to the webs between the

Fig. 27.— Horizontal Section of the Hand through the middle of the
Thenar and Hypothenar Eminences (Tillaux).

a, Metacarpal bone ; b, first dorsal interosseous ; c, palmaris brevis ; d, abductor
min. digit! ; e, flexor brevis min. dig. ; /, opponens min. dig. ; g, flexor brevis
poll.; h, abductor poll.; i, opponeus poll.; /.adductor poll.; k, flexor long.
pol.; I, dorsal interossei ; TO, palmar interossei ; n, flexor sublimis; o, flexor

. , , , ,

prof undus ; p, superflc. volse ; q, median nerve, and (on inner side) ulnar artery
and nerve; r, deep palmar arch ; 1,
septum ; 4, deep fascia of palm.

, . , ,

and nerve; r, deep palmar arch ; 1, palmar fascia; 2, outer septum ; 3, inner

fingers, and give passage to the lumbricales and the
digital vessels and nerves. When pus, therefore,
forms in the palm, beneath the palmar fascia, it
cannot come forward through that dense membrane,
but escapes rather along the fingers, or makes its way
up into the fore-arm. So rigid is the resistance offered
by the palmar fascia, that pent-up pus will make its
way through the interosseous spaces and appear on the
dorsum of the hand, rather than come through the
coverings of the palm. The passage of pus, however,
towards the dorsum is resisted by a layer of fascia

246 SURGICAL APPLIED ANATOMY. [Chap. xv.

that lies deeply beneath the flexor tendons, and covers
in the interossei muscles, the bones, and the deep
palmar arch. This fascia joins on either side the
fasciae enclosing the thenar and hypothenar " spaces "
(Fig. 27).

In opening a palmar abscess, when it points above
the wrist, the incision should be in the long axis
of the fore-arm, should be above the annular ligament,
and is most conveniently made a little to the ulnar
side of the palmaris longus, for a cut in this position
would escape both the ulnar and radial arteries and
also the median nerve.

The tendons about the wrist are bound down and
held in place by the annular ligaments. So dense
is the anterior ligament, that even in extensive abscess
of the palm reaching into the fore-arm, and in severe
distension of the sy no vial sheaths beneath the liga-
ment, it remains firm, and will not yield. The
lower border of the posterior annular ligament
corresponds to the upper edge of the anterior band,
and these structures together act the part of the
leather bracelet that the labourer sometimes wears
around his wrist, and that, in fact, takes the function
of an additional annular ligament.

The fit>roiis slieatlis for the flexor tendons ex-
tend from the metacarpo-phalangeal joints to the upper
ends of the third phalanges. The pu]p of the third
phalanx, therefore, rests practically upon the perios-
teum. Opposite the finger joints the sheaths are lax
and thin, and spaces may occur between the decussat-
ing fibres of the sheaths, through which the synovial
membrane lining the sheath may protrude. It is, I
believe, through this less protected part of the sheath
that suppuration without often finds its way into the
interior of the sheath. The sheaths in the rest of
their course are dense and rigid, and when cut across
remain, in virtue of this rigidity, wide open (Fig.

chap, xv.] THE WRIST AND HAND. 247

28). Thus, after the division of the sheath, as in
amputation, an open channel is left leading into the
palm of the hand, and offering the greatest facility for
the spread of pus into that part. It
is this rigidly open fibrous sheath that
probably may explain the frequency of
suppuration in the palm after amputa-
tion of a part of a finger, and I am
decidedly of opinion that some steps
should be taken to protect or shut off
this channel in any case where the
sheath has been accidentally or inten-

tioiially divided.

Synovial sacs and sheaths. —

There are two synovial sacs beneath a, Flexor profun-

.-, IT i p j_i n dus tendon: 6.

the annular ligament for the flexor fibrous sheath of

-, ¥ . -. n i tendon ; c, exten-

tendons, one for the flexor longus sor tendon; d,

n. • Xl ,1 r» ,i YI i digital artery and

pollicis, the other tor the flexor sub- nerve.
limis and profundus tendons. The
former extends up into the fore-arm for about 1|-
inches above the annular ligament, and follows its
tendon to its insertion in the last phalanx of the
thumb. The latter rises about 1-J- inches above the
annular band, and ends in diverticula for the four
fingers. The process for the little finger usually
extends to the insertion of the flexor profundus tendon
in the last phalanx. The remaining three diverticula
end about the middle of the corresponding metacarpal
bones. The synovial sheaths for the digital part of the
tendons to the index, middle, and ring-fingers, end
above about the neck of the metacarpal bones, and are
thus separated by about a quarter to half an inch from
the great synovial sac beneath the annular ligament.
Thus there is an open channel from the ends of the
thumb and little finger to a point in the fore-arm
some inch and a half above the annular ligament.
The arrangement explains the well-known surgical

248 SURGICAL APPLIED ANATOMY. [Chap. xv.

fact that abscesses of the thumb and little finger are
apt to be followed by abscesses in the fore-arm, while
such a complication is not usual after suppuration in
the remaining fingers. The synovial sac for the
flexor tendons is narrowed as it passes beneath the
annular ligament, and thus it happens that when
distended with fluid or with pus, it presents an
hour-glass outline, the waist of the hour-glass corre-
sponding to the ligament. The two synovial sacs be-
neath the ligament sometimes communicate with one
another.

In one form of whitlow, that form where the pus
occupies the synovial sheaths of the tendons on the
fingers (thecal abscess), the suppuration can often be
seen to end abruptly where the sheath ends, when the
index, middle, or ring-finger is involved, viz., opposite
the neck of the corresponding metacarpal bones. In
another form of whitlow (the abscess in the pulp at
the end of the finger) the periosteum, of the third
phalanx is readily attacked, there being no inter-
vening tendon sheath over that bone. In this
affection the bone often necroses and comes away,
but it is significant to note that it is very seldom that
the whole of the phalanx perishes. The upper part,
or base, of the bone usually remains sound, and is
probably preserved by the insertion of the flexor
profundus tendon. It is also interesting to bear in
mind that the base of the bone is an epiphysis that
does not imite to the shaft until the eighteenth or
twentieth year.

Beneath the posterior annular ligament there are
six synovial sheaths for tendons, corresponding to the
six canals formed by that ligament. The sheath most
frequently inflamed is that for the extensores ossi meta-
carpi and primi internodii pollicis. It runs from
a point about three-quarters of an inch above the
radial styloid process to the first carpo-metacarpal

chap, xv.j THE WRIST AND HAND. 249

joint. The other sheaths reach above to the upper
border of the annular ligament, that for the two
radial extensors, however, beginning about half an
inch above the ligament. The sheaths for the extensor y
communis and the extensor minimi digiti extend below
to the middle of the metacarpus. That for the
extensor indicis barely reaches the metacarpus. The
other sheaths follow the tendons to their insertions.

Blood-vessels and lymphatics. — The hand
is very well supplied with blood, and indeed the finger
pulp is one of the most vascular parts in the body.
Cases are recorded where the tip of the finger has been
accidentally cut off, and has grown again to the limb
on being immediately re-applied. The position of the
palmar arches has been pointed out. Wounds of these
arches, and indeed of most of the arteries of the palm
and wrist, are serious, on account of the difficulty of
reaching the bleeding point without seriously damaging
important structures, and on account of the free anas-
tomoses that exist between the vessels of the part.
The deep palmar arch may be wounded by a pene-
trating wound from the dorsum, and indeed Delorme
has pointed out that this arch may be ligatured
from the dorsum after a preliminary resection of
the upper part of the third metacarpal bone. It is
well known that hsemorrhage from either of the
palmar arches cannot be checked by ligature of the
radial or ulnar artery alone, on account of the connec-
tion of the arches with those vessels ; and it is also
known that simultaneous ligation of the two vessels
may have no better effect, owing to the anastomoses
between the palmar arches and the interosseous
vessels. The anastomosis is carried on by means of
the carpal arches. The anterior carpal arch communi-
cates with the anterior interosseous artery above, and
with the deep palmar arch, by the recurrent vessels
below. The posterior carpal arch communicates with

250 SURGICAL APPLIED ANATOMY, [chap. xv.

the two interosseous vessels above, and with the deep
palmar arch below, by means of the perforating
branches from the latter vessel. The anastomosis
between the two palmar arches is well known, and is
freely established both by the main vessels themselves
and by the communion that exists between the digital
arteries from the superficial arch and the palmar inter-
osseous branches from the deeper vessel. In bleeding
from the palm, the simultaneous ligature of the
radial and ulnar arteries may also entirely fail in
those cases where the arches are freely joined, or are
more or less replaced by large and abnormal inter -
osseous vessels, or by a large "median" artery.
When either the radial or the ulnar part of the arches
is defective, the lack is usually supplied by the other
vessel ; and it is well to note that the deficiency is
most common in the superficial or ulnar arch.
Pressure applied to the palm to arrest bleeding is apt
to cause gangrene, owing to the rigidity of the parts
and the ease with which considerable pressure can
be applied.

The radial artery, as it curves round the back of
the hand to reach the deeper part of the palm, is in
close contact with the carpo-metacarpal joint of the
thumb. This fact must be borne in mind in amputa-
tion of the entire thumb, and also in resection of the
first metacarpal bone. The superficialis volse, if large,
may bleed seriously. It adheres to the surface of
the annular ligament, and may therefore be difficult
to pick up when wounded.

From the larger size and great number of the
lymphatics about the fingers and on the dorsum of the
hand, it follows that lymphangitis is more common
after wounds of those parts than it is after wounds
of the palm.

The bones and joints. — The inferior radio-
ulnar joint is supported by the powerful triangular

chap, xv.] THE WRIST AND HAND. 251

fibre-cartilage, which forms the strongest and most
important of all the ligamentous connections between
the two bones. The synovial sheath of the extensor
minimi digiti sometimes communicates with this joint,
and may therefore be involved when that articulation
is diseased.

The strength of the wrist joint depends not so
much upon its mechanical outline or its ligaments as
upon the numerous strong tendons that surround it,
and that are so closely bound down to the bones about
the articulation. Its strength depends also upon its
proximity to the numerous bones and joints of the hand,
whereby all movements and shocks are distributed
between several articulations. Moreover^ in the case
of the wrist the long lever does not exist on the distal
side of the joint. The movements of the wrist are
greatly supplemented by those of the mid-carpal joint.
The anterior ligament of the wrist is the strongest
ligament of the joint, while the posterior is the
weakest. The former structure limits extension, and
the latter flexion ; and in connection with this arrange-
ment it is interesting to note that injury from forced
extension is more common than from forced flexion.
Thus, when a man falls upon the hand, he more
usually falls upon the palm (forced extension) than
upon the dorsum (forced flexion). Owing to the
thinness of the posterior ligament, together with the
more superficial position of the hinder part of the
joint, it follows that the effusion in wrist-joint disease
is first noticed at the back of the hand. As the
tendons on the front and at the back of the wrist
fairly balance one another, the hand in wrist-joint
disease shows little tendency to be displaced, but is
fixed rather in the mid-position between flexion and
extension. It can be understood that in this disease
the neighbouring synovial sheaths are readily involved.

In connection with this joint it may be noted

252 SURGICAL APPLIED ANATOMY. [Chap. xv.

that the middle finger is, from its greater length,
the one most exposed to injury and to shocks received
by the fingers. Its metacarpal bone is directly
received by the strongest carpal bone, the os magnum,
and the latter bone is brought by means of the
semi-lunar in connection with the widest and strongest
part of the radius.

But little movement is allowed in the metacarpo-
carpal joints of the first three fingers, but in the like
joints of the thumb and little finger movements are
free, and their preservation is of great importance to
the general usefulness of the hand. The glenoid liga-
ments in front of the three finger-joints are firmly
attached to the distal bone, and but loosely to the
proximal. Thus it happens that in dislocation of the
distal bone backwards, the glenoid ligament is carried
with it, and offers a great obstacle to reduction. In
flexing the second and third finger joints alone, it will
be seen that the first phalanx is steadied by the ex-
tensor tendon as a preliminary measure, and in
paralysis of the extensors flexion of these two joints
alone is not possible.

Very few persons have the power of flexing the
last finger joint without at the same time bending the
articulation above it ; but in certain inflammatory
affections about the last phalanges the terminal joint
is sometimes seen to be fixed in a flexed posture while
the other finger joints are straight. I imagine that
this position must always indicate some disease of the
articulation itself.

Colles' fracture. — This name is given to a
transverse fracture through the lower end of the
radius, from a half to one inch above the wrist joint.
It is associated with -a certain definite deformity, and
is always the result of indirect violence, a fall upon
the outstretched hand. There are good reasons why
the bone should break in this situation. The lower

chap, xv.] THE WRIST AND HAND. 253

end of the radius is very cancellous, while the shaft
contains a good deal of compact bone. At about
three-quarters of an inch from the articular surface,
these two parts of the bone meet, and their very
unequal density greatly tends to localise the fracture
in this situation. As to the mechanism of this lesion,
many different opinions are still held, and a vast
deal has been written on the subject. I subjoin Pro-
fessor Chiene's account of this lesion, because it may
be taken as representing with admirable clearness the
views most generally accepted at the present time as
to the nature of this injury. Into the discussion itself
I do not propose to enter. The deformity in Colles'
fracture is entirely due to the displacement of the
lower fragment. " The displacement is a triple one : (a)
backwards, as regards the antero-posterior diameter of
the fore-arm ; (b) rotation backwards of the carpal sur-
face on the transverse diameter of the fore-arm ; (c) rota-
tion through the arc of a circle, the centre of which is
situated at the ulnar attachment of the triangular
ligament, the radius of the circle being a line from the
ulnar attachment of the triangular ligament to the tip
of the styloid process of the radius, (a) When a
person in falling puts out his hand to save himself, at
the moment the hand reaches the ground the force is
received principally by the ball of the thumb, and
passes into the carpus, and thence into the lower end
of the radius. If, at the moment of impact, the angle
between the axis of the fore-arm and ground is less
than 60°, the line representing the direction of the
force passes upwards in front of the axis of the fore-
arm ; the whole shock is therefore borne by the lower
end of the radius, which is broken off, and, the force
being continued, the lower fragment is driven back-
wards. When at the moment of impact the angle
is greater than 60°, the line of the force, instead
of passing in front of the axis of the arm, passes up

254 SURGICAL APPLIED ANATOMY. [Chap. xv.

the arm, and the usual result is either a severe sprain
of the wrist, or a dislocation of the bones of the fore-
arm backwards at the elbow joint, (b) The carpal
surface of the radius slopes forwards, and therefore
the posterior edge of the bone receives the greater
part of the shock ; there is, as a result, rotation of the
lower fragment backwards on the transverse diameter
of the fore-arm, (c) The carpal surface of the radius
slopes downwards and outwards to the radial edge of
the arm ; therefore the radial edge of the bone receives
the principal part of the shock through the ball of the
thumb. As a result, this edge of the lower fragment
is displaced upwards to a greater extent than the
ulnar edge of the fragment, which remains firmly
attached to the ulna by the triangular ligament."
This rotation also depends upon, the integrity of the
inferior radio-ulnar ligament in a typical Colles' frac-
ture. These ligaments hold on to the ulnar part of
the lower fragment, and prevent its being displaced
to so great an extent as is the radial part of the frag-
ment. By means of this rotatory displacement, the
tips of the two styloid processes come to occupy the
same level, or the radial process may even mount above
the ulnar. In nearly every case there is some pene-
tration of the fragments, the compact tissue on the
dorsal aspect of the upper fragment being driven (by
a continuance of the force that broke the bone), into
the cancellous tissue on the palmar aspect of the lower
fragment. It is only in very rare instances that the
fragments are so separated as to ride the one over the
other. In such cases the radio-ulnar ligaments are
probably ruptured, and the wrist ceases to present the
typical deformity of a Colles' fracture. That the
deformity in Colles' fracture is due to the nature and
direction of the force is indirectly proved by an
isolated case or so, where the patient fell upon the
back of the hand, with the result that the radius was

chap, xv.] THE WRIST AND HAND. 255

broken in the usual position of a Colles' fracture, but
the lower fragment was carried forwards instead of
backwards. According to R. W. Smith and others,
the peculiar deformity is produced by muscular action,
principally by the supinator longus, the extensors of
the thumb, and the radial extensors. Lecomte and
many French writers assert that the fracture is due
to a tearing (arrachement) of the bone by strain upon
the ligaments of the wrist. Thus they assert that in
forcible extension of the hand the carpal condyle is
thrust against the anterior wrist ligaments ; these are
intensely stretched, and tear off the lower end of the
radius, fracturing it through what is acknowledged to
be the weakest part of the bone. It is true that in
young subjects the lower epiphysis of the radius can
be separated in the cadaver by very forcible flexion or
extension of the wrist (B. Anger). This epiphysis is
often separated by accidental violence. It joins the
shaft about the twentieth year. Its junction with
the shaft is represented by a nearly horizontal line,
and the epiphysis includes the facet for the ulna
and the insertion of the supinator longus. Fractures
of the lower end of the radius, due to direct
violence, are usually associated with but trifling dis-
placement.

There is no special anatomical interest attach-
ing to fractures of the carpus, metacarpus, or pha-
langes.

Dislocations. — (1) At the wrist joint. — So
strong is this articulation, for the reasons above
given (page 251), that carpo- radial luxations are ex-
tremely rare. For the same reasons, when they do occur
they are usually complicated, and are associated
with tearing of the skin, or rupture of tendons,
or fractures of the adjacent bones. The luxations
of the carpus may be either backwards or for-
wards, the latter being extremely rare. They

256 SURGICAL APPLIED ANATOMY. [Chap. xv.

would appear to be produced with equal ease by
a fall upon either the front or the back of the
hand. Bransby Cooper gives the case of a lad who
fell upon the outstretched palms of both his hands :
both wrists were dislocated, one backwards, the other
forwards.

(2) Some dislocations about the hand (os magnum).
— In forcible flexion of the hand, the os magnum
naturally glides backwards, and projects upon the
dorsum. In very extreme flexion (as in falls upon the
knuckles and dorsum of the metacarpus), this move-
ment of the bone backwards may be such as to lead
to its partial dislocation, the luxation being associated
with some rupture of ligaments. In one recorded
case, this luxation was produced by muscular force.
The patient, a lady, while in labour, " seized violently
the edge of her mattress, and squeezed it forcibly."
Something was felt to give way in the hand, and the
head of the os magnum was found to be dislocated
backwards.

Dislocation at the m,etacarpo-phalangeal joint of
the thumb. — In this luxation, the phalanx is usually
displaced backwards, and the lesion is of interest on
account of the great difficulty often experienced in
reducing the bone. Many anatomical reasons have
been given to explain this difficulty, which are well
summarised by Hamilton in the following passage :
" Hey believes the resistance to be in the lateral liga-
ments, between which the lower end of the metacarpal
bone escapes and becomes imprisoned. Ballingall,
Malgaigne, Erichsen, and Yidal think the metacarpal
bone is locked between the two heads of the flexor
brevis, or, rather, between the opposing sets of muscles
which centre in the sesamoid bones, as a button is
fastened into a button-hole. Pailloux and others
affirm that the anterior ligament, being torn from one
of its attachments, falls between the joint surfaces,

Chap, xv.i THE WRIST AND HAND. 257

and interposes an effectual obstacle to reduction.
Dupuytren ascribes the difficulty to the altered rela-
tions of the lateral ligaments, ... to the spasm
of the muscles, and to the shortness of the member, in
consequence of which the force of extension has to be
applied very near to the seat of the dislocation.
Lisfranc found in an ancient luxation the tendon of
the long flexor so displaced inwards, and entangled
behind the extremity of the bone, as to prevent
reduction." The explanation most usually accepted
is that that ascribes the irreducibility to the
" button - hole action" of the sesamoid bones and
their tendons.

Avulsion of one or more fingers may be effected
by severe violence. In such cases the finger torn off
usually takes with it some or all of its tendons. These
tendons are practically drawn out of the fore-arm,
and may be of considerable length. Billroth figures a
case where the middle finger was torn out, taking
with it the two flexor and extensor tendons in
their entire length. When one tendon only is torn
away with the finger, it is usually that of the flexor
profundus.

Amputation at the wrist joint by double
flaps (see Heath's " Operative Surgery "). In the
dorsal flap would be cut the following tendons : the
extensores secimdi, indicis, communis, minimi cligiti.
and ulnaris, the radial nerve, and the dorsal branch
of the ulnar nerve. The two radial extensors will be
cut short in the radial angle of the flap, as will also be
the extensores ossis and primi. The radial artery will
be divided close to the radius. In the palmar flap
would be found the ulnar artery, the superficialis volee,
the ulnar and median nerves, the oppoiiens, flexor
brevis, and abductor pollicis in part, the flexor brevis,
opponens, and abductor minimi digiti in part (the
bulk of the opponens being left behind on the hand),
n

258 SURGICAL APPLIED ANATOMY, [chap. xv.

and the tendons of the flexor sublimis and flexor carpi
radialis. The tendons of the flexor profuiidus and
flexor longus pollicis are usually cut short close to the
bones.

Amputation of the thumb at the carpo-m eta-
carpal j oint by flaps. In the palmar flap would be cut the
adductor, the short and long flexor, the opponens, and
abductor pollicis. The extensores ossis and primi
would be cut short in the posterior angle of the flap.
The extensor secundi and a considerable portion of the
abductor indicis would be found in the dorsal flap.
The vessels divided would be the two dorsal arteries
of the thumb and the princeps pollicis. There is great
danger, in this operation, of wounding the radialis
indicis and the radial artery itself where it begins to
dip into the palm.

Injuries to the main nerves of the upper
limb* — The entire brachial plexus has been ruptured,
leading to complete paralysis of the upper limb. In
these cases, it would appear that the nerves are torn
away from their attachments to the cord rather than
broken across at some distance from it. In several
instances the biceps muscle has retained some of
its functions, while the whole of the other muscles
have been paralysed, a circumstance difficult to
explain.

Paralysis of the musculo-spiral nerve. —
When complete, the hand is flexed and hangs flaccid
("drop wrist"), and neither the wrist nor the fingers
can be extended. The latter are bent and cover the
thumb, which is also flexed and adducted. When
attempts are made to extend the fingers, the interossei
and lurnbricales alone act, producing extension of the
last two phalanges and flexion of the first. Supi-
nation is lost, especially if the elbow be extended
so as to exclude the action of the biceps muscle.
Extension at the elbow is lost, and sensibility is

chap, xv.] NERVES OF THE UPPER LIMB.

259

9 10

Fig. 29. — Cutaneous Nerve-supply of Upper Limb.

Anterior aspect : 1, Cervical plexus ; 2, circumflex ; 3, ext- cut. of muse, spiral ;

4, ext. cutaneous ; 5, median ; 6, ulnar ; 7, int. cutaneous ; 8, n. of Wrisberg.
Posterior aspect: 1, Cervical plexus; 2, circumflex ; 3, int. cut. of muse, spiral;

4, intercosto-humeral ; 5, n. of Wrisberg ; 6, int. cutaneous j 7, ext. cut. of

muse, spiral ; 8, ext. cutaneous ; 9, ulnar ; 10, radial.

260 SURGICAL APPLIED ANATOMY. [Chap. xv.

disturbed over the skin supplied by the nerve
(Erb).

Paralysis of the median nerve. — Flexion of
the second phalanx is impossible in every finger, as is
also a like movement of the last joint of the index and
middle fingers. Partial flexion of the third pha-
langes of the two inner digits is possible, the inner
part of the flexor profundus being supplied by the
ulnar nerve. Flexion of the first phalanx with exten-
sion of the second and third can still be performed
in all the fingers by the interossei. The thumb is
extended and adducted, and can neither be flexed
nor opposed. Bending of the wrist is only possible
when the hand is forcibly adducted by means of the
flexor carpi ulnaris, which is not paralysed. Pronation
is lost. Sensation is disturbed over the skin supplied
by the nerve (Erb).

Paralysis of the ulnar nerve. — Ulnar flexion
and adduction of the hand are limited. Complete
flexion of the two inner fingers is impossible. The
little finger can scarcely be moved at all. The action
of the interossei and two inner lumbricales is lost.
The patient is unable to adduct the thumb, and sen
sibility is impaired over the cutaneous area supplied
by the nerve (Erb).

It is well to note that the skin over the back of
the last two phalanges of the index and middle fingers
and of the outer part of the ring finger is supplied by
the median nerve, and not by the radial, as sometimes
described (Fig. 29).

After complete division of any one of the three
great nerves of the upper limb, the loss of sensa-
tion in the cutaneous parts supplied by that nerve
is often quite slight. This is accounted for by the
interlacings that occur between the principal nerves of
the arm, so that when a given trunk is injured the
sensory impressions are returned by another route.

chap, xv.] NERVES OF THE UPPER LIMB. 261

Thus are explained those cases where the median
has been sutured after accidental division, with the
effect that sensation has returned in the cutaneous
parts supplied by the nerve within a few hours.
Such return of sensation is probably due to the sup-
plementary action of the interlacing nerve-fibres bound
up with other trunks, and not to the " immediate
union of a divided nerve," as was at one time an-
nounced.

262

ABDOMEN AND PELVIS.

CHAPTER XYI.

THE ABDOMEN.

THE abdominal parietes. — Surface anatomy.
— The degree of prominence of the abdomen varies
greatly. The protuberance of the belly in young
children is mainly due to the relatively large size of
the liver, which occupies a considerable part of
the cavity in early life. It also depends upon the
small size of the pelvis, which is not only unable to
accommodate any abdominal structure (strictly so-
called), but can scarcely provide room for the pelvic
organs themselves. Thus in infancy the bladder and
a great part of the rectum are virtually abdominal
viscera. After long-continued distention, as, for ex-
ample, after pregnancy, ascites, etc., the abdomen
usually remains unduly prominent and pendulous.

In cases of great emaciation it becomes much sunken,
and its anterior wall appears to have collapsed. This
change is most conspicuous about the upper part of the
region. Here the anterior parietes immediately below
the line of the costal cartilages, instead of being in the
same plane with the anterior thoracic wall, may so sink
in as to be almost at right angles with that wall on the
one hand, and with the lower part of the abdominal
parietes on the other. In such cases the abdominal
walls just below the thoracic line may appear to be
almost vertical when the patient is in the recumbent

Chap, xvi.] THE ABDOMINAL PARIETES. 263

posture. This cliange of surface is of importance
in gastrostomy, since the subjects for that operation
are usually much emaciated, and the incision has to be
made close below the costal line.

The position of the linea alba above the umbilicus
is indicated by a slight median groove, but no such
indication exists below the navel. The linea semi-
lunaris may be represented by a slightly curved line
drawn from about the tip of the ninth costal car-
tilage to the pubic spine. In the adult it would be
placed about three inches from the navel. Above
the umbilicus the line is indicated on the surface by
a shallow depression. The outline of the rectus can be
well seen when the muscle is in action. It presents
three "liiieae trans versse," one usually opposite the
xiphoid cartilage, one opposite the umbilicus, and a
third between the two. The two upper of these lines
are obvious on the surface in well-developed subjects.

The site of the umbilicus varies with the obesity of
the individual and the laxity of the abdomen. It is
always below the centre of the line between the
xiphoid cartilage and the pubes. In the adult it is
some way above the centre of the body, as measured
from head to foot, while in the foatus at birth it is
below that point. It corresponds in front to the disc
between the third and fourth lumbar vertebrae, and
behind to the tip of the third lumbar spinous process.
It is situated about three-quarters of an inch to one
inch above a line drawn between the highest points of
the two iliac crests.

The anterior superior spine, the pubic spine, and
Poupart's ligament are all conspicuous and important
landmarks. The pubic spine is nearly in the same hori-
zontal line with the upper edge of the great trochanter.
It is very distinct in thin subjects. In the obese it
is entirely lost beneath the pubic fat. In such indi-
viduals, however, it can be detected, when the subject is

264 SURGICAL APPLIED ANATOMY. [Chap. xvi.

a male, by invaginating the scrotum so as to pass the
finger beneath the subcutaneous fat. Tn the female the
position of the process may be made out by adducting
the thigh and thus making prominent the tendon of
origin of the adductor longus muscle. This muscle
arises from the body of the pubes immediately below
the spine, and by running the finger along the muscle
the bony prominence may be reached. If the finger be
placed upon the pubic spine it may be said that a
hernia descending to the inner side of the finger will
be inguinal, while one presenting to the outer side
will be femoral. In the erect position of the body the
anterior superior spine is a little above the level of the
promontory of the sacrum, while the tip of the xiphoid
cartilage corresponds to about the lower part of the
tenth dorsal vertebra.

In that part of the back which corresponds to
the abdominal region the erector spinse masses are
distinct, and in any but fat subjects their outer
edges can be well defined. Between these masses
is the spinal furrow, which ends below in an angle
formed by the two great gluteal muscles. Immediately
above the middle of the crest of the ilium is Petit's
triangle, or the gap between the external oblique and
latissimus dorsi muscles. The fourth lumbar spine
is about on a level with the highest part of the iliac
crest. In counting the ribs it is well to commence
from above, since the last rib may not project beyond
the outer edge of the erector spin*, and may conse-
quently be overlooked.

The aorta bifurcates opposite the middle of the
body of the fourth lumbar vertebra just to the left of
the middle line. This spot corresponds very nearly to
the highest point of the iliac crest, and will therefore
be situate about three-quarters of an inch below and to
the left of the umbilicus. A line drawn on either side
from the point of bifurcation to the middle of Pou part's

chap. xvi. j THE ABDOMINAL PARIETES. 265

ligament will correspond to the course of the common
and external iliac arteries. The first two inches of
this line would cover the common iliac, the remainder
the external.

The coeliac axis comes off opposite the lower part
of the twelfth dorsal vertebra, at a spot about four or
five inches above the navel, and that corresponds
behind to the twelfth dorsal spine. The superior
mesenteric and suprarenal arteries are just below the
axis. The renal vessels arise about half an inch below
the superior mesenteric, opposite a spot some 3|-
inches above the umbilicus, and on a level behind
with the gap between the last dorsal and first lumbar
spines. The inferior mesenteric artery comes off from
the aorta about one inch above the umbilicus. The
deep epigastric artery follows a line drawn from the
middle of Poupart's ligament to the umbilicus. Along
the same line may sometimes be seen the superficial
epigastric vein.

The abdominal " rings " will be referred to in the
paragraph on hernia.

Anterior abdominal parietes. — The skin
over the front of the abdomen is loosely attached in the
region of the groin. This condition is taken advantage
of in certain operations, e.g.. Wood's procedure for the
radical cure of hernia. It also allows of the incision
for herniotomy in the inguinal region being made by
transfixing a fold of skin that has been pinched up
over the external ring. The skin is more adherent to
the deeper parts in the middle line than elsewhere, but
not so adherent as to hinder the spread of inflammation
from one side of the abdomen to the other. In cases
of great obesity two transverse creases form across
the belly, one crossing the umbilicus and the other
passing just above the pubes. In the former of the
two creases the navel is usually hidden from sight.
In cases of anchylosed hip-joints transverse creases are

266 SURGICAL APPLIED ANATOMY. [Chap. xvi.

often noted running across the middle of the belly.
They are produced by the freer bending of the spine,
that is usually permitted in anchylosis, some of the
simpler movements of the hip joint being transferred to
the column when the articulation is rendered useless.

After the skin has been stretched, from any gross
distention of the abdomen, certain silvery streaks
appear in the integument over its lower part. They
are due to an atrophy of the skin produced by
the stretching, and their position serves to indicate
the parts of the parietes upon which distending
forces within the abdomen act most vigorously.
They are well seen after pregnancy, ascites, ovarian
tumours, etc.

Beneath the skin is the superficial fascia, which
over the lower half of the abdomen can be readily
divided into two layers. The great bulk of the
subcutaneous fat of this region is lodged in the more
superficial of the two layers. In cases of great obesity
the accumulation of fat is perhaps more marked
beneath the skin of the abdomen than it is elsewhere.
A layer of fat six inches in depth has been found in
this region in cases of great corpulence. The super-
ficial vessels and nerves lie for the most part between
the two layers of the fascia, so that in obese subjects
incisions may be made over the abdomen to the depth
of an inch or so without encountering blood-vessels of
any magnitude.

The deep layer of the superficial fascia contains
elastic fibres, and corresponds to the tunica abdominalis
or " abdominal, belt " of animals. It is attached to
the deeper parts along the middle line as far as the
symphysis; and to the fascia lata just beyond Poupart's
ligament. In the interval between the symphysis arid
the pubic spine it has no attachment, but passes down
into the scrotum and becomes the dartos tissue.
Extravasated urine that has reached the scrotum may

Chap, xvi.] THE ABDOMINAL PARIETES. 267

mount up on to the abdomen through this interval, and
will then be limited by the deeper layer of the fascia.
It will not be able to pass down into the thigh on
account of the attachments of the fascia, nor, for a like
reason, will it tend to pass over the middle line. In
the same way emphysematous collections following
injuries to the chest, when beneath the deeper layer
of the fascia, receive a check at the groin, and lipomata
also that grow beneath the membrane tend to be limited
by the middle line and that of Poupart's ligament.

The anterior abdominal parietes vary in thick-
ness in different subjects. In cases of emaciation the
outlines of some of the viscera may be readily made
out or even seen through the thinned wall. In some
cases of chronic intestinal obstruction the outlines
of the distended intestine are visible, and their move-
ments can be watched. The relative thickness of the
abdominal wall in various subjects depends rather
upon the amount of the subcutaneous fat than upon
the thickness of the muscles. This muscular boundary
affords an admirable protection to the viscera within.
By contracting the abdominal muscles the front of the
belly can be made as hard as a board, and in acute
peritonitis this contraction can sometimes be seen to
produce a remarkable degree of rigidity.

A blow upon the abdomen when the muscles are
iirmly contracted will probably do 110 injury to the
viscera unless the violence be extreme. The rigid
muscular wall acts with the efficacy of a dense india-
rubber plate. It may be bruised or torn, but it will
itself receive the main shock of the contusion.

The probable effect on the contained viscera of
a blow upon the abdomen will depend upon many
factors ; but, so far as the walls themselves are con-
cerned, the effect greatly depends upon whether the
blow was anticipated or not, and upon the extent of
the padding of fat that is furnished to the parietes.

268 SURGICAL APPLIED ANATOMY. [Chap. xvi.

If the blow be anticipated the muscles of the belly
will be instinctively contracted, and the viscera be at
once provided with a firm but elastic shield. Thus
the abdominal muscles have been found bruised and
torn while the viscera were intact, and, on the other
hand, in cases probably where the muscles were inert
or taken unawares, a viscus has been found to be
damaged without any conspicuous lesion in the belly
wall.

Along the linea alba the abdominal wall is thin,
dense, and free from visible blood-vessels. Hence in
most operations upon the abdominal cavity the incision
is made in the middle line. Along the outer border of
the rectus muscle (i.e., about and just beyond the
linea semilunaris) the parietes are also thin and lacking
in vessels, and consequently that situation is well
suited for an incision. There are, however, few
operative circumstances that could be met by an
incision so placed. In most cases it is a question of
either opening the abdomen in the middle line or in
one of the loins. Below the navel the two recti
muscles are almost in contact, and hence the white
line is very narrow. Above the umbilicus the two
muscles tend to separate a little, and the " line "
increases greatly in width. In pregnancy and in other
forms of distended abdomen the median interval
between the recti may be much increased.

The structures immediately behind the linea alba
are, from above downwards, the liver, stomach, and
transverse colon above the umbilicus, and the small
intestines and bladder (when distended) below it.
There are often little spaces between the fibres of
the linea alba, and through these pellets of fat from
the subperitoneal tissue may grow. If of fair size these
little masses may be mistaken for irreducible hernise.

The fibrous ring of the umbilicus is derived from
the linea alba. To this ring the adjacent structures,

chap, xvi.] THE ABDOMINAL PARIETES. 269

skin, fasciae, and peritoneum, are all closely adherent.
The adhesion is such, and the amount of tissue
between the skin and peritoneum is so scanty, that in
operating upon an umbilical hernia it is scarcely
possible to avoid opening the sac.

In the foetus three vessels enter at the navel, and
immediately separate on reaching the abdominal cavity,
the vein passing directly upwards and the arteries
obliquely downwards. Running down from the um-
bilicus in the middle line is also the remains of the
urachus. In the foetus, the spot where the three
vessels part company is about the centre of the navel,
and it thus happens that in a congenital umbilical
hernia the gut as it escapes separates the three vessels,
which become to some extent spread over it. The
congenital hernia, indeed, works its way in among the
structures of the cord and receives its main coverings
from them. These hernise are fortunately rare, for in
certain instances they extend some way into the
cord, and in at least two reported cases the gut was
cut across by the accoucheur in dividing the cord
at birth.* As the abdomen increases in height the
contraction of the two obliterated arteries and of the
urachus drags upon the cicatrix and pulls it backwards
and downwards. Thus, in the adult umbilical ring, as
viewed from the inner side, the cords representing
not only the obliterated arteries and the urachus, but
alsc the vein, appeal- to start from the lower border
of the cicatrix. In adult hernise, indeed, the gut
escapes above both the obliterated arteries and the
vein. The upper half of the cicatrix is thin when
compared to the lower half, and is supported also by
less firm adhesions.

* The congenital hernia must be distinguished from the infantile
umbilical hernia so commonly met with after separation of the
cord. For an account of these congenital hernise see paper by the
author in the Lancet, vol. i., 1881, p. 323.

270 SURGICAL APPLIED ANATOMY. [Chap. xvi.

In some cases a fistula is found at the navel that
discharges urine. This is due to a patent urachus.
The urinary bladder is formed by a dilatation of the
stalk of the allantois. The part below this dilatation
becomes the first part of the urethra, that above
becomes the urachus. In one instance of patent
urachus the abnormal opening was one inch in diameter.
The patient, a man aged 40, had a stone, which was
extracted by passing the finger into the bladder through
the opening at the umbilicus.

Sometimes a fistula discharging faeces is met with
at the navel. This depends upon the persistence of the
vitello-intestinal duct, a duct that at one time connects
the rudimentary intestine with the yolk sac, and that
generally disappears without leaving any trace. The
persistent duct, when it occurs, is known as Meckel's
diverticulum, and springs from the ileum from one
to three feet above the ileo-csecal valve.

The position of the transverse intersections of the
rectus muscle should be borne in mind. They
adhere to the anterior layer of the rectus sheath,
but not to the posterior. They are able, therefore,
in some extent to limit suppurative collections and
haemorrhages beneath the sheath on its anterior
aspect. This muscle is often the seat of one form of
" phantom tumour." These tumours are mostly met
with in the hysterical and hypochondriac, and when
associated with some vague abdominal symptoms are
apt to mislead. They are due to a partial contraction
of the muscle, usually to a part between two inter-
sections, and are said to be more common in the left
rectus. When the fibres of the muscle are contracted
the "tumour" is obvious, but when they relax it
disappears. Other phantom tumours depend upon
irregular contraction of the other abdominal muscles
associated with flatulent or faaculent distention of the
bowel. In great distention of the abdomen the fibres

Chap, xvi.] THE ABDOMINAL PARIETES. 271

of the reetus may be much stretched, since they bear
the brunt of the distending force. The direction of
the fibres also renders them liable to be torn in the
opisthotonos, or extreme arching of the back, of
tetanus. Portions of the muscle have also been
ruptured by muscular violence.

The lateral muscles of the front abdominal wall
are separated from one another by layers of loose
connective tissue. These extensive layers favour
the spread of interstitial abscesses of the abdominal
parietes. Such abscesses will be guided in their
course by the attachments of the muscles between
which they spread, and will be limited by the semi-
lunar lines in front, by the lower parts of the ribs and
their cartilages above, by Poupart's ligament and the
iliac crest below, and by the edge of the erector
spinse behind. The same remark applies to hsemorr-
hagic or emphysematous collections between these
muscles.

Between the abdominal parietes and the perito-
neum is a layer of loose connective tissue, the subserous
connective tissue. The looseness of this layer greatly
favours the spread of abscess, to the progress of which
it offers little resistance. Such an abscess may spread
from the viscera, especially from those that have an
imperfect peritoneal covering, as, for example, the
kidney, the vertical parts of the colon, etc. The
laxity of this tissue is of great service in certain
surgical procedures. Thus the external and common
iliac arteries can be reached by an incision made some
way to the outer side of the vessels and without
opening the peritoneum. That membrane having
been exposed in the lateral wound, the artery is
reached by working a way with the finger through
the subperitoneal tissue, and by actually stripping
the serous membrane from its attachments. This
condition of the subserous layer also favours that

272 SURGICAL APPLIED ANATOMY., [Chap. xvi.

stretching of the peritoneum which occurs under
certain circumstances.

Wounds of the abdomen may give trouble in
their treatment, since, when inflicted, they may open
up several layers of fascia and so lead to bagging of
pus and to the spread of suppuration should an abscess
follow the lesion. When the more muscular parts
are divided the condition of the layers incised is
such that great facilities are offered for the em-
bedding of small foreign bodies, such as pieces of
glass, etc., which, hidden between the muscular layers,
may well be overlooked. Mr. Pollock records a case
where the metal part of a steel fork with two prongs
was overlooked and allowed to remain buried in
the abdominal walls for a considerable time.

The frequent movement of the belly walls does
not favour that rest which is so essential to the healing
of wounds.

In penetrating wounds the contraction of the
muscles may encourage the protrusion of the viscera,
especially when the incision is transverse to the
direction of the muscular fibres. In reducing small
portions of protruded viscera it is quite possible to
push them into one of the connective tissue spaces
between the muscles or into the subserous tissue
instead of into the peritoneal cavity. In applying
sutures to wounds involving the whole thickness of
the parietes it is necessary that the threads should
include the peritoneum so that earty healing of that
membrane may be brought about. Without such
precaution a gap may be left in the surface of the
peritoneum which would favour the formation of a
hernia in the site of the old wound.

Blood-vessels. — The only arteries of any magni-
tude in the abdominal walls are the two epigastric
arteries, some branches of the deep circumflex iliac,
the last two intercostal vessels, the epigastric branch

Chap, xvi.] THE ABDOMINAL PARIETES. 273

of the internal mammary, and the abdominal divisions
of the lumbar arteries. The superficial vessels are
of small size, although Verneuil reports a case of
fatal haemorrhage from the superficial epigastric
vessel.

The superficial veins on the front of the abdomen
are numerous, and are very distinct when varicose. A
lateral vein uniting the axillary and femoral veins is
often rendered in this way very prominent. It has
been shown by Mr. Fenwick that the surface
abdominal veins probably take no part as alterna-
tive blood channels in cases of obstruction of the
inferior vena cava. Clinical experience shows that
these veins may be also enormously varicose in
instances where the inferior cava is quite patent. In
one case under my care there was extensive varicosity
of the surface veins from the pectoral region to the
groin that involved one side of the body only. It
has been shown, moreover, that the valves of these
vessels are so arranged that the blood in the surface
veins above the navel goes to the axilla, that in the
veins of the sub-umbilical region to the groin, while
the blood in the immediate vicinity of the umbilicus
flows either up or down, occupying indeed a kind of
neutral position.

As regards the surface lymphatics of the front of
the abdomen, it may be said in general terms that
those above the umbilicus go to the axillary glands,
and those below to the glands of the groin.

Nerves. — The abdominal wall is supplied by the
lowest seven dorsal or intercostal nerves, and by the
first two lumbar nerves. These nerves run obliquely
to the long axis of the abdomen downwards and
inwards from the sides to the middle line. Their
direction is represented by a continuation of the
lines of the ribs : they are placed parallel to one
another, and at fairly equal distances apart. It is

274 £ra GICA L APPLIED ANA TO MY. [Chap, x v i .

important to note that they supply not only the
abdominal integument, but also the muscles of the
belly, viz., the rectus, the two oblique muscles, and
the transversalis. This association is of great prac-
tical importance. If a cold hand be suddenly placed
upon the belly the muscles at once contract and the
abdomen is instinctively rendered rigid. The safety
of the viscera, so far as at least protection from
contusions is concerned, depends upon the readiness
with which the muscles can contract at the first
indication of danger. As has been already stated, the
viscera have a very efficient protection against the
effects of blows when the belly muscles are in a state
of rigid contraction. The sensitive skin acts the part
of a sentinel, and the intimate association of the surface
nerves with the muscular nerves allows the warnings
of this sentinel to be readily given and immediately
acted upon. If the skin and the muscles had each
an independent nerve-supply, a longer interval would
elapse between the warning to the skin and the
muscular contraction than occurs when those two
parts are both supplied by the same nerves. The
rigidity of the muscles in certain painful affections of
the skin over the abdomen is often very conspicuous.
I might instance the case of a man with a burn over the
belly. While the burn is protected by the dressings
the abdominal muscles are lax and the parietes move
with the respiratory act. The moment the dressings
are removed, the surface becoming painful, the
muscles at once contract and the belly becomes
rigid. It will be noticed that seven of the abdominal
nerves supply intercostal muscles, and are thus
intimately associated with the movements of respira-
tion. The abdominal muscles are of course concerned
in the same movements. These associations are illus-
trated when cold water is suddenly dashed upon the
belly. The subject of such experiment at once

Chap, xvi.] THE ABDOMINAL PARIETES. 275

experiences a violent respiratory movement in the
form of a deep gasp. When the abdominal muscles
are firmly fixed the lower ribs are also rigid, and
respiration is limited to the higher ribs and to the
thorax proper.

There are other practical points about these nerves.
In caries of the spine, and in certain injuries to the
column, the spinal nerves may suffer injury as they
issue from the vertebral canal. This injury may show
itself by modified sensation in the parts supplied by
such nerves. Thus in Pott's disease the patient often
complains of a sense of tightness about the abdomen,
as if a cord were tied around it. This sense of
constriction depends upon an impaired sensation in the
parts supplied by a certain pair of nerves ; or, if the
sense of constriction be wider spread, by two or more
pairs of nerves. In other cases a sense of pain may
take the place of that of constriction. It would hardly
be believed that spinal disease has been mistaken for
" belly-ache." But many such cases have been recorded.
A child complains of pain over the pit of the stomach
or about the umbilicus, and this feature may quite
absorb for a while the surgeon's attention. The
abdomen is carefully poulticed, while the only mischief
is in the vertebral column, Other symptoms, however,
develop, and it becomes evident that the pain is
due to pressure upon the nerves supplying the skin
over the epigastric or umbilical regions, and that that
pressure is a circumstance in the course of spinal bone
disease. The site of the painful part depends, of
course, upon the position of the spinal ailment, and
thus the cutaneous symptoms may serve to localise
the caries in the vertebrae. Thus the skin over the
" pit of the stomach " is supplied by the sixth and
seventh dorsal nerves, the tenth nerve is nearly in a
line with the umbilicus, while the two lumbar nerves
run close above Pou part's ligament. The position of

276 SURGICAL APPLIED ANA TO MY. [Chap. xvi.

the intermediate trunks can be readily estimated.
Pain referred to districts supplied by the lower ab-
dominal nerves in connection with spinal caries may
mislead the surgeon from the real seat of the malady,
and may arouse a suspicion of mischief in the kidneys
or bladder.

It may be noted that some of these nerve disturb-
ances, especially the sense of a constricting band,
are common in certain affections of the spinal cord,
such as locomotor ataxia, etc.

These nerves of the belly- wall have still more
important associations. Not only are they supplied
to the skin of the abdomen, and to the abdominal
muscles, but they also share in the nerve supply of the
abdominal contents. It is well known that the most
conspicuous supply of the abdominal viscera is derived
from the sympathetic. This nerve cord receives many
contributions from the spinal nerves, and the mixed
trunks thus formed are distributed to the various
organs. It, however, happens that that segment of
the gangliated cord of the sympathetic that is within
the abdomen (viz. the lumbar segment) has practically
nothing to do with the strictly abdominal viscera.
The lumbar cord communicates with the lumbar
nerves, but only two of these have any concern
with the abdominal parietes, and that concern is of
very insignificant extent, and relates rather to the
pelvic than to the abdominal parts of the parietes.
The spinal nerves mostly concerned with the belly-
wall are the last seven dorsal. These nerves have
communication with the lower seven sympathetic
ganglia in the thorax, and it is to the thoracic sympa-
thetic that we must look for some more direct interest
in the abdominal nerve-supply so far as it affects the
viscera. This connection is afforded by the splanchnic
nerves that come off from the lower seven or eight
thoracic ganglia, and are in communion with the

chap. xvi.] THE ABDOMINAL PARIETES. 277

very nerves that supply the parietes.* These
nerves go to the great plexuses that provide the
nerve supply for the abdominal viscera, to the great
solar plexus, and to some of those more or less
directly derived from it. Without some such expla-
nation it is difficult to understand why the sympa-
thetic supply of the abdominal organs should be
derived from a nerve cord half way up in the thorax,
when that very cord extends into the abdomen itself,
and could provide a much more direct supply. This
nerve relationship is illustrated in disease in many
ways. Thus, in acute peritonitis and in laceration of
certain of the viscera the abdominal muscles become
rigidly contracted, so as to insure as complete rest as
possible to the injured parts. In acute peritonitis
the belly is very hard, the respirations are purely
thoracic, and so entirely do the cutaneous portions of
these nerves enter into the situation, that the patient
is often unable to tolerate even the most trifling
pressure upon his abdomen.

Congenital deformities of the abdomen.—
In the foetus the intestinal canal is cut off from the
yolk sac by the gradual growth of the ventral plates
and their ultimate union in the middle line. This
union occurs latest at the umbilicus, and when,
complete the abdominal cavity is entirely enclosed.
In some cases of imperfect development the anterior
abdominal wall is more or less entirely absent, and
the viscera are either entirely uncovered or protected
only by a scanty membrane. This condition is usually
associated with other deformities, which are incon-
sistent with any but very brief existence. In many

* Beck (Phil. Trans., 1846) and others state that the great
splanchnic nerve is in connection with the upper as well as with
the lower thoracic ganglia, and such a connection would place the
abdominal viscera in relation with a still larger number of respi-
ratory muscles, and would further support the interest of those
viscera in the respiratory movements generally.

278 SURGICAL APPLIED ANATOMY. [Chap. xvi.

cases the abdominal walls are fairly complete, but
there is a lack of union in the middle line about the
umbilicus. Thus result the various forms of con-
genital exomphalos, which may vary in severity from
a small hernia to a protrusion of the whole of the
more moveable viscera. One of the most remarkable
deformities is that known as extroversion of the
bladder. Here, not only is a part of the belly wal]
absent, but also a part of the geni to-urinary apparatus.
In complete cases there is an absence of the umbilicus
and of the anterior abdominal wall below it. There is
no symphysis pubis, an absence of the anterior
wall of the bladder, of the principal part of the penis,
and the whole of the roof of the urethra. The
scrotum, also, as may be expected from a reference to
the development of that part, is bifid.

Hernia,. — 1. Inguinal hernia. — In this form of
rupture the herniated bowel occupies the inguinal
canal for the whole or part of its entire length. This
canal runs obliquely from the internal to the external
abdominal ring, and is about one and a half inches in
length. It represents the track followed by the testis
in its descent. It is, in a sense, a passage right through
the abdominal walls, and is occupied by the spermatic
cord. It is not a free canal, however, in the same
sense as one would speak of an open tube, but is rather
a potential one, a tract of tissue so arranged as to
permit of a body being thrust along it. It is a breach
in the abdominal wall, not a doorway ; a breach
that is forcibly opened up and widened in the acquired
forms of hernia. When a hernia occupies the in-
guinal canal it is covered in front by the integuments,
the external oblique aponeurosis, and the lower fibres
of the internal oblique and transversalis muscles. It
rests behind upon the transversalis fascia, the
conjoined tendon, and the triangular ligament ; over
it arches the transverse and internal oblique

Chap, xvi.] HERNIA. 279

muscles, while below it is the angle formed by
the union of Poupart's ligament with the transver-
salis fascia. The herniated bowel is contained within
a " sac/' which is always formed of peritoneum. In
congenital hernia the sac exists already formed in the
form of an abnormally patent "processus vaginalis."
In acquired hernise the sac consists of that part of the
parietal peritoneum which the gut pushes before it in
its descent.

The external abdominal ring is readily felt by
invaginating the scrotum with the point of the finger,
and then passing the digit up in front of the cord.
If the nail be kept against the cord the pulp of the
finger can readily recognise its triangular slit-like
opening. Under ordinary circumstances in adults it
will just admit the tip of the little finger.* The
internal ring is situate about half an inch above the
middle of Poupart's ligament.

There are two principal forms of inguinal hernia,
which can be best understood by a view of the anterior
abdominal parietes from within. From such an aspect
it will be seen that the peritoneum is marked by three
linear ridges that run, roughly speaking, from the
umbilicus to the pelvic brim. One of these ridges
follows the middle line from the navel to the symphysis,
and represents the urachus; a second, that may be
indicated by a line drawn from the middle of Poupart's
ligament to the navel, represents the deep epigastric
artery ; while between these two, and much nearer to
the epigastric vessel than to the middle line, is the line
formed by the obliterated hypogastric artery. By
means of these ridges the peritoneum is made to pre-
sent three fossae, an external to the outer side of the

* In cases of congenital or acquired absence of the cord the
external ring may be almost obliterated. Paulet quotes from
Malgaigne the case of an old man whose testicle had been removed
in infancy, and in whom the external ring was so small as to be
scarcely recognisable.

280 SURGICAL APPLIED ANATOMY. [Chap. xvi.

epigastric artery, an internal between the urachus
and the hypogastric artery, and a middle between the
tract of the latter vessel and the epigastric trunk.
The internal ring (so called) is just to the outer side
of the epigastric artery, and the site of the summit of
the inguinal canal is indicated by a depression in the
peritoneum. When a hernia follows the inguinal
canal throughout its entire length, it is called oblique,
indirect, or external; " oblique" or "indirect" from
its taking the oblique direction of the canal, "external"
from the position of its neck with reference to the
epigastric vessel. The coverings of such a hernia
would be the same as those of the cord, viz., the skin,
the superficial, intercolumnar, cremasteric and infundi-
buliform layers of fascia, the subserous tissue, and
the peritoneum. When the hernia escapes to the
inner side of the deep epigastric artery, through the
space known as Hesselbach's triangle, it is called a
direct or internal hernia for reasons that will be
obvious. There may be two forms of direct hernia. In
one form the gut escapes through the middle fossa
above described, in the other through the inner fossa
between the hypogastric artery and the outer edge of
the rectus muscle, The middle fossa is nearly oppo-
site to the summit of the external ring. A hernia
escaping through that fossa would enter the inguinal
canal some little way below the point of entrance of
an oblique hernia, and would have the same coverings
as that hernia, with the exception of the infundibuli-
form fascia. The first covering, indeed, that it would
receive from the canal structures would be the cre-
masteric fascia. The inner fossa corresponds, so far
as the inguinal canal is concerned, with the external
ring. A hernia escaping through this fossa would be
resisted by the conjoined tendon and the triangular
ligament. These structures are either stretched over
the hernia so as to form one of its coverings, or the

Chap, xvi .] HERNIA . 281

conjoined tendon is perforated by the hernia, or lastly
the gut deviates a little in an outward direction so as
to avoid the tendon and appear at its outer side
(Velpeau). In any case the hernia is forced almost
directly into the external abdominal ring. The
coverings of such hernise are the skin and superficial
fascia, the intercolunmar fascia, the triangular liga-
ment and conjoined tendon (with the exceptions above
mentioned), the transversalis fascia, subserous tissue,
and peritoneum.

An examination of the abdominal wall, apart from
clinical experience, would lead one to suspect that the
direct hernia would be more common than the indirect,
since the parietes are certainly less resisting opposite
Hesselbach's triangle than they are in the parts imme-
diately external to the epigastric artery. Indeed, just
to the outer side of the conjoined tendon the belly wall
is remarkably thin. These conditions, however, seem
to offer less facilities for the escape of a hernia than
does the inguinal canal itself. The funnel-shaped
depression in the peritoneum at the summit of that
canal seems to offer particular inducements for rupture,
and there are, besides, certain congenital defects in the
vaginal process of the peritoneum that render hernia
almost unavoidable along the inguinal canal.

Direct versus indirect inguinal hernia. —
The indirect hernia, as just hinted, may be congenital,
the direct is never congenital. In the congenital
oblique hernia the outline of the inguinal canal and
the relations of the various parts concerned are but
little disturbed, and the differences between this
form of rupture and the direct variety are conspicuous.
The acquired oblique hernia, however, does not present
such a contrast to the direct form as may be expected.
In the first-named rupture, from constant dragging
upon the parts the internal ring becomes more or less
approximated to the external ring, and the length of

282 SURGICAL APPLIED ANATOMY. [Chap. xvi.

the canal and consequently the obliquity of the hernia
are considerably reduced. Thus the axes of the two
forms of rupture do not present such differences as to
make their nature at once obvious. The direct hernia,
however, on reduction, will pass directly back into the
belly, while the indirect will, even in old cases, take a
slight but appreciable direction outwards. After the
reduction of the direct hernia, the edge of the rectus
muscle may be readily felt to the inner side of the aper-
ture, and the pulsation of the epigastric artery will
probably be detected on its outer side, features that
are both lacking in the oblique variety. From the
slight inducement offered to its progress, and from its
insignificant neck, the direct hernia is usually small
and globular, while for opposite reasons the oblique
rupture may attain large size, and tends to assume a
pyriform outline.

Forms of* oblique hernia depending* upon
congenital delects in the " vaginal process."
— It is well known that the testis in the foetus descends
from the region of the kidney into the scrotum by
making a way through the abdominal wall that is
afterwards known as the inguinal canal.

Its descent is preceded by the passage into the
scrotum of a process of the peritoneum, the vaginal
process. The testicle usually enters the internal ring
about the seventh month of foetal life, and by the
eighth month is in the scrotum. The vaginal process
is often found open at birth, but it is more usually
found cut off from the peritoneal cavity, the portion
thus isolated forming the tunica vaginalis. This
vaginal process will have a narrowed part or neck, as
it passes along the inguinal canal, and will be free to
enlarge again on reaching the scrotum. The manner
in which it is cut off is as follows. It becomes oblite-
rated in two places, at the internal ring and at a spot
just above the epididyuais, the obliteration usually

chap, xvi.] HERNIA. 283

beginning at the higher point first. Supposing oblitera-
tion to have taken place at these two points, the
vaginal process between them will be represented
by an isolated tube. This soon shrinks, closes, and
dwindles to an insignificant fibrous cord. It may,
however, remain patent in part, and if fluid accumu-
lates in this patent portion, an " encysted hydrocele of
the cord " is produced. As regards the mode of closure,
three contingencies may happen, each giving rise to a
particular form of hernia : (1) The " process " may not
close at all ; (2) it may close at the upper point only ;
and (3) it may close at the lower point only.

(1) When the vaginal process is entirely open, gut
can readily descend at once into the scrotum. Such a
condition is called a congenital hernia. (2) When
the process is closed only at the internal ring, there
appears to be merely a thin septum between the
peritoneal cavity and the cavity of the tunica
vaginalis. The gut pressing upon this septum may
push it before it, or come down behind it. In
either case, three layers of peritoneum would have
to be cut through before the gut could be reached.
This is known as an infantile or encysted
hernia. The condition of parts that favours the
development of this rupture serves also to explain
those anomalous cases of congenital hernia that appear
suddenly and for the first time in adult life. Here,
under some unwonted exertion, the septum above
described gives way and the gut at once passes into
the cavity beyond, and so appears in the condition of
a congenital hernia. (3) In the last-named circum-
stance a tubular process of peritoneum leads down as
far as the top of the testicle, and there ends, the normal
tunica vaginalis being beyond. Hernia into this
process is called a hernia into the funicular
process.

In the first of these forms the testicle is quite

284 SURGICAL APPLIED ANATOMY. [Chap. xvi.

enveloped in the hernia. In the second and third
forms, as well as in the acquired form, it is to be felt
quite distinct from the rupture, being actually behind
and below it.

A congenital hernia may form in cases where the
testicle has not descended at all. In such instances
the vaginal process may occupy the would-be canal,
and along this process a hernia may descend. It is
well known that the testicle may make its first appear-
ance in the scrotum, months and even years after birth.
In such cases the vaginal process may be normally
developed at birth (i.e., may occupy the scrotum), or
it may be abortive.

In the foetus the inguinal canal is relatively
much shorter than it is in the adult. As the pelvis
develops, however, the relations of the canal approach
more to the normal. In the congenital hernia the
relations of the canal are not disturbed as they are
in the acquired form. Thus, it happens that such
ruptures have long and narrow necks, and the difficulty
in steadying this neck constitutes one of the special
obstacles in the effectual reduction of the hernia.

There is another possible congenital defect that
may predispose to hernia, viz., an abnormally long
mesentery. If, in the dead subject, the inguinal canal
be opened up, and an attempt made to draw a piece of
gut down from the abdomen into the scrotum, it will
be found that it cannot be done, owing to the shortness
of the mesentery. In any case of scrotal hernia, there-
fore, the mesentery must become lengthened, and it is
a question whether or not an abnormally long mesen-
tery may exist as a congenital defect, and so predispose
the patient to rupture. More information is required
upon the subject.

The ingiiiaial canal in the female is much
smaller and narrower, although a trifle longer, than it
is in the male. It is occupied by the round ligament,

chap, xvi.] HERNIA. 285

and offers such slight inducement to the formation of
a rupture, that acquired inguinal hernia is as rare
among females as it is common among men. In the
female foetus, a process of peritoneum descends for a
little way along the round ligament. It corresponds
to the processus vaginalis of males, and is known as
the canal of Nuck. If this process remains patent,
as it not infrequently does, it may lead to a rupture
that corresponds to the congenital hernia of males.
Indeed, in quite early life the inguinal rupture is
about the only form met with in female children, if
exception be made of umbilical hernia. In all such
instances of early inguinal hernia, the gut has travelled
down a patent canal of Nuck.

It only remains to be said, that in endeavouring to
reduce an inguinal hernia by taxis, the thigh should
be flexed and adducted, for in that position the ab-
dominal parietes that bound the inguinal canal are
the most relaxed. This position of the thigh affects
the inguinal region mainly . through the attachments
of the fascia lata to Poupart's ligament.

In hermotomy an incision is made along the
middle of the tumour and in its long axis, being
so arranged that its centre shall correspond to
the external ring. The superficial external pudic
artery is usually divided in the operation. It is im-
possible to distinguish the various layers of tissue that
cover the hernia, the only one, as a rule, that is re-
cognisable being the layer from the cremaster. In
dividing the constriction it is usually recommended to
cut upwards in all forms of inguinal hernia. The only
vessel in risk of being damaged is the deep epigastric.
In the oblique form of rupture an incision directly
upwards would quite avoid this artery ; but in a direct
hernia, where there is reason to suppose that the vessel
is in close connection with the neck of the sac, it is
well that the incision be directed a little inwards as

2 86 SURGICAL APPLIED ANATOMY. [Chap. xvi.

well as upwards. It should be remembered that the
incision required to relieve a constriction is, if pro-
perly applied, of the most insignificant character.

Femoral hernia. — In this form of rupture the
gut leaves the abdomen through the femoral ring and
passes down into the thigh along the crural canal.
The name " crural canal " is given to the narrow
interval between the femoral vein and the inner wall
of the crural sheath. Like the inguinal canal, it is
a potential rather than an actual canal, and exists
only when the sheath has been separated from the
vein by dissection or by a hernia! protrusion of some
kind. The canal is funnel-shaped, about half an inch
in length, and ends opposite the saphenous opening.
Femoral hernise are always acquired, and possess a sac,
made by themselves out of the parietal peritoneum
covering the crural ring and its vicinity. The canal
is larger in women than in men, and thus it happens
that this species of rupture is much more common in
the former sex. The tendency to this hernia in
women appears also to be increased by the weakening
effects of pregnancy upon the abdominal walls. As
the gut descends it pushes in front of it its sac of
peritoneum and the septum crurale (the name given
to the subserous tissue that covers in the femoral ring)
and enters the crural sheath. The adhesions of the
sheath limit its downward progress when it has
travelled about half an inch, and it therefore passes
forwards through the saphenous opening, pushing
before it the cribriform fascia. It then receives a
covering from the superficial fascia and the skin.
Owing to the rigidity of the structures about the
femoral ring, the neck of the sac must always be
small. For similar reasons its dimensions while in
the femoral canal must of necessity be insignificant,
but when once it has escaped through the saphenous
opening the loose subcutaneous fasciae of the groin

chap, xvi.i HERNIA. 287

afford it ample opportunities for increase. When the
hernia has passed through the saphenous opening it
tends to mount upwards over Poupart's ligament, in
the direction of the anterior superior iliac spine. Even
when it overlaps the ligament considerably it can
hardly be mistaken for an inguinal hernia, since it
must always lie to the outer side of the pubic spine.
The upward tendency of a femoral hernia has been
variously explained. It has been ascribed to a
supposed curve in the crural canal, the concavity of
which is forwards. Scarpa believed it to receive its
direction from the frequent flexion of the thigh.
Probably one of the most important factors in the
matter is the unyielding character of the lower edge
of the saphenous opening. This edge tends to direct
the gut forwards, while the traction upon the
mesentery, that is inevitable as the rupture proceeds,
may be conceived as favouring an upward direction.
The coverings of a hernia that has found its way
beneath the skin are often very scanty.

Relations. — When a hernia occupies the crural
canal there are in front of it the skin and super-
ficial fasciae, the iliac part of the fascia lata, the
crural arches, the cribriform fascia, and the anterior
wall of the crural sheath. Behind are the pos-
terior wall of the crural sheath, the pubic portion
of the fascia lata, the pectineus muscle, and the bone.
The boundaries of the femoral ring are, in front,
Poupart's ligament and the deep crural arch ; behind,
the bone covered by the fascia lata and the pectineus ;
on the inner side, the conjoined tendon, Gimbernat's
ligament, and the inner part of the deep crural arch ;
on the outer side, the femoral vein in its sheath. The
spermatic cord lies (in the male) just above the anterior
border of the ring, and the epigastric artery skirts its
upper and outer part. The little pubic branch of this
artery passes round the ring to ramify over Gimbernat's

288 SURGICAL APPLIED ANATOMY, [Chap. xvi.

ligament. In one case out of three and a half the
obturator artery arises from the epigastric. Out
of one hundred and one cases where the vessel so
arose it reached its destination in fifty-four instances
by passing along the outer side of the crural ring,
a position quite free from danger in herniotomy.
In thirty-seven cases it passed backwards across the
ring, and in ten instances around its inner border
(R Quain). When in the last-named position the
vessel could hardly escape being wounded in the
operation upon a femoral hernia. Indeed, several
cases have been recorded of fatal haemorrhage from
this abnormal vessel in such operations. In one
instance the pulsations of the abnormal artery were
felt before the parts were divided. In addition to the
vessels about the ring there is also a pubic vein,
which, ascending from the obturator vein in the
thyroid foramen, enters the external iliac vein. Its
relation to the crural ring varies in the same way
as the abnormal artery last named.

The size of the femoral canal and the degree of
tension of its orifices varies greatly with the position
of the limb. If the thigh be extended, abducted, and
rotated outwards, these parts are made very tense,
while they are the most lax when the limb is flexed,
adducted, and rotated inwards. It is consequently
in the latter position that the thigh should be placed
when the taxis is being attempted. In herniotomy
the incision is made along the inner side of the
tumour, arid is so arranged that its centre corresponds
to about the upper part of the saphenous opening.
The constriction is usually at the neck of the sac, and
caused by Gimbernat's ligament. It is divided by an
incision directed upwards and inwards.

Obturator hernia. — In this form the gut. push-
ing before it a sac of peritoneum, escapes through the
obturator canal between the horizontal ramus of the

chap, xvi.] HERNIA. 289

pubes and the uppermost fibres of the obturator ex-
ternus muscle. The obturator vessels may be either
found on the outer or inner side of the sac, or above it.
The proximity of the nerve renders it very liable to
be pressed upon, and pain along the nerve is often a
marked feature of the rupture. The hernia presents
beneath the pectineus muscle, to the inner side of the
capsule of the hip, behind and to the inner side of the
femoral vessels, and to the outer side of the adductor
longus tendon. Pain on moving the hip is generally
a conspicuous symptom. This hernia is more common
in females ; and it is worthy of note that the orifice of
the obturator canal can be examined, to some extent,
through the vagina. Professor Wood reports a re-
markable case where a hernial protrusion of a part of
the adductor longus through a rent in its aponeurosis
was mistaken for an obturator hernia.

Rare forms of hernia. — In perineal hernia
the sac, covered by the recto-vesical fascia, escapes
through the anterior fibres of the levator ani muscle,
between the prostate (or vagina) and the rectum.
In pudendal hernia the sac lies in the posterior inferior
half of the labium pudendi, escaping between the
ascending ramus of the ischium and the vagina. In
sciatic hernia the gut escapes through the sciatic
notch in front of the internal iliac vessels, above or
below the pyriformis, and appears under the gluteus
maximus muscle. As regards umbilical hernia,
nothing remains to be added to what has been already
said (page 269), save that the sac from its position
nearly always contains omentum, and may contain
stomach. In lumbar hernia the gut escapes in front
of the quadratus lumborum muscle, and appears on the
surface through the triangle of Petit (the gap between
the latissimus dorsi and external oblique muscles), and
therefore just above the highest point of the iliac
crest. The sac must either force before it, or (in cases
T

290 SURGICAL APPLIED ANATOMY. [Chap. xvi.

of injury) come through the fascia lumborum and
internal oblique muscles, since those structures form the
floor of the triangle. Diaphragmatic hernice may be
congenital or acquired. The former variety is by far
the more common, and is due to simple arrest in the
development of the diaphragm and persistence of the
original connection between the thorax and abdomen.
The acquired form usually follows a laceration of the
diaphragm from injury. In any case some of the
abdominal viscera are protruded, through the gap in
the midriff, into the thoracic cavity. Owing to the
presence of the liver on the right side, these hernias
are much more common on the left side. Of the
organs, the stomach is the most frequently dislodged,
then the transverse colon, omentum, small gut, spleen,
liver, pancreas, and kidneys in the order named (Leich-
tenstern). The hernia may escape through the foramen
for the gullet, but never through that for the vena
cava, nor through the hiatus aorticus. The parts
commonly selected are the connective tissue intervals
between the sternal and costal origins of the diaphragm
in front and its vertebral and costal origins behind.
These hernise are more common in males.

Posterior abdominal parietes. — The lateral
and posterior walls of the abdomen are lined inside with
two fascia?, the trans versalis and iliac. Thetransversalis
fascia lines the whole of the transversalis muscle, and is
much thicker below than above. Above it joins the
fascia covering the diaphragm, while below it is at-
tached to the iliac crest, and to the whole of Poupart's
ligament, save at that spot where it passes into the
thigh to form the anterior layer of the crural sheath.
The iliac fascia encloses the ilio-psoas muscle, the part
over the psoas being the thinner. This part is attached
on the inner side to the sacrum, and to the spine at
points corresponding to the psoas origin. Above, it is
attached to the ligamentum arcuatum internum, and

Chap, xvi.] ILIAC FASCIA. 291

on the outer side to the anterior layer of the lumbar
fascia along the outer edge of the psoas. Below, the
fascia encloses the iliacus, and is attached to the iliac
crest, to the pelvic brim, and to Poupart's ligament,
save at that part where the membrane passes beneath
the ligament to form the posterior wall of the crural
sheath. It follows the ilio-psoas muscle to its insertion,
and ends by blending with the fascia lata.

The arrangement of these fasciae greatly influences
the progress and direction of abscess. Thus an abscess
beneath the transversalis fascia will be very definitely
enclosed. If it progresses backwards it will be stopped
at the outer edge of the psoas muscle. If it spreads
downwards it will be arrested by the attachments of
the fascia to the iliac crest and to Poupart's ligament,
and will be unable to spread (unless the fascia, be
pierced) into either the pelvis or the thigh. On the
inner side it will be checked at the middle line ; and
above, although it will meet with no actual resis-
tance, it would be indisposed to spread, since its move-
ments would be against gravity. Thus, it happens
that collections so placed point either just above the
iliac crest or Poupart's ligament, or run down along the
spermatic cord, and distend the inguinal canal.

The iliac fascia encloses the ilio-psoas in a very
distinct osseo-aponeurotic space. Between the fascia
and the muscle (especially its iliac division) there is
a good deal of loose connective tissue, and thus every
facility is offered for the progress of subf ascial abscesses
in this region. The osseo-aponeurotic space is practi-
cally closed on all sides within the abdomen, and is
only open below where the fascia passes with its
muscle into the thigh. This opening being at the
most dependent part of the space, it follows that the
psoas or iliac abscess very commonly points on the
upper part of the thigh, just to the outer side of the
femoral vessels. An abscess in the iliac fossa, although

292 SURGICAL APPLIED ANATOMY. [Chap. xvi.

most likely to reach the thigh, might mount up to the
superior attachments of the fascia, and point at the iliac
crest, or at the outer part of Poupart's ligament. Or it
may disregard the inner attachments of the fascia and
gravitate into the pelvis. If the patient should occupy
for long the recumbent posture, there is no reason why
it should not extend upwards along the psoas muscle.

The term iliac abscess, however, is often applied to
collections that are not within the space formed by the
iliac fascia, but that are situated rather in the subserous
connective tissue. This tissue is very extensive in the
iliac fossae, and favours the formation of large purulent
collections. Kcenig's experiments of injecting fluid
into this subserous space show that an abscess so
placed may spread in any direction by simply dissect-
ing off the peritoneum. Clinically, however, such col-
lections are greatly limited by gravity. They are apt to
remain in the iliac fossa, bulging out the abdominal
wall just above Poupart's ligament, and occupying the
angle formed by the union of the iliac and transver-
salis fasciae. In some cases they are disposed to
extend into the pelvis.

The abscess, when in the subserous tissue, is
brought in close contact with certain of the viscera,
especially with the csecum and sigmoid flexure, and
into these portions of the colon it may open. Thus, I
have seen a case of iliac abscess, due to pelvic necrosis,
that opened into the sigmoid flexure, and at the same
time discharged through sinuses about the groin. In
this case some pus passed by the anus, while on the
other hand some faecal matter escaped by the groin.
Retro-peritoneal abscesses in the pelvis (pelvic cellu-
litis) may mount up into the iliac fossae, may appear
as " iliac abscesses," and may ultimately discharge
themselves by many openings in the lower parts of
the anterior abdominal wall.

It may be well to note that the common and

Ch*p. xvi.] PSOAS ABSCESS. 293

external iliac vessels, the lymphatics and the ureters
are outside the iliac fascia, and rest upon its abdo-
minal surface, while the anterior crural nerves and
abdominal parts of the lumbar nerves are within
the osseo-aponeurotic space. Thus, the suprafascial
abscess may, with little difficulty, reach the thigh, by
following the iliac vessels ; while the subfascial
collection would pursue the anterior crural nerve.

A psoas abscess, or abscess within the fascial
sheath of the psoas muscle, is usually due to spinal
caries, although it may appear independently of that
disease. If the lumbar spine be involved, the matter
can pass directly into the substance of the muscle,
which it will more or less entirely destroy. If the mis-
chief be in the dorsal spine, the matter gravitates along
the front of the column until it reaches the diaphragm,
which it pierces by an inflammatory process. It is
now brought into relation with the heads of the psoas,
and has to pass through a narrow strait. "It is
prevented from enlarging on the fore-part by the liga-
merita arcuata, and at the back by the spine and lowest
rib ; hence, in order to proceed it has to force its way
in the line of the psoas muscle. That, however, can
only be done by penetrating into its interior. It ac-
complishes this, in the first place, by inserting its most
advanced part, like a wedge, between the two origins
(viz., from the bodies of the vertebrse, and from the
corresponding transverse processes) : it then splits and
distends the fibres, so as to form a cavity for the
reception of the pus .... and the psoas at length is
converted more or less thoroughly into an abscess"
(Shaw). The pus, following the muscle, at last reaches
the thigh, and usually points, just below the groin, to
the outer side of the femoral vessels.

The abscess, however, often shows much variation.
It may avoid the psoas, or leave it when once it has
entered it, and make its way into the lumbar region,

294 SURGICAL APPLIED ANATOMY. [Chap. xvi.

to find an exit in the loin. Or it may extend into the
iliac fossae, and open above the groin, or mount up over
the iliac crest, and discharge in the gluteal region.
It may pass along the inguinal canal, and be mis-
taken for a hernia. It may sink into the pelvis, and
may open into the bladder, or discharge itself through
the great sciatic foramen, or through a sinus in the
perineum. Some of the latter cases have led to much
confusion in diagnosis, since there would appear to be
little connection between caries of the spine and a
perineal abscess.

Lumbar region. — The muscles that form the
lateral and posterior walls of the abdomen, and that fill
in the interval between the iliac crest and the lowest
rib, are the external oblique and latissimus dorsi,
the internal oblique, the transversalis muscle and
fascia lumborum, the erector spinae and quadratus
lumborum.

The external oblique and latissimus dorsi muscles
are separated by a small triangular interval below (the
triangle of Petit), but above they overlap. The interval
between these two muscles may be represented by a
line drawn vertically, upwards from the middle of the
crest of the ilium. The outer edge of the quadratus
lumborum corresponds to this line, just above the iliac
crest ; but as the border of the muscle slopes upwards
and backwards, it may be about an inch behind the
line, at a point midway between the crest and the last
rib. The edge of the muscle is overlapped by the
internal oblique, and its inner half or two-thirds is
overlapped by the erector spinse. The subcutaneous
tissue in the lumbar region is very extensive, and is a
favourite locality for chronic abscess. The looseness
and extent of the tissue also permit of large extrava-
sations of blood. It is in the muscles and fascia
along the spine in this region that the rheumatic
affection known as lumbago has its seat.

Chap, xvii.] THE ABDOMINAL VISCERA. 295

Between the last rib and the iliac crest is stretched
the dense fascia lurnborum, the posterior aponeurosis
of the trans versalis muscle. It is pierced near the rib
by the last intercostal artery and nerve and near the
ilium by the ilio-hypogastric nerve and its accompany-
ing artery. It is along these structures that an abscess
may possibly find its way through the fascia in certain
cases. The fascia divides behind into three layers, to
enclose in definite spaces the quadratus and erector
spinse muscles. Within these spaces or compartments
suppuration may be for some time limited. A lumbar
abscess commencing in some adjacent part, as in the
spine or in the loose tissue around the kidneys,
usually spreads backwards by piercing the fascia
lumborum or the quadratus muscle. It then finds its
way through the internal oblique, and appears on the
surface between the external oblique and latissimus
dorsi muscles, and at the outer border of the erector
spinse. It should be noted that the quadratus muscle
is very thin, and offers little resistance to protrusions
from within, while a great part of the muscle is firmly
supported behind by the erector spirise.

CHAPTER XVII.

THE ABDOMINAL VISCERA.

THE peritoneum.— Certain of the viscera, as,
for example, the stomach, spleen, and small intestines,
are so closely invested with peritoneum that they could
not be wounded without that membrane being wounded
also. Inflammatory affections of such viscera are also
very apt to involve the peritoneum. Other organs,
such as the kidney, descending colon, pancreas, etc.,

296 SURGICAL APPLIED ANATOMY. [Chap. xvn.

are so imperfectly covered with the serous membrane
that a wound of those organs need not involve it,
nor need it be implicated in even extensive inflam-
matory changes. Large abscesses may, for instance,
form about the kidney and discharge themselves
through the skin without any peritonitis being
induced. Spontaneous perforation of the small intes-
tine must involve the peritoneum, while, on the
other hand, the caecum and descending colon may
become perforated and the matter escape into the
subserous tissue, without the serous membrane being
in any way involved. It is a strange fact that it is
singularly easy to set up inflammation of the perito-
neum if the membrane be approached from its inner
surface, but comparatively difficult if it be approached
from without. Thus a small puncture of the mem-
brane may, on the one hand, lead to fatal peritonitis,
while, on the other, it may be extensively torn
from its attachments (as in ligaturing the common
iliac artery from the side) without any peritonitis
following. Or, again, a little pus escaping on the
inner surface of the membrane may lead to inflam-
mation, while the outer surface may be bathed with
pus for a long while (as in large perityphlitic
abscesses) without any peritonitis being produced.
Inflammation of the peritoneum may lead to the
formation of a great variety of bands and adhesions,
beneath which pieces of intestine may be caught and
strangulated.

The peritoneum will allow of very considerable
stretching, if only that stretching be effected gradu-
ally. This is frequently seen in cases of gradual dis-
tension of the bowel, and in the formation of the
sac in hernia. Abrupt stretching of the membrane
leads to certain rupture of ifc. The parietal peri-
toneum may be ruptured by violence without damage
to any of the viscera.

Chap, xvii.] THE PERITONEUM. 297

The great omentum is, from its position,
very apt to be wounded. In small wounds of
the front of the belly it very often protrudes,
and acts as an excellent plug to prevent the
escape of other and more important structures.
It is often found in hernia, especially in umbilical
hernia, where it is almost constant. Its limits
vary, and it is said to generally incline to the left.
According to Paulet, omental hernise are much more
common upon the left side for this reason. The
omentum, like other parts of the peritoneum, is apt to
inflame, and to contract adhesions to the neighbouring
parts. These adhesions are often of the greatest
service in limiting inflammatory and hsemorrhagic
extravasations, by matting the bowels together and
forming spaces between them. In perforation of the
bowel from disease, an opportune adhesion of the
omentum over the aperture may prevent escape
of the intestinal contents. In hernise the omentum
generally contracts adhesions to the sac, and be-
comes irreducible, or it may form a kind of second
sac about the gut itself ("omental sac"). The end
of the omentum, by becoming adherent to distant
parts, as to the pelvic viscera, may form itself
into a firmly attached band, beneath which the
bowel may be fatally strangled. In like manner
the intestine has been strangulated through slits
and holes that have developed in the omentum,
usually as a result of inflammatory adhesions. When
the great omentum contains much fat it must act as
an excellent protection to the bowels, and must, as a
layer of non-conducting material, help to maintain
the equality of their temperature.

The mesentery extends obliquely from the attach-
ment of the transverse meso-colon, just to the left of
the second lumbar vertebra, to the right iliac fossa.
From this oblique direction it follows that, when.

298 SURGICAL APPLIED ANATOMY. [Chap. xvn.

haemorrhage takes place in the abdomen on the right
side of the mesentery, the blood is conducted into the
right iliac fossa, when on the left side into the pelvis.
This may explain the circumstance that collections of
blood are more common in the right than in the
left iliac fossa. Slits and holes are sometimes found
in the mesentery through which intestine has been
strangulated. Some of these apertures are apparently
congenital, while others are due to injury. If from
accident or from congenital defect a hole be formed
in one of the layers of the mesentery, it is possible
for a coil of the neighbouring small intestine to
find its way through that hole and occupy the retro-
peritoneal tissue between and behind the layers of the
mesentery. In this way is produced the " mesenteric
hernia " of Astley Cooper, who figures a case where
the whole of the small intestine was lost to view, it
having disappeared between the layers of the mesen-
tery. A like condition may be met with in the meso-
colon, and the whole of the small bowel has been
found to have passed through an aperture in one
layer of the meso-colon, to have occupied the retro-
peritoneal tissue, and to have entirely hidden itself
within a sac formed from the meso-colon. This con-
dition was named by Cooper " meso-colic hernia."
Hernise have also been described as occurring through
the foramen of Winslow.

THE STOMACH.

Above.
Liver, small omentum, diaphragm.

In front. Behind.

(From left to right) Transverse rneso-colon,

diaphragm, abdominal Sktrfim««*>l« pancreas, crura, solar
wall, liver. plexus, great vessels,

spleen, left kidney, and
capsule.

Below.
Great omentum, transverse colon, gastro- splenic oinentuni.

chap, xvii.] THE STOMACH. 299

When empty, the stomach lies at the back of the
abdomen, beneath the liver and some way from the
surface. When distended, the greater curvature is ele-
vated and carried forwards, the anterior surface is
turned upwards, and the posterior downwards (Fig.
34). The direction of the rotation depends upon
the fixity of the smaller curvature. When dis-
tended, the stomach is brought well against the
anterior belly wall, and may occupy the whole of the
middle line as far as the navel. Thus the stomach
is much more exposed to injury when full than
when empty. The cardiac orifice is situate behind
the seventh left costal cartilage, about one inch from
the sternum (Fig. 30). The pylorus, when the viscus
is empty, lies just to the right of the middle line, from
two to three inches below the ster no-xiphoid articula-
tion on the level of a line drawn between the bony ends
of the seventh ribs. When the stomach is distended
the pylorus may be moved nearly three inches to
the right (Braune). The cardiac orifice is on a level
behind with the ninth dorsal spinous process, the
pylorus with the twelfth dorsal spine (Fig. 31). A
horizontal line drawn between the extreme tips of the
tenth costal cartilages will about correspond to the
lower border of the non-distended stomach. The
f imdus of the stomach reaches on the left side as high
as the level of the sixth sterno-chondral articulation,
being a little above and behind the heart apex. The
close relations of the stomach to the diaphragm and
thoracic viscera serve in part to explain the shortness
of breath and possible palpitation of the heart, etc.,
that may follow upon distension of the organ (Fig. 33).
The near proximity of the heart to the stomach is
illustrated by a case where a thorn (of the Prunus
spinosa), half an inch long, had been swallowed, and
had then found its way through the diaphragm and peri-
cardium into the wall and cavity of the right ventricle.

300

SURGICAL APPLIED ANA TO MY. [Chap. xvn.

Fig. 30, — Diagram showing the Kelations of the Viscera to the Parietes

(Anterior view).
s, Stomach ; L, liver ; K, kidney ; TO, transverse colon ; o, umbilicus.

chap. xvii. i THE STOMACH. 301

On reference to the development of the stomach, it
will be seen that it is originally placed vertically in
the abdomen. This position may be to a great extent
maintained in adult life. The feats of an acrobat who
styles himself "the sword swallower," can hardly be
explained on any other supposition than that his
stomach is vertical ; but whether such condition is
congenital, or has been produced by the manoeuvre
he practises, must be an open question.

Although the mobility of the stomach is not con-
siderable, yet it is frequently found to occupy both
diaphragmatic and epigastric hernise.

The stomach has been frequently wounded. In
most cases a fatal result rapidly follows upon these
injuries, for the contents of the stomach escape
into the peritoneal cavity and set up an acute
peritonitis. The most certainly and rapidly fatal
cases, therefore, are those in which the stomach was
full of food at the time of the accident. The
empty stomach, being deeply placed and lying
against the posterior abdominal wall in a collapsed
state, is but little exposed to injury. A small punc-
tured wound of the stomach need not be followed by
escape of contents, since the loosely attached mucous
membrane may escape from the wound and effectually
plug it. The stomach has protruded through wounds
in the abdominal walls, and has been returned, with
no evil results following. In a few cases the belly
wall in front of the stomach has been wounded, the
viscus has protruded, its anterior wall has been
wounded by the same injury that penetrated the pa-
rietes, and a fistulous opening leading into the stomach
cavity has resulted. The best example of such cases
is afforded by the well-known instance of Alexis St.
Martin, the subject of so many physiological experi-
ments. In this man the abdominal parietes in front
of the stomach were torn away by a gunshot wound,

302 SURGICAL APPLIED ANATOMY. [Chap. xvn.

a part of the anterior wall of the stomach sloughed,
and a permanent fistula resulted. Dr. Murchison
reports the case of a woman in whom a gastric fistula
was produced by the continued pressure of a copper
coin worn over the epigastric region. This coin was
deliberately worn by the patient in order to excite
a lesion that would arouse the sympathy of her
friends. The pressure led to an ulceration that
finally opened up the stomach. In many cases the
fistula has been due to ulcerative diseases commencing
in the stomach itself and spreading outwards.

Some remarkable cases have been recorded
where foreign substances have been swallowed and
have lodged in the stomach. Certain of these
cases serve to illustrate the capacity of the stomach,
and among the most striking is an instance where
the viscus at death was found to contain thirty-one
entire spoon handles, each about five inches long, four
half -handles, nine nails, half an iron shoe-heel, a screw,
a button,* and four pebbles. The whole mass weighed
2 Ibs. 8 ozs. The patient was a lunatic. In spite of
the narrowness of the pylorus, large substances that
have been swallowed have been passed by the anus
without trouble. Among these may be noted a metal
pencil-case 4^ inches long, ten ounces of garden nails
and fragments of crockery- ware swallowed by a lunatic ;
a fork, a door-key, and other strange bodies. Needles
and similar sharp substances that have been swallowed
have travelled out of the stomach or bowels and have
found their way to the surface at various points in the
body. In a. patient under my care at the London
Hospital, I extracted from beneath the skin, near the
groin, a needle swallowed some months previously.
In a case reported in the Lancet, a needle was ex-
tracted from the middle of the thigh six months after
it had been swallowed, and like instances are recorded
elsewhere.

chap, xvn.] THE STOMACH. 303

Gastrotomy and gastrostomy. — Gastrotomy
consists in opening the stomach through the anterior
abdominal wall for the purpose of removing a foreign
body ; gastrostomy in opening the stomach in a like
situation with the object of establishing a gastric
fistula through which the patient may be fe'd in cases
where the gullet is occluded by disease. The un-
covered part of the stomach, accessible in these opera-
tions, is represented by a triangular area, bounded on
the right by the edge of the liver, on the left by the
cartilages of the eighth and ninth ribs, and below by a
horizontal line passing between the tips of the tenth
costal cartilages (Fig. 30). The incision in these opera-
tions must be situate in this triangle, and may be made
either parallel to, and about two fingers' breadth from,
the free border of the costse, or along the left semi-
lunar line. In the former incision the three flat
muscles of the abdomen are cut through. In gastros-
tomy the stomach is not opened at the time of the
operation, but is merely secured to the wound, and a
few days are then allowed to elapse so that adhesions
may form. At the end of this time the viscus is
opened. Much difnculty is occasioned by the loose-
ness of the mucous membrane, which is apt to pro-
trude at the wound by reason of its great laxity.

Resection of the pylorus. — The pylorus is
frequently the seat of cancer. As a means of re-
lieving the patient of this fatal disease, Billroth and
others have removed the whole of the diseased
pylorus, and have then united by sutures the cut
ends of the stomach and duodenum and closed the
abdominal wound. The situation of the cancerous
pylorus within the abdomen varies considerably, as
the diseased part is very apt to shift its position. It is
often found to have sunk down by its weight to a
point below the umbilicus, and to have contracted
adhesions to adjacent organs. The usual incision is

3°4

SURGICAL APPLIED ANATOMY. [Chap. xvn.

Fig. 31.- -Diagram to show the Belatkms of tlie Viscera to the Parietes

(Posterior view),
s, Stomach; L, liver; K, kidney; 8 p, spleen; E, rectum.

Chap, xvii.] THE SMALL INTESTINES. 305

transverse, or nearly so, is about four or five inches in
length, and is commonly made across the middle line
just above the umbilicus. The diseased part has to
be isolated and the omental connections of the right
end of the stomach freely divided. The vessels that
require most attention are the pyloric branch of the
hepatic artery and the gastro-epiploica dextra from
the same vessel. The cancer is excised, and the
cut end of the duodenum united to the cut edges of
the stomach, so as to re-establish the canal. The
details of the operation are very complicated, and
need not be here more fully dealt with, further than
to say that since the section of the stomach must be
much greater than that of the duodenum, the aperture
in the former viscus is united by sutures until the gap
left is equivalent in calibre to that of the divided
duodenum .

The small intestines. — The length of the small
intestine is about twenty feet, of which eight feet are
contributed by the jejunum and twelve by the ileum.
The length of the duodenum is about ten inches.
The division into jejunum and ileum is quite arbi-
trary. There is no one point where it can be said
that the jejunum ends and the ileum commences.
When the small intestines are exposed by accident or
operation, it is often difficult, especially when there
is abdominal disease, to recognise the upper from the
lower part of the gut. It may be noted, however,
that the coils of the jejunum occupy mainly the left
lumbar and left iliac regions, and a part of the
umbilical area, while the ileum occupies rather the right
lumbar and iliac regions, the hypogastric area, and a
part also of the umbilical. The jejunum is wider
than the ileum (its diameter being a quarter of an inch
greater than that of the ileum), and its coats are
thicker and more vascular. If the gut be empty, and
can be rendered translucent by being held against a
u

306 SURGICAL APPLIED ANATOMY. [Chap. xvn.

light, the lines of the valvulse conniventes can be well
seen. These folds are large and numerous in the
jejunum, but become small and scanty in the upper
ileum, and are wanting in the lower third of that
bowel.

Injuries to the jejunum are more serious than
are those to the ileum, since an intestinal lesion
is (other things being equal) the more serious the
nearer it approaches to the stomach. The fatality of
umbilical hernise probably depends in part upon the
fact that the contained bowel is usually jejunum. \ Of
all the viscera the small intestines are the most exposed
to injury, and at the same time it must be noted that by
their elasticity, and by the ease with which their coils
slide over one another and so elude the effects of
pressure, they are the best adapted to meet such
injuries as contusions and the like. A minute punc-
tured wound of the small gut does not lead to extra-
vasation of contents. The muscular coat contracts
and closes the little opening. Thus, in excessive
tympanitis the bowels are often freely punctured in
many places with a fine capillary trochar, to allow the
gas to escape, without any evil resulting. A case
of intestinal obstruction of sixteen weeks' duration
is reported, in which the abdomen was punctured
150 times (Boston Med. Journ.). If the wound
be a little larger the loose mucous membrane be-
comes everted or protruded through the wound and
effectually plugs it. Gross found that a longitudinal
cut in the small bowel two and a half lines in length
was immediately reduced to a wound one and three-
quarter lines in length by muscular contraction,
and that the eversion of the mucous membrane in
addition to this contraction entirely sealed the
opening.

Owing to the greater power of the circular layer
of muscle a longitudinal wound gapes more than a

Chap, xvii.] THE SMALL INTESTINES. 307

transverse, and, in consequence of the greater mus-
cular development of the jejunum, wounds of that part
gape more than do those of the ileum. Transverse
wounds gape most when inflicted across the free
border of the gut, since in that place the longitudinal
muscular fibres are thickest.

In one remarkable case a man was stabbed in
the belly. It was subsequently found that there
was a small puncture in the ileum, which had
been plugged by the mucous membrane, and further
secured by recent lymph. The man did well until
the fourth day, when he died somewhat suddenly.
It was then found that an intestinal worm (ascaris
lumbricoides) had worked its way through the
wound, breaking down the adhesions, and had escaped
into the peritoneal cavity. Extravasation followed,
and thus the worm was the immediate cause of the
man's death.

Any part of the small gut may be ruptured
by severe contusions. The calibre of any piece of
the intestine depends mainly upon the condition of
its muscular wall. In peritonitis and in certain other
conditions the muscular coat is paralysed and the
bowel becomes intensely dilated by gas (tympanitis).

The second and third parts of the duodenum are the
most fixed portions of the small bowel, and the only
parts that have not a complete peritoneal investment.
The termination of the duodenum is held in place
by a strong fibrous band that descends from the left
crus, so that, no matter how much the gut may be
disturbed by distension, that part will still retain a,
constant position. It will be understood that the
duodenum, if approached from behind, may be
wounded without injuring the peritoneum, since it has
a large non-peritoneal surface (Fig. 33). On account of
their fixed position the second and third parts of the
duodenum are never herniated. In connection with

308 SURGICAL APPLIED ^x ATOMY. [Chap. xvn.

the spread of disease by continuity of tissue, it is well
to note that these two parts of the bowel are only
separated by connective tissue from the aorta, vena
cava, spine, renal vessels, left kidney, back of the
hepatic flexure of the colon, and the head of the
pancreas. In the duodenum are Brunner's glands,
which are sometimes the seat of a perforating ulcer in
cases of burn. They are mostly seated in the first
part of this bowel, and the perforation, therefore,
usually opens into the peritoneal cavity, the first part
of the gut being almost entirely covered by peritoneum.

The ileum is the part of the intestine that is the
most frequently found in external hernise. It is also
the part that most usually is involved in cases of
strangulation by internal bands, and by the borders of
abnormal slits in the mesentery, etc. From one to
three feet from the end of the ileum is sometimes
seen a diverticulum (Meckel's) that represents the
remains of the vitello-intestinal duct. This diverti-
culum usually exists as a tube of the same structure as
the intestine. Its length varies. It may sometimes
extend as a patent tube as far as the umbilicus. It is
more often but a few inches long, and may then end in a
free conical or globular extremity, or in a fibrous cord.
This diverticulum may cause intestinal obstruction in
many ways. Its end may contract adhesions, and be-
neath the bridge thus formed a loop of bowel may be
strangled. It may twist itself about a piece of intes-
tine so as to form a knot around it. It may, from its
adhesions, so drag upon the ileum as to cause " kink-
ing " of the tube at its point of origin. In more than
one case it has been found in an external hernia.

Owing to the presence of the ileo-csecal valve, it is
about the ileo-csecal region that obstruction from
foreign bodies usually occurs. Foreign bodies that have
been swallowed, as well as immense gall-stones that
have passed from the gall bladder to the small gut

Chap, xvii.] THE SMALL INTESTINES. 309

by a direct ulcerative process, have been lodged here,
and have caused fatal results. Some most remarkable
substances have, however, been passed with safety
through the valve ; and, in addition to those mentioned
when speaking of the stomach (page 302), instances may
be given where an irregular gold plate, fixing several
teeth and provided with one or two hook-like processes,
has been swallowed and passed per anum without
trouble. Other substances are not so easily passed.
Thus, in the intestines of one lunatic were found three
cotton reels, two bandages partly unrolled, some
skeins of thread, and a pair of braces. It is in the
ileo-csecal region, moreover, that intussusception most
frequently occurs. In this condition one part of the
bowel is prolapsed, or " telescoped," into another,
and more or less obstruction ensues. In the
present locality the narrow ileum is prolapsed or
intussuscepted into the capacious caecum. Sometimes
it is prolapsed through the valve, while in other
instances the ileum and valve sink into the colon
entire, the valve forming the summit of the "intus-
susceptum." By a gradual increase of the condition it
may at last happen that the intussuscepted bowel will
reach the ileum ; and the ileo-csecal valve has, in fact,
been recognised protruding from the anus.

liaparotomy.— In this procedure the abdomen is
opened from in front for the purpose of exploration,
or for the relief of a piece of bowel strangulated by a
band, and under certain other circumstances. It much
more frequently concerns the small bowel than the
large. The incision is usually made in the middle
line below the umbilicus, and a cut from three to
four inches long is usually found to be sufficient. It
may be made in either of the semi-lunar lines or
over any spot especially indicated by the disease.
Enterotomy is the operation of opening the small
intestine above some obstruction that threatens to be

310 SURGICAL APPLIED ANATOMY. [Chap. xvn.

fatal. The incision is made in one or other iliac
region parallel to Poupart's ligament and some little
way above it, and to the outer side of the epigastric
artery. The cut, which is about three inches in
length, extends through the three flat muscles of the
abdomen ; the peritoneum is incised, a knuckle of
small intestine is secured to the wound and is then
opened.

Resection. — Portions of the small intestine have
been resected with success for various diseased condi-
tions. In one case more than two yards of the small
intestine were cut away, and the patient (a young
woman) made an excellent recovery.

The large intestine. — From the csecum to the
sigmoid flexure, this portion of the bowel is accessible
to pressure except at the hepatic and splenic flexures,
which are deeply placed. The hepatic flexure is
under the shadow of the liver, and the splenic curve,
which reaches a higher level, is behind the stomach.
The position of the transverse colon can often be well
marked out. Tt crosses the belly transversely, so that
its lower border is on a level with the umbilicus (Fig.
30). In cases of faecal accumulation, the outline of the
colon, with the exception of the two flexures above
named, may be distinctly defined. In distension of the
small intestine the belly tends to present the greatest
degree of swelling in front, and about and below the
navel. In distension of the larger gut, the front of
the abdomen may remain (for a while at least) com-
paratively flat, while the distension will be most
obvious in the two flanks and in the region just above
the umbilicus. Tumours of the transverse colon, and
of the lower two-thirds of the ascending and descend-
ing colon, can be well defined, even when of moderate
size, and in cases of intussusception the progress of the
mass along the colon can often be traced with great
ease, and the effects of enemata and other methods of

chap, xvii.) THE COLON. 311

reduction carefully watched. The diameter of the large
intestine (excluding the rectum) gradually diminishes
from the caecum to the sigmoid flexure, the diameter
of the former being about two and a half inches, of the
latter one and a half inches. The narrowest part of this
segment of the bowel is at the point of junction of the
sigmoid flexure with the rectum, and it is significant
that it is at this point that stricture is the most
common.

The ccecum is said to be rudimentary in man and
in the carnivora. In herbivorous animals it is of
great size, and appears to serve as a reservoir for
the elaboration and absorption of food, since its
removal causes great emaciation. In man, therefore,
the caecum has been said to exist as an anatomical
protest against vegetarianism. The caecum is covered
in front, below, and at the sides with peritoneum,
the lower rounded end being completely invested,
while its posterior surface is connected by a great-
deal of loose areolar tissue with the iliac fascia.
It is in this loose tissue that inflammation spreads
in cases of perityphlitis, an inflammation that
usually originates in the caecum, and is often
due to a perforation on the posterior surface of that
part of the colon. The caecum when first developed
has an extensive mesentery. This condition may
sometimes be found in the fcetus at birth, and may
persist during life. The meso-caecum may be long
enough to allow the caecum to be herniated at the
umbilicus or even on the left side.

Foreign bodies that have been swallowed are very
apt to lodge in the caecum, and to cause ulceration
and perforation of that bowel by their impaction. It
is significant that the otter has no caecum. This
animal lives largely on fish, and must swallow a
number of fish-bones. Had it a caecum it would pro-
bably soon fall a victim to perityphlitis and its effects.

312 SURGICAL APPLIED ANATOMY. [Chap. xvn.

Intestinal calculi and concretions are also more often
met with in the caecum than in any other part of the
bowel. In distension of the colon from obstruction the
caecum suffers the most severely, and appears to bear the
brunt of the pressure exercised from within. The
caecum has been ruptured by forcible enemata admini-
stered per rectum, while the rest of the colon has re-
mained intact. In many cases of great fsecal accumula-
tion death has been due to perforation of the caecum as
an effect of extreme pressure, and in less severe cases
the peritoneum over the caecum has been found to be
ruptured, while it has remained sound over the re-
mainder of the larger bowel. This part of the intes-
tine is susceptible of enormous distension, provided
that it be gradually effected, and in certain instances
an engorged caecum has been found to occupy a
large part of the abdominal cavity. When the ab-
domen is opened in any doubtful case of intestinal
obstruction the condition of the caecum is of great
value in pointing to the seat of the obstacle. In
closure of the colon it will be found greatly distended,
while in obstruction of the small gut it will be empty,
or at least in a normal condition.

The tip of the vermiform appendix may adhere to
a neighbouring peritoneal surface, and thus form a
" band," beneath which a piece of the small gut may be
strangled. It is favourably placed for the accumu-
lation of intestinal concretions and in it foreign bodies
are apt to lodge. For these and other reasons it
happens that ulceration of the appendix is a frequent
cause of perityphlitis.

As regards the colon generally, the tendency to
stricture increases as one proceeds downwards from
the caecum to the anus. A stricture is frequent in
the descending colon, and is still. more common at the
point of junction of the sigmoid flexure with the
rectum. In the ascending colon it is comparatively

Chap, xvii.] THE COLON. 313

rare. When gradually distended the colon may as-
sume enormous dimensions, and it will be readily
understood that in some cases of great faecal accumu-
lation the thoracic organs may, with certain abdominal
viscera, be displaced. In one case, for example, the
heart was so displaced by the distended colon that
the apex beat was found to be one and a half inches
above and one inch to the inner side of the left
nipple. When the fsecal collection had been removed
it returned to its normal position. Thus it happens
that a distended colon is often associated with short-
ness of breath, with palpitation, and other thoracic
symptoms.

The right-hand part of the transverse colon is in in-
timate relation with the gall bladder, and is commonly
found to be bile-stained after death. In some cases
where gall stones have been lodged within the gall
bladder, the walls of that structure have ulcerated
from pressure, the ulceration has involved the sub-
jacent transverse colon, and thus a fistula has been
established between the gall bladder and the gut,
through which large stones have been passed. Hepatic
abscesses also have discharged themselves through the
transverse colon.

The anatomical arrangement of the sigmoid flexure,
together with its great mobility, render it more
liable to obstruction by twist or volvulus, than is any
other part of the intestinal tube. The condition that
especially predisposes to volvulus is a narrow root to
the sigmoid meso-colon, whereby the two ends of the
loop of gut are brought close together, and thus a
pedicle is formed, which may readily be twisted upon
its own axis by any rotation of the loop of bowel. In
cases of congenital absence, or deficiency of the rectum,
it is commonly advised that the sigmoid flexure be
opened in the groin and an artificial anus established
there. This operation, known as Littre's operation,

314 SURGICAL APPLIED ANATOMY. [Chap. xvn.

is, it must be confessed, not very successful. One
difficulty has been said to depend upon the uncertain
position of the sigmoid flexure in cases of congenital
deformity, it being sometimes on the right side and
sometimes in the pelvis at the middle line. Surgeons
have, indeed, advised that in these cases the right groin
be always made the seat of operation, since the sigmoid
flexure may be found there, and if it is not present in
that place there is at least the caecum that may be
opened. This procedure would avoid the inconve-
nience of opening the left iliac region and finding it
unoccupied by bowel. The frequency with which the
sigmoid flexure is misplaced in young infants is shown
in the following record. In 150 autopsies on young
infants, Bourcart found the sigmoid flexure on the left
side in 111 cases, on the right in 33, and in the pelvis
in 6. In 134 autopsies by Giraldes, the gut was
found in its proper place in 114 instances ; and
out of 100 like post-mortem examinations on
young infants, Curling found it on the left side in
85 cases.

Congenital malformations of the colon. —
These are of moment with regard to operative pro-
cedures. It may be very briefly said, that in the foetus
the small bowel occupies at one time the right side of
the abdomen, while the large gut is represented by a
straight tube that passes on the left side vertically
from the region of the umbilicus to the pelvis. The
caecum is at first situated within the umbilicus, and then
ascends in the abdomen towards the left hypochon-
drium. It next passes transversely to the right hypo-
chondrium/and then descends into the corresponding
iliac fossa. It may be permanently arrested at any part
of its course. Thus the caecum may be found about the
umbilicus, or in the left hypochondriac region (the
ascending and transverse parts of the colon being
absent), or it may be found in the right hypochondrium,

chap, xvii.i THE COLON. 315

the ascending colon only being unrepresented.* The
whole of the large intestine has at one time an exten-
sive mesentery, and in some rare cases this condition
may persist throughout life.

Lumbar colotomy. — The operation so named
consists in opening the colon in the loin behind the
peritoneum, for the purpose of establishing an arti-
ficial anus. The operation is performed, when possible,
upon the left side, in preference to the right, inasmuch
as the descending colon is nearer to the anus, is
more fixed than is the ascending colon, and has the
larger non-peritoneal surface. A meso-colon, moreover,
is more commonly met with in the ascending than in
the descending part of the large intestine. The position
of the descending colon may be represented by a line
drawn vertically upwards from a point half-an-incli
behind the centre of the iliac crest. In performing
left lumbar colotomy an ink line may be drawn
vertically upwards from the centre of the crest of
the ileum. It will hit the outer end of the last
rib. An incision is made across the centre of
this line parallel to the last rib, and so planned
that the centre of the incision corresponds to the
centre of the line. The superficial tissues having been
incised, the following structures are then divided
in layers in the following order: (1) The latissimus
dorsi and external oblique muscles to an equal extent.
(2) The internal oblique in the entire length of the
incision. (3) The fascia lumborum, with a few of the
most posterior fibres of the transversalis muscle.
(4) The transversalis fascia. The quadratus lumborum
will be exposed in the posterior inch or so of the incision,
and usually does not need to be cut. At the seat of
the operation the descending colon occupies the angle

* See a valuable and exhaustive paper on the subject of these
malformations in the Brit. Med. Jour. (vol. ii., 1882, p. 574), by
Mr. C. B. Lockwood.

316 SURGICAL APPLIED ANATOMY. [Chap. xvn.

between the psoas and quadratus lumborum muscles,
and the non-peritoneal surface is exactly represented
by that part of the bowel that faces this angle

G' a

Fig. 32.— Horizontal Section through the Body at the Level of the

Umbilicus. (Ajter Braune.)

a, Spine of the fourth lumbar vertebra ; 6, disc between third and fourth verte-
bne; c, umbilicus; d, quadratus lumborum; e, psoas ; /, external oblique,
with internal oblique and transversalis muscles beyond; g, rectus; h, de-
scending colon ; i, transverse colon ; j, aorta ; k, inferior vena cava ; I, ureter.

(Fig. 32). Thus, if during the operation the curved
finger be placed in this angle, and the patient be
rolled over to the left side, the bowel that falls
into the finger cannot well be other than the descend-
ing colon. The gut is drawn forwards, stitched to
the wound, and opened by a transverse cut. The

chap, xvii.] THE COLON. 317

width of the non-peritoneal surface varies from four-
fifths of an inch to an inch in the empty state, and
may attain to two inches or more in the distended
condition (Braune). The part of the descending colon
usually opened is the highest portion of that bowel, so
that the finger can often be thrust into the transverse
colon, or the opening of that intestine can be seen.
In this, or in other circumstances, the large bowel may
be distinguished from the small by its.sacculi, its three
longitudinal muscular bands, and its appendices epi-
ploicse. As regards dimensions, the small intestine
may, especially in cases of obstruction, be much larger
than the so-called large intestine. When empty, the
diameter of the descending colon is about equal to that
of the jejunum, the measurement in the two cases
being about one and a half inches. The average dia-
meter of the ileum is one and a quarter inches, and
of the caecum and commencing colon two and a half
inches.

Lumbar colotomy is often performed through a
vertical or oblique incision in the place of the one just
given. The operation does not materially differ from
that described, when it is performed on the right
side.

Colectomy consists in resecting a portion of either
the ascending or descending colon that is the seat of a
carcinomatous or other stricture. It is most con-
veniently performed in the lumbar region, and then
involves the formation of an artificial anus that will
probably be permanent. Colectomy, may, however, be
carried out through an incision in the middle line ; in
such a case the ends of the divided bowel are united,
and the abdominal wound closed.* Lumbar colectomy
may be performed through any one of the incisions
practised in colotomy.

* See " Resection of Portions of Intestine," by the author.
Trans. Royal Med.-Chir. Soc., 1882.

318 SURGICAL APPLIED ANATOMY. [Chap. xvn.

The liver.— :The liver is moulded to the arch of the
diaphragm, and lies over a part of the stomach (Fig.
34). The convex surface is protected on the right side
by the ribs, from the seventh to the eleventh inclusive,
and in front by the xiphoid cartilage and the costse
from the sixth to the ninth inclusive, the diaphragm
being interposed. The diaphragm separates the liver
from the thin margin of the base of the right lung,
which descends in front of it. It extends to the leit
about one and a half inches beyond the left margin of
the sternum. In the middle line the liver lies close
beneath the skin in front of the stomach, and reaches
about half way between the xiphoid cartilage and the
navel. The lower edge, as it crosses the subcostal angle,
is represented by a line drawn from the ninth right to
the eighth left costal cartilage (Quain) (Fig. 30). In
the erect posture the lower edge on the right side is
about half or quarter of an inch below the margins of the
costal cartilages. In the recumbent position the liver
ascends about an inch, and is entirely covered by the
costse, except at the subcostal angle. It descends also
in inspiration and rises in expiration. " The extent of
the liver upwards, if traced on the surface of the body,
is indicated by a line crossing the mesosternum close to
its lower end, and rising on the right side to the level
of the fifth chondrosternal articulation, and on the
left to that of the sixth" (Quain). Behind, the liver
comes to the surface below the right lung, at a part
corresponding, both in position and width, to the tenth
and eleventh dorsal vertebrae. On the extreme right,
the liver descends to the level of the second lumbar
spine (Figs. 31 and 33). The fundus of the gall
bladder approaches the surface behind the ninth costal
cartilage, close to the outer border of the right
rectus muscle.

The liver is more often ruptured from contusions
than is any other abdominal viscus. This is explained

Chap, xvii.] THE LIVER. 319

by its large size, its comparatively fixed position, and its
great friability of structure. Death, in such injuries,
usually ensues from haemorrhage, since the walls of
the portal and hepatic veins, being incorporated with
the liver substance, are unable to retract or to collapse.
The hepatic veins also open direct into the vena cava,
and being unprovided with valves, could allow of the
escape of an immense quantity of blood, if any retro-
grade current were established. It is possible for the
liver to be ruptured without the peritoneal coat being
damaged. Such injuries may be readily recovered
from. The liver presents, behind, a fairly extensive
non-peritoneal surface, at which rupture or wound may
occur without extravasation into the abdominal cavity.
From the relation of the liver to the right lower ribs,
it follows that this viscus may be damaged when the
ribs are fractured, and in some cases the broken ends
of the bones have been driven through the diaphragm
into the liver substance. Stabs through the sixth or
seventh right intercostal space, over the liver region,
would wound both the lung and the liver, would involve
the diaphragm, and open up both the pleural and peri-
toneal cavities. The intimate relation of the liver to the
transverse colon is illustrated by a case where a tooth-
pick, four inches in length, was found in the substance
of the liver. It had worked its way there, from the
colon, along an abscess cavity that connected the two
viscera. The relation of the liver to the heart may be
illustrated by a case still more remarkable. In this
instance, a loose piece of liver, weighing one drachm, was
found in the pulmonary artery. The patient had been
crushed between two waggons, the liver was ruptured,
and the diaphragm torn. A piece of the liver had been
squeezed along the vena cava into the right auricle,
whence it had passed into the right ventricle, and so
into the pulmonary artery. The heart itself was quite
uninjured. Portions of the liver may protrude through

320

SURGICA L APPLIED ANA TOMY. [Chap. xvn.

Fig. 33. — View of some of the Abdominal Viscera from behind

(Riidinger).

a, Thoracic aorta; 6, oesophagus ; c, common carotid artery and internal jugular
vein ; d, root of right lung ; e, inferior vena cava ; /, spleen ; g, stomach, and
to its right the liver ; h, pancreas ; i, descending part of duodenum (opened) ;
j, superior mesenteric vein joined by splenic above. ; k, ascending colon ; I, de»
scendmg colon ; m, superior hteniorrlioidal vein joining inferior mesenteric.

chap, xvii.] THE LIVER. 321

abdominal wounds, and are usually easy to reduce. In
one instance of such protrusion the surgeon did not
find the reduction easy, so he placed a ligature round the
projecting part of the viscus, and then cut this obstinate
portion of the liver off. The patient recovered.

From a reference to the relations of the liver, it
will be readily understood that an hepatic abscess may
open into the pleura, and in some cases, indeed, the
pus from the liver has been discharged by the bronchi.
Thus, it has been possible for a patient to cough up
some portion of his liver, although, of course, in a very
disintegrated and minute form. Hepatic abscess may
also readily open into either the duodenum or the trans-
verse colon. The liver is very frequently the seat of
the secondary abscess of pyaemia, and, according to Mr.
Bryant's statistics, abscesses in this viscus are more
common after injuries to the head, than after injuries
elsewhere. They are rare in pyaemia following affec-
tions of the urinary organs, and are equally rare in the
pyaemia after burns. The liver is more often the seat
of hydatid cyst than are all the viscera taken together.
The cyst may discharge itself externally, or into the
pleural or peritoneal cavities, or into any adjacent part
of the intestine.

The gall bladder and the bile duct have been
ruptured alone without rupture of the liver. The
injury is rapidly fatal, owing to the escape of bile into
the peritoneal cavity. The gall bladder is often occu-
pied by gall stones. These concretions are composed
mainly of cholesterin, and vary in size from a hemp
seed to a hen's egg. Although the common bile duct
is only about three lines in width, it is remarkable to
note what comparatively large stones have been passed
along it Gall stones have suppurated out through the
anterior belly wall, and have been removed from
abscesses in the parietes. Thus Dr. Burney Yeo reports
a case where more than one hundred gall stones were

322 SURGICAL APPLIED ANATOMY. [Chap. xvn.

discharged through a spontaneous fistula in the hypo-
gastric region, five inches below the umbilicus. In cases
where the bile duct is occluded by gall stones, or by
other causes, the gall bladder may become enormously
distended, and may form a tumour extending some way
beyond the umbilicus. For the relief of this condition,
cholecystotomy, or incision into the gall bladder, has
been performed. In this operation, the incision or
puncture is made over the most prominent part of the
tumour.

THE SPLEEN

In front.

Stomach.

Splenic flexure of colon.

Outer side. Inner side.

Diaphragm. €2 w»l *»*»*! Stomach.

9th to llth ribs between Pancreas.

axillary lines. L. kidney and capsule.

The spleen. — The spleen most closely approaches
the surface in the parts covered by the tenth and
eleventh ribs. Above this it is entirely overlapped
by the edge of the lung. It is in all parts separated
from the parietes by the diaphragm. " It lies very
obliquely, its long axis coinciding almost exactly with
the line of the tenth rib- Its highest and lowest points
are on a level, respectively, with the ninth dorsal and
first lumbar spines ; its inner end is distant about an
inch and a half from the median plane of the body,
and its outer end about reaches the mid-axillary line "
(Quain) (Figs. 31, 33, and 34).

Injuries. — Although extremely friable in structure,
the normal spleen is not very frequently ruptured.
Its connections, indeed, tend to minimise the effects of
concussions and contusions. It is swung up by the
peritoneum, rests upon the elastic costo-colic fold, and

Chap, xvii.] THE SPLEEN. 323

is protected by the stomach and lungs to a considerable
extent. When the spleen, however, is enlarged, it is
very readily ruptured, and often by quite insignificant
violence. Thus, several cases have been recorded of
rupture of an enlarged spleen by muscular violence.
For instance, a woman ruptured her spleen in an

Fig. 34.— Horizontal Section through Upper part of Abdomen
(Riidmger).

a, Liver ; 6, stomach ; c, transverse colon ; d, spleen ; e, kidneys ; /, pancreas ;
g, inferior vena cava ; fe, aorta with thoracic duct behind it.

attempt to save herself from falling, and another in
springing aside to avoid a blow. The patients in each
instance were natives of India, and the latter case
gave rise to a charge of homicide. The spleen being ex-
tremely vascular, it follows that ruptures of the viscus
are usually, but not necessarily, fatal from haemorrhage.
It is well to note, in connection with this matter, that
the spleen contains most blood during digestion. A
case is reported, however, of a boy, who met with an
accident just after dinner, and who managed to walk

324 SURGICAL APPLIED ANATOMY. [Chap. xvn.

some distance, although his spleen, as the autopsy
revealed, was separated into three portions. He lived
some days. In severe fractures of the ninth, tenth,
and eleventh ribs, the spleen may be damaged and
lacerated.

The capsule of the spleen contains muscular tissue,
and must possess some contractile power. This fact
may serve to explain cases of recovery from limited
wounds of the organ, such as small gunshot wounds.
In such lesions the capsule may contract and greatly
narrow the hole in the viscus, while the tract of the
bullet or knife may become filled with blood clot, and
the bleeding thus be stayed.

The spleen may be greatly enlarged in certain
diseased conditions. The hypertrophied spleen may
attain such dimensions as to fill nearly the whole
abdomen, and in one case a cystic tumour so com-
pletely occupied both iliac fossae, that it was mistaken
for an ovarian cyst, and the operation for ovariotomy
was commenced. It is said that the enlarged spleen,
in its earlier stages, encroaches upon the thoracic
cavity, relatively more in the child than in the adult.
This is explained by the statement that the costo-colic
fold, upon which the spleen rests, is much more
resisting in the young than it is in those of more
mature age.

Extirpation of the spleen has been very
successful in cases of abdominal wounds with pro-
trusion of the viscus. It has also been performed
with good results in many cases of hypertrophied
spleen. The operation is not considered justifiable in
cases of leucsemic enlargement of the organ, it having
proved invariably fatal in such instances. In cases of
wounds with protrusion, the spleen is, of course, re-
moved through the wound. In other instances the
incision is usually made in the middle line, the most
convenient being one so arranged that the umbilicus

Chap, xvii.] THE PANCREAS. 325

corresponds to the centre of the cut. The viscus is
then slowly pressed out of the wound. The only
difficulty is with the gastro-splenic ornentum, which
has to be divided and its vessels secured.

The pancreas lies behind the stomach, in front
of the first lumbar vertebra. It crosses the middle
line on a level with a point about three inches above
the umbilicus. In emaciated subjects, and when the
stomach and colon are empty, it may sometimes be
felt on deep pressure. It is in relation with many
most important structures, but presents but little
surgical interest (Figs. 33 and 34). It has, I believe,
never been ruptured alone, and it could scarcely be
wounded without the wound implicating other and
more important viscera. It has been found herniated
in some very rare cases of diaphragmatic hernia, but
never alone.

It may become invaginated into the intestine, and
portions of the gland have sloughed off and been
passed in the stools. In resections of the pylorus
and spleen it is undesirable that a ligature be placed
on any part of the pancreas during the operation.
There are two reasons for this precaution : " First, we
know that after ligature of the parotid (a gland of like
character to the pancreas) great swelling and numer-
ous small abscesses not infrequently form, leading
to necrosis of portion of the gland ; secondly, there is
some fear that (in pyloric resections) the secretion
escaping from the pancreas may dissolve the cicatrix
of the stomach by its peptonising properties" (Billroth).

The common bile-duct is covered by, or included
in, the head of the pancreas. It thus happens that
in carcinoma of this part of the gland the duct may
become entirely occluded and jaundice result. Or the
duodenum and even the colon may be more or less
obstructed by pressure, or the neighbouring vessels
be closed.

326 SURGICAL APPLIED ANATOMY. [Chap. xvn.

THE KIDNEY.

Right.

Under surface of liver.
Duodenum. Commence-
ment of transverse colon.
Ascending colon.

In front.

Left.

Fundus of stomach.

Descending- col n.

Pancreas.

Externally.
(On left side) Spleen.

Behind.

Lower part of arch of diaphragm.
Quadrat us luinborurn. Psoas.

The kidneys are deeply placed, and cannot be felt
and distinctly identified when normal. They are
most accessible to pressure at the outer edge of the
erector spinse, just below the last rib. The right
kidney lies about three-quarters of an inch lower
down than does the left ; but even the lower end of
the right gland barely reaches to the level of the
umbilicus. The upper end of the left kidney is on a
level with the eleventh dorsal spine behind, the right
being a little lower (Figs. 30 and 31). The inferior
extremity of the left gland is about two inches from
the iliac crest, that of the right about one and a
quarter inches. The hilus lies about two inches from
the middle line, and is opposite to the first lumbar
spine. The kidney has been reached by the finger
when the entire hand has been introduced into the
rectum, but the procedure has failed to prove of much
use in diagnosis.

The anterior surface is but slightly covered by
peritoneum, being only in contact with that membrane
in such parts as are not in relation with the cellular
tissue at the back of the colon and at the back of
the duodenum or pancreas. The external border
is more closely in connection with the peritoneum,
while the posterior surface is quite devoid of that

327

' Fig. 35. — View of the Kidneys, etc., from behind (Riidinger).

;, Pharynx ; b, innominate artery ; c, subclavian artery ; d, oesophagus, with the
aorta and thoracic duct on one side and the azygqs vein on the other ; e,
lungs ; /, diaphragm : y, kidney ; h, on peritoneum, points to spermatic vessels
crossed by ureter; i, os innominatum above sacro-iliac-syncbondrogjs ; j,
psoas : k, gluteus medius ; I, gluteus maximus ; m, rectum and sup. haemorr-
hoidal artery.

328 SURGICAL APPLIED ANATOMY. [Chap. xvn.

membrane (Figs. 34 and 35). Rupture of the
kidney is more often recovered from than is a
like lesion of any other of the more commonly
injured abdominal viscera. This depends upon its
extensive non-peritoneal surface, whereby the extrava-
sation of blood and urine that follows the accident is
very often entirely extra-peritoneal. The gland may
be readily wounded from behind or from the loin,
without the peritoneum being injured. When the
spine is much bent forwards, the kidney lies in the
angle of the bend, at a part where the flexion of the
column is the most acute. In. extreme flexion, there-
fore, of the spine it may be squeezed between the
ilium and the lower ribs. Thus hsematuria is not
uncommon after injuries to the back, associated with
extreme bending of the spine forwards, as when a
heavy weight falls upon the bowed shoulders.

The kidney is embedded in a large quantity of
loose fatty tissue, and suppuration extending in this
tissue constitutes a perinephritic abscess. Such an
abscess may be either due to disease of the kidney
itself, to affections of the adjacent parts (spine, colon,
etc.), or to injuries. The pus is at first in front
of the quadrat us lumborum, and then usually makes
its way through that muscle or through the lumbar
fascia. It then presents itself at the outer edge of the
erector spinse, having passed between the adjacent
borders of the external oblique and latissimus dorsi
muscles. It may, however, spread into the iliac
fossa, or extend into the pelvis along the loose
connective tissue behind the descending colon and
rectum, or open into the colon or bladder, or even
into the lung. Most rarely of all does it perforate
the peritoneum. Renal abscess usually opens upon
the non-peritoneal surface of the gland. It may open
into the adjacent colon. In one case a renal abscess,
due to stone, made its way from the right kidney into

Chap, xvii.] THE KIDNEY. 329

the pyloric end of the stomach, so that a communi-
cation was established between those two organs.
Movable kidney. — The kidney is fixed in position
mainly by the tension of the peritoneum that passes
over it, and that is connected with the fatty tissue
supporting the gland. If this fatty tissue be absorbed
for any reason, the kidney can be readily moved about
and displaced in the subserous tissue ; the peritoneum
at the same time becomes lax, and the gland by its
own weight can drag still further upon it. Moreover,
a laxity of the peritoneum from any cause may loosen
the firm connections of the kidney and allow the
organ to become more movable. Thus, the movable
kidney is often met with in badly nourished subjects,
and especially in those who have become emaciated
by disease. It is far more common in women
than in men. In the former sex, the influence of
pregnancy appears to have especial effect, acting,
probably, by dragging upon the peritoneum and by
loosening its connections, as well as by inducing, after
delivery, a general laxity of the abdominal walls.
The movable kidney can, of course, only be moved
within a segment of a circle whose radius corresponds
to the length of the renal vessels, and its displacement
is seldom considerable. There is a congenital form of
movable kidney where the gland is suspended in a
peritoneal fold of its own, the meso-nephron, and
where the renal vessels are of undue length. Such a
kidney may be found near the anterior abdominal wall.
One kidney may be very small, and the other
unusually large. Both glands may be situated in the
pelvis, or the two kidneys may be joined together by
their lower ends across the middle line, forming a
" horse-shoe kidney," with the concavity upwards.
There may be only one large kidney ; and, lastly,
cases are recorded where three kidneys have been
found.

330 SURGICAL APPLIED ANATOMY. [Chap. xvn.

Operations on the kidney. — (1) Nephrotomy.
Incision into the kidney for exploration, or the
evacuation of pus. (2) Nephro-litkotomy. Incision
into the gland for the removal of a calculus. (3)
Nephrectomy. Removal of the entire organ. (4)
Nephroraphy. The operation of securing a movable
kidney in its normal position. In the first, second, and
fourth operations, the kidney is reached through the
loin by a transverse incision, such as is used in colotomy
(page 315). In nephrectomy a like incision may be
used, or, if more room be required, an oblique cut is
made running downwards and forwards from the middle
of the last rib. The capsule is incised and peeled off,
the gland being removed from within its capsule. In
some instances the last rib has been resected to obtain
more space for the operation. This can be done
without risk to the pleura. In one case the twelfth
rib was rudimentary, and the eleventh rib was re-
moved under the impression that it was the twelfth.
The pleura was opened and death ensued. When the
kidney is free from its capsule, the structures at the
hilus are secured en masse by a ligature. In removing
large renal growths an abdominal incision is advised,
the cut being made along the corresponding semilunar
line, and on a level with the diseased mass. The
abdominal operation of course involves an opening
into the peritoneal cavity, but it has the advantages of
greater ease and rapidity in performance.

The ureters are strong tubes about fifteen inches
long, with thick muscular walls, and are placed entirely
behind the peritoneum. ' The average width is that
of a goose-quill. The narrowest part of the tube is
the portion within the bladder walls, and when renal
calculi pass along the ureter they are often arrested
at this point. The ureters permit of great distension,
and in certain cases of gradual dilatation they have
attained a width equal to that of the thumb and even

chap, xvii.] THE ABDOMINAL NERVES. 331

of the small intestine. Several cases are recorded of
rupture of the ureter from external violence. When
such an accident occurs a large urinary collection
usually forms behind the peritoneum, which, leading
to suppuration, will produce a fluctuating tumour
beneath the parietes.

The nerve supply of the abdominal viscera.
— Some account has already been given of these nerves
and their communications (page 273). The abdominal
viscera are mainly supplied by the sympathetic system
through a series of remarkable plexuses. The most
important of these is the solar, from which is more
or less directly derived the nerve supply of the
stomach, liver, spleen, kidneys, suprarenal capsules,
pancreas, and such parts of the intestine as are in
connection with the superior mesenteric artery. The
solar plexus and its appendages receive the splanchnic
nerves and some branches from the vagus, while com-
munications from the phrenic go to the hepatic and
suprarenal plexuses. It may be well understood that
tin impression brought to bear upon nerve centres of
such extent and with such important relations would
produce considerable effects. These effects we see in
the profound collapse, vomiting, and other grave
symptoms that attend severe injuries to the viscera,
and especially to those that are the most directly asso-
ciated with these large centres. The descending
colon and sigmoid flexure are supplied by the
inferior mesenteric plexus, a cord that has but an
indirect connection with the solar plexus ; and
this fact may serve to account for the less serious
symptoms often seen in strangulation of the colon
when compared with a like lesion of the small
gut. The upper part of the colon, although supplied
by the superior mesenteric plexus, is only supplied by
that part of it that is most remote from the great
centres, and it is a conspicuous fact that the nearer

332 SURGICAL APPLIED ANATOMY. [Chap. xvu.

the lesion is to the stomach the graver, other things
being equal, are the nervous phenomena produced.
It would appear that some lesion of these nerve
plexuses is sometimes active in producing a remark-
able pigmentation of the skin. This is seen in
Addison's disease, a disease marked by a general
bronzing of the surface, and usually associated with
some disintegration of the suprarenal capsules. The
very direct relation of these bodies to the solar plexus
is well known. In pregnancy also, in abdominal
tuberculosis, in cancer of the stomach, and in liver
diseases, a pigmentation of the face is sometimes seen,
that may in such instances be probably ascribed to a
disturbance of the great abdominal nerve centres.

In some diseases of the liver and stomach, " sympa-
thetic" pains are complained of between the shoulders
or about the inferior angles of the scapulse. These
parts are supplied with sensation by the fourth,
fifth, and sixth dorsal nerves. The great splanchnic
cord can probably explain the peculiar seat of these
pains, since it is connected on the one hand with the
plexuses that supply the stomach and liver, and on
the other hand with these very dorsal nerves that are
distributed about the lower interscapular space. Much
discussion has taken place as to the cause of the
" shoulder tip " pain often complained of in liver ail-
ments. Some imagine that the pain is conducted
along the hepatic plexus to the vagus, thence to the
spinal accessory, and so to the point of the shoulder.
Others trace it from the liver plexus to the
phrenic, thence to the third and fourth cervical nerves
(from whence the phrenic is in great part derived),
and finally to those branches of these cervical trunks
that go to the shoulder tip (the acromial branches).

There would seem to be but little connection
between a disease in the sigmoid flexure and a pain in
the knee, yet in cases of cancer of the flexure, and in

chap, xvii.] THE ABDOMINAL VESSELS. 333

instances where it has been distended with faeces, such
a pain has been complained of. The pain is conveyed
along the obturator nerve, which lies beneath the
sigmoid flexure, and could be readily pressed upon by
that gut when diseased.

The blood-vessels of the abdomen. — Some
of the visceral branches of the abdominal aorta are of
large size, and would bleed very copiously if wounded.
Thus, the cceliac axis, and the superior mesenteric
artery, are as large as the common carotid ; the splenic,
hepatic, and renal vessels are about the size of the
brachial ; while the largest part of the inferior mesen-
teric trunk has dimensions equal to those of the ulnar
artery. Aneurisms of the aorta are especially apt to
occur at the cceliac axis, that being a point where a
number of large branches are abruptly given off, and
where the course of the circulation undergoes in con-
sequence a sudden deviation.

When it is remembered that the lumbar glands
lie about the vena cava and iliac veins, it will be
understood that great enlargement of those bodies
may cause oedema from pressure.

A number of minute but most important anasto-
moses exist between some of the visceral branches
of the abdominal aorta, and certain of the vessels
supplied to the abdominal parietes. These anasto-
moses are situated behind the peritoneum, and
mostly concern such viscera as have a fair surface
uncovered by that membrane. The visceral branches
that join the anastomoses are derived from the hepatic,
renal, and suprarenal arteries, and from the vessels
supplying the lower part of the duodenum, the pan-
creas, the caecum, and the ascending and descending
segments of the colon. The parietal vessels joining
with the above are derived from the phrenic, lumbar,
ilio-lumbar, lower intercostal, epigastric, and circum-
flex iliac trunks. In a case detailed by Professor

334 SURGICAL APPLIED ANATOMY. [Chap. xvm.

Chiene (Journ. Anat. and Phys., vol. iii.) the cceliac
axis and mesenteric vessels were plugged, but blood in
sufficient amount to supply the viscera had reached the
branches of these arteries through their parietal com-
munications. This anastomosis gives an anatomical
demonstration of the value of local blood-lettings and of

o

counter-irritants in inflammatory affections of certain
of the viscera, and also a scientific basis to the ancient
practice of poulticing the loin and the iliac region in
nephritis and in inflammation about the caecum.

Cases have been recorded of communications
between the external iliac vein and the portal vein.
These have generally been effected by the deep epi-
gastric vein joining with a pervious umbilical vein in
the vicinity of the navel.

Thoracic duct. — Some six cases of wound of
this duct have been reported, the injury being usually
a stab. In each case lymph and chyle in large
quantities escaped from the wound. In one instance
the duct is said to have been injured by a bullet
that entered just below the left scapula, since from
the wound in the integuments large quantities of
lymph escaped freely. The duct has been- found to
have been obliterated, and that, too, without produc-
ing any marked symptoms during life.

CHAPTER XVIII.

THE PELVIS AND PERINEUM.

THE mechanism of tlie pelvis. — Besides
forming a cavity for certain viscera, a support for
some abdominal organs, and a point for the attachment
of the lower limb, and of many muscles, the pelvis

Chap, xviii.] THE PELVIS. 335

serves to transmit the weight of the body both in the
standing and sitting postures. The transmission is
effected through two arches, one available for the
erect position, the other for the posture when sitting.
The sacrum which supports the spinal column is the
centre or keystone of both these arches. When stand-
ing, the arch is represented by the sacrum, the sacro-
iliac synchondroses, the acetabula, and the masses of
bone extending between the two last-named points. If
all other parts of the pelvis were to be cut away but
these, the portions left would still be able to support
the weight of the body, and would represent in its
simplicity the arch through which that weight is
transmitted. When sitting the arch is represented by
the sacrum, the sacro-iliac synchondroses, the tubera
ischii, and the strong masses of bone that extend
between the two last-named parts. Morris terms
these two arches the femoro-sacral and the ischio-
sacral. On examining the innominate bone it will
be seen that its thickest and strongest parts are such
as are situate in the line of these. " When very con-
siderable strength is requisite in an arch, it is
continued into a ring so as to form a counter-arch,
or what is called a tie is made to connect together the
ends of the arch, and thus to prevent them from
starting outwards. By these means a portion of the
superincumbent weight is conveyed to the centre of
the counter-arch, and borne in what is called the sine
of the arch. The body and horizontal rami of the
pubes form the tie or counter-arch of the femoro-sacral,
and the united rami of the pubes and ischium the tie
of the ischio-sacral arch. Thus the ties of both arches
are united in front at the symphysis pubis, which, like
the sacrum or keystone, is common to both arches

This explains how it is that so much strain

is made upon the symphysis when any increased weight
has to be supported by the pelvis, as in pregnancy ;

336 SURGICAL APPLIED ANATOMY. [Chap. xvm.

why there is such powerlessness, with inability to
stand or sit, in cases in which this joint is weakened
or diseased ; and why the anterior portion of the
pelvis yields under the weight of the body, and
becomes deformed in rickets and mollities ossium." *
The pelvic deformity in rickets, it may be here
observed, varies greatly according to the age at which
the disease sets in, and the usual attitude of the child
when it becomes affected. The deformity sometimes
produced in very young infants has been ascribed
to muscular contraction (ilio-psoas, erector spinse,
gluteus medius, etc.). In the rickety pelvis, par
excellence, the two acetabula approach one another,
the anterior part of the pelvis yields, so that the
symphysis is pushed forward, and the cavity be-
comes greatly narrowed in its antero - posterior
diameter. In severe cases the anterior arch
may practically collapse, and the horizontal rami
of the pubes be for some little way parallel to one
another.

In the erect attitude the pelvis is so inclined that
the plane of the brim of the true pelvis forms with the
horizon an angle of from 60° to 65° ; the base of the
sacrum is about 3f inches above the upper border of
the symphysis, while the tip of the coccyx is a little
higher than its lower border. The centre of gravity
of the whole body (adult) is at a spot just above the
sacro-lumbar angle, and exactly over the mid-point of
a line drawn between the heads of the femora. The
obliquity of the pelvis materially assists in breaking
shocks, and in distributing forces applied from below
throughout the pelvic ring. In modifying the effect
of shocks, also, it is aided by the arches of the pelvis,
and by the buffer-like discs of cartilage at the
symphysis and sacro-iliac joints.

* Henry Morris on "The Joints, "p. 116, where a most valuable
account of the mechanism of the pelvis will be found.

chap, xviii.j THE PELVIS. 337

Fractures of the pelvis. — From what has
been already said, it may be surmised that the weakest
parts of the pelvis are at the symphysis and the sacro-
iliac joints. The bones of these parts, however, are so
very firmly knit together by powerful ligaments that
it is very rare for these articulations to give way,
fracture of the adjacent bones being more common.
The commonest fracture of the pelvis is in the weak
counter arch, and involves the rami of both the pubes
and the ischium. The* fracture is often associated with
some tearing of ligaments about the sacro-iliac synchon-
drosis, and is met with in accidents due to the most
varied forms of violence. This last remarkable cir-
cumstance is thus explained by Tillaux. If the pelvis
be compressed in (a) an antero-posterior direction, the
main brunt of the force comes upon the weak counter
arch, which fractures from direct violence. The force
continuing, tends to push asunder the two iliac bones,
and so causes rupture of the anterior ligaments at the
sacro-iliac joint. If the force be applied (6) trans-
versely, the two acetabula tend to be pressed towards
one another, the counter arch becomes more bent, and
ultimately gives way by indirect violence. The
violence continuing, forces the two ilia towards one
another, the strain then falls upon the sacro-iliac
synchondrosis, and the posterior ligaments of that joint
are apt to yield, or portions of the bone adjacent to
the joint are torn away. In cases of falls, when the
patient alights upon the feet or ischial tuberosities, it
can be understood how in many instances the main
arches will escape injury owing to their great strength,
while the counter arch becomes fractured. Any part
of the pelvis, including the sacrum, may be broken
by well-localised direct violence. More or less of the
iliac crest, the anterior superior and posterior superior
spines, have been knocked off. The first-named part
may be separated as an epiphysis. It joins the bone
w

338 SURGICAL APPLIED ANATOMY. [Chap. xvm.

at about the twenty-fourth year. In one case the an-
terior inferior spinous process was torn off by the rectus
muscle during the act of running a race. The os
innominatum has been broken into its three anatomical
portions. This accident cannot take place after about
the seventeenth year, since by that time the Y-shaped
cartilage is usually fully ossified, and the three
elementary bones are firmly united. Before such
consolidation occurs abscess in the hip joint not very
infrequently makes its way through the cartilage into
the pelvis. The acetabulum has been fractured, and
the head of the femur driven through its thinnest part
into the pelvis. In fractures of the pubes and
ischium the bladder has been torn by the sharp
fragments. In one case a loose piece of boiio that
had been driven into the bladder became the nucleus
for a stone. The urethra and vagina also have been
lacerated, or seriously compressed by the displaced
bones. In fractures of the sacrum the rectum has
been torn, or has been so compressed by the lower
fragment (which is almost always carried forwards)
as to be nearly closed.

Special parts of tlie pelvis.— Symphysis.—
Separation of the bones at the symphysis without
fracture has occurred from severe violence. Malgaigne
reports three cases where the separation was brought
about by muscular violence only, by extreme action
of the adductor muscles of the two sides. The
Sigaultean operation consisted in dividing the sym-
physis pubis in cases of contracted pelvis, with the
idea of obtaining more room during labour, and of so
avoiding Caesarian section* It has been shown, how-
ever, that to gain half an inch in the antero-posterior
diameter the bones must be separated to the extent of
two inches. Such a separation involves laceration of
the sacro-iliac ligaments, and more or less damage to
the attachments of the pelvic viscera.

chap, xviii.] THE PELVIS. 339

The sacro-iliac sychondrosis may be the seat
of disease. Normally, there is no movement at this
joint, but when the ligaments are softened by disease,
and effusion occurs between the opposed bones, some
movement may be demonstrated. As this joint lies in
the line of the great arches of the pelvis, it follows
that when inflamed much pain is felt in the part,
both when the patient is standing or sitting. When
abscess forms it tends to come forwards, owing to the
fact that the anterior ligaments are less dense than
the posterior. Having reached the pelvic aspect
of the joint, the pus may occupy the iliac fossa, or
gain the ilio-psoas sheath. Or it may follow the
lumbo-sacral cord and great sciatic nerve and point in
the thigh behind the great trochanter, or it may be
guided by the obturator vessels to the inner side of
the thyroid foramen, and ultimately appear at the
inner side of the thigh. The abscess may, however,
proceed backwards, and point over the posterior aspect
of the joint.

The nerve relations of this joint are important.
It is supplied by the superior gluteal, by the lumbo-
sacral cord and first sacral nerve, and by the first and
second posterior sacral nerves (Morris). The lumbo-
sacral cord and the obturator nerve pass over the
front of the joint, the former being very closely con-
nected with the articulation. It will be understood
from these relations that in sacro-iliac disease pain
is felt over the sacral region (upper sacral nerves) and
in the buttock (gluteal nerve). Much pain is also
often complained of in the hip or knee-joint, and
along the inner part of the thigh (obturator nerve).
In one or two reported cases there has been severe
pain in the calf and back of the thigh, with painful
twitchings in the muscles of those parts (lurnbo-
sacral cord and connection with great sciatic nerve).
Dislocation of the sacrum at this joint is prevented by

34° SURGICAL APPLIED ANATOMY. [Chap. xvm.

the remarkable double-wedge-shaped outline of the
bone, and by the very dense ligaments that bind it in
its place. The thick end of the main wedge of the
sacrum is in front, and therefore the strongest
ligaments are to be found behind the bone, as if to
prevent it from slipping forwards, or from becoming
rotated forwards on its transverse axis. The laminae
and spinous processes of the upper part of the sacrum
may be absent from congenital defect. A like
deficiency will probably be observed in the lower
lumbar vertebrae in such cases, and through the
median gap so formed the spinal membranes may
protrude, forming a large cystic tumour, known as
spina bifida. The sacro-coccygeal region is very often
the seat of congenital tumours, some of them of such
a shape as to form " human tails ; " and to this part
of the pelvis has also been found attached a third
lower limb leading to the condition known as "tri-
podism."

The sacro-coccygeal joint may be dislocated
or diseased. In either affection great pain is
kept up from the frequent movement of the part
by the muscles attached to the coccyx (the gluteus
maximus, coccygeus, levator ani, and sphincter). In
the luxation the bone may project into the rectum,
and thus give trouble. The joint and the parts about
it may be the seat of such severe neuralgia ("coccygo-
dynia ") as to require excision of the coccyx, or a free
division of the structures that cover it behind. The
joint and the fibrous tissue about it are supplied by
the following nerves ; the posterior divisions of the
second, third, and fourth sacral, and the anterior and
posterior divisions of the fifth sacral and coccygeal.

The thinnest parts of the os innominatum are at
the bottom of the acetabulum, and in the hollow of
the wing of the ilium. In the latter situation the
bone has been successfully trephined for iliac abscess.

chap, xviii.] THE PELVIS. 341

The floor of the pelvis and the pelvic fascia.

— The outlet of the bony pelvis is occupied in the
recent state with the following structures from behind
forwards : the pyriformis, the sacro-sciatic ligaments,
the coccygeus, the levator ani, and the triangular
ligament of the urethra. These form the floor of the
pelvis. The three structures last named serve to
separate the pelvic cavity from the perineum.

The walls and floor of the pelvis are lined by a
fascia, the pelvic fascia, of which a brief general
description may be given. This fascia is divided into
two distinct parts, a parietal layer and a visceral
layer. (1) The parietal layer begins at the brim of
the true pelvis, to which it is attached. From this
attachment it passes down along the pelvic wall, forming
a lining for that part, covering in the obturator internus
muscle, and becoming adherent below to the rami of
the pubes and ischium, and to the tuber ischii. More
posteriorly it gives a thin covering to the pyriformis
muscle. (2) The visceral layer comes off from 'the
parietal along a line running from the lower
part of the symphysis pubis to the ischial spine.
This line is known as the white line, and corre-
sponds to the origin of the levator ani from the pelvic
fascia.

Starting from this line the visceral layer passes
down into the pelvis on the abdominal surface of the
levator am, and attaches itself to all the pelvic viscera
with which it comes in contact, forming fibrous expan-
sions or "ligaments," that serve to hold the viscera in
place. Were there no pelvic viscera, this layer of
the fascia would be continued evenly across the pelvic
floor from one side to the other, just as the subperi-
toneal fascia is continued over the under surface of
the diaphragm. Having given "reflections" to the
pelvic organs the visceral layer passes on, and, covering
the opposite levator muscle, ends at the opposite white

342 SURGICAL APPLIED ANATOMY. [Chap. xvur.

line. This visceral layer is usually known as the
recto-vesical fascia.

As regards the parietal division, it will be seen
that that part of it above the origin of the
visceral layer (i.e., above the white line) is in the
pelvic cavity, while that part below the line is in the
perineum. To this lower segment the name obturator
fascia is commonly given. Now, the peritoneum lines
some part of the pelvic floor, and covers a great part
of the pelvic viscera. Between this peritoneum and
the visceral layer of the pelvic fascia is a good deal of
loose connective tissue. Inflammation may be set up
in this tissue, may spread readily in it, and may
of course lead to suppuration. Such suppuration
will be limited to the pelvic cavity, and will be
hindered from escaping from that cavity by the pelvic
fascia. Inflammations of any extent so located are
included under the term pelvic cellulitis. Suppura-
tion, therefore, above the visceral layer of the pelvic
fascia will be limited to the pelvic cavity, while that
below the fascia will be limited to the perineum, to
either the urethral or the anal segment of that district.
Thus it will be seen that the pelvic fascia is of much
surgical importance. Wounds through the perineum
that involve this fascia will be serious, in that they
will open up the loose tissue on the pelvic aspect of
the fascia in which inflammation so readily spreads,
while unless the fascia be wounded the pelvic cavity
cannot be said to have been opened.

The fascia is so reflected upon the viscera that certain
parts of them are excluded by the attachments of the
membrane from the pelvic cavity. The parts so ex-
cluded are the following : the prostate, the neck of the
bladder, all that part of the base of the bladder that
is between the seminal vesicles, the seminal vesicles
themselves, and about the last two and a half or
three inches of the rectum. On the side of the

Chap, xviii.] THE PELVIS. 343

rectum the fascia Teaches the level of • a line drawn
from the top of the'^serrdrml vesicles tto ;fche middle oii the
fifth piece of the sacrum. In the middle line it
reaches a point scmo little vay be^ow the rsoto
vesical cul-de-sac of '"tli:e"pefitonerr«]. These excluded
portions of the various viscera may be wounded
without the pelvic cavity being opened up, and
suppuration spreading from them would tend to
spread towards the perineum, and not into the pelvis.
Pelvic cellulitis, to use the term in the strict sense,
means inflammation of the connective tissue between
the pelvic fascia and the peritoneum.* This connec-
tive tissue is chiefly situated between the anterior
wall of the bladder and the pelvis, about the base and
neck of the bladder, between the latter viscus and the
rectum ; and in the female, between the layers of the
broad ligament and about the lower part of the
uterus and commencement of the vagina. All this
connective tissue is continuous, and inflammation in
one part of it may spread to the other parts. In
women the mischief is often found between the folds
of the broad ligament, or in the hollow between the
uterus and the rectum. As may be supposed, the
abscess formed in such cases tends to mount up in the
pelvis, being unable to escape below, and usually
points in the inguinal region. It may, however, open
into one of the pelvic viscera or into the peritoneum,
but both these terminations are rare. Out of thirty-
seven cases of puerperal pelvic cellulitis with suppu-
ration, twenty-four burst externally, and for the most
part in the inguinal region (McClintock).

It should be borne in mind that the blood-vessels
of the pelvis are placed on the peritoneal aspect of the
fascia. The branches of the internal iliac artery,
therefore, that leave the pelvis, escape by piercing that

* Clinically the term pelvic cellulitis includes also pelvic peri-
tonitis, and often inflammation of one or other of the viscera.

344 SURGICAL APPLIED ANATOMY. [Chap. xviu.

membraoie. The ob.toratpr a^ter^ is an exception to this
rule, since it parses 'over the upper border of the
paiietal pelvic fascia (Cunningham). The nerves in
ike pelvis lie behind or oiitsyie ohp^fa^oia, and, there-
fore, the pelvic ve-^els. and, ih^ pelvic nerves are,
excepting the obturator, separated from one another
by this layer of tissue.

The male perineum. — The perineum is a
lozenge-shaped space bounded by the symphysis, the
rami of the pubes and ischia, the ischial tuber osities,
the great sacro-sciatic ligaments, the edges of the two
great gluteal muscles, and the coccyx. A transverse
line drawn across the space between the anterior ex-
tremities of the tubera ischii, and just in front of
the anus, divides the perineum into two parts. The
anterior part forms nearly an equilateral triangle,
measuring about three and a quarter inches on all
sides. It is called the urethral triangle. The posterior
part is also somewhat triangular, contains the rectum
and ischio-rectal fossa, and is called the anal triangle.
The whole space measures about three and a half inches
from side to side, and about four inches from before
backwards in the middle line. The average antero-
posterior diameter of the pelvic outlet in the male
averages three and a quarter inches. This measure-
ment in the undissected subject is increased to four
inches by the curving of the surface. The average
transverse diameter of the male pelvic outlet is three
and a half inches, and corresponds to the measurement
of the perineum above given.

The bony framework of the perineum can be felt
more or less distinctly all round, and in thin subjects
the great sacro-sciatic ligaments can be made out
beneath the great gluteal muscle. The anus is in the
middle line between the tubera ischii, its centre being
about one and a half inches from the tip of the
coccyx. The rop/je, a central mark or ridge in the

Chap. XVI 1 1.]

2* HE PERINEUM.

345

skin, can be followed from the anus along the middle
line of the perineum, scrotum, and penis. No vessels

i a

Fig. 36.— The Male Perineum. (After EUdinger.)

a, Gluteus maxiruus ; 6, senri-tendinosus and biceps ; c, adductor rnagnus: d,
gracilis; e, pyriformis : /, obturator internus ; #,quadratus femoris; /(, leva-
tor ani ; i, external sphincter; j, accelerator urma) ; Jc, erector penis: I,
transversus perinei ; 1, great sciatic nerve ; 2, external ha-morrboidal vessels
and nerve; S, superficial perinea! vessels and nerves; 4, pudic nerve (.cut)
and pudic artery ; 5, pudendal branch of small sciatic nerve.

cross this line, and, therefore, in making incisions
into the perineum this line is always chosen when
possible. In the middle line, midway between the
centre of the anus and the spot where the scrotum joins

346 SURGICAL APPLIED ANATOMY. [Chap. xvm.

the perineum, is the central point of the perineum.
The two transverse perineal muscles, the accelerator
urinse, and the sphincter ani meet at this point, which
also corresponds to the centre of the inferior edge of
the triangular ligament. The bulb is just in front of
it, as is also the artery to the bulb, and in lithotomy,
therefore, the incision should never commence in
front of this spot.

The perineal space is separated from the pelvic
cavity by the levator ani muscles and recto-vesical
fascia, as already mentioned. The depth of the perineum
means the distance between the skin and the pelvic
floor. This depth depends, to a great extent, upon the
amount of fat under the integument. It varies
considerably in different parts, measuring from two to
three inches in the hinder and outer parts of the
perineum, and less than one inch in the anterior parts
of the space.

The iscMo-rectal fossa is of pyramidal shape,
its apex being at the white line, and its base being
formed by the skin between the anus and the ischial
tuberosities. It measures about two inches from be-
fore back, one inch from side to side, and is between
two and three inches in depth. Its boundaries are: on
the outer side, the obturator interims muscle covered
by the parietal layer of the pelvic fascia; on the inner
side, the levator ani, covered by the anal fascia ; in
front, the base of the triangular ligament and the
trans versus perinei muscle ; and behind, the gluteus
maximus, great sacro-sciatic ligament, and coccygeus.
The pudic vessels and nerves are on the outer wall,
embedded in the fascia over the obturator muscle, and
are placed about one and a half inches above the lower
border of the tubera ischii.

The part of the rectum which occupies the space
between the two fossae is supported by the levatores
ani, external sphincter, and recto-vesical fascia. Its

Chap, xviii.] THE PERINEUM. 347

lateral wall is exposed for a distance of nearly three
inches, its posterior wall for about an inch (Quain).
The fossa is occupied by a mass of fat which affords
to the rectum the support of an elastic cushion. This
fatty tissue is badly supplied with blood, and this fact,
in addition to the dependent situation of the part, and
its exposure when the patient sits upon damp, cold
seats, etc., leads to abscess being very frequent in the
space (ischio-rectal abscess). These abscesses are hem-
med in on all sides, soon fill the fossa, and then tend
to discharge themselves in the two directions where
the resistance is least, viz., through the skin and
through the wall of the rectum. When this double
discharge of the abscess has taken place, a complete
fistula in ano is established. It is well to note that in
all fistulse in" ano the opening into the rectum is nearly
always within half an inch of the anus. An opening
into the bowel higher up is resisted by the attachment
of the levator ani, by the anal fascia and by the recto-
vesical fascia.

Crossing the space obliquely from its hinder part
to the anus are the external hsemorrhoidal vessels
and nerves ; crossing the anterior and outer corner
of the fossa are the perineal vessels and nerves,
and about the posterior border of the space are the
fourth sacral nerve and some branches of the small
sciatic nerve. It will be readily understood, therefore,
that ischio-rectal abscesses are associated usually with
extreme suffering until they are relieved. The most
severe pain is probably due to the stretching of the
external hsemorrhoidal nerve by the abscess as it
progresses towards the surface. In opening an abscess
in the fossa the main structures to avoid are the
rectum, the pudic and external hsemorrhoidal vessels.
Anus. — (See paragraph on the Rectum.)
The urethra! triangle.— The skin of the peri-
neum between the anus and the scrotum is thin, and

348 SURGICAL APPLIED ANATOMY. [Chap. xvm.

shows very readily any extravasations of blood that
may form beneath it. The superficial fascia is divided
into two layers, of which the more superficial is quite
unimportant, and contains what little subcutaneous
fat exists in this part.

The deeper layer, known as the perineal fascia or
fascia of Colles, is attached on either side to the rami
of the pubes and ischium, and behind to the base of
the triangular ligament. In front it becomes continuous
with the dartos tissue. This fascia, therefore, by its
attachments forms with the triangular ligament a well-
isolated apoiieurotic space, containing the bulb with
all that part of the spongy urethra between the
triangular ligament and the attachment of the scrotum,
the penile muscles, the transverse perineal muscles,
vessels, and nerves, and the perineal vessels and nerves.
When extravasation of urine follows upon a rupture
of the part of the urethra above named, the course of
the escaping fluid is directed by the fascia of Colles.
It fills the aponeurotic space. It is unable to gain to
ischio-rectal fossa on account of the attachment of the
fascia to the triangular ligament. The lateral attach-
ments of this membrane prevent the urine from
passing into the thighs. It is, therefore, guided into
the scrotum, and there finds itself beneath the
dartos tissue. It distends the scrotal tissues, and
then mounts up on to the abdomen through the gap
left between the symphysis pubis and pubic spine
(page 266). It must be remembered that the fascia
of Colles, the dartos tissue, and the deeper layer of
the superficial fascia of the abdomen, are continuous,
and merely represent different parts of the same
structure. Pus or blood within this aponeurotic
space would follow the same course if the effusion
were extensive enough. The pain occasioned by
such effusion can be understood when it is noted
that the three chief sensory nerves of this region

chap, xviii.] THE PERINEUM, 349

(the three long scrotal nerves) are included within
the space.

The triangular ligament has a depth of about
one and a half inches in the middle line, and is formed
of two layers, of which the posterior is derived from
the pelvic fascia. The membranous urethra, surrounded
by the compressor urethrae, lies between the two layers,
and runs about one inch below the symphysis, and
about three-quarters of an inch above the central point
of the perineum. The artery to the bulb passes in-
wards between the two layers about half an inch above
the base of the ligament and one inch and a-half in
front of the anus. The dorsal vein and the terminal
part of the pudic artery and nerve pierce the anterior
layer of the ligament about half an inch below the
symphysis. In uncomplicated rupture of the mem-
branous urethra, the urine extravasated would be
limited to the space beween the layers of the ligament,
until subsequent suppuration had made a way for it to
escape. When extravasation occurs behind the trian-
gular ligament, the effusion barely escapes the pelvic
cavity, and usually by following the rectum gains the
anal part of the perineum.

Just beyond the triangular ligament is the pro-
state, surrounded by its capsule, and the prostatic
venous plexus. In dissecting down from the surface
to the prostate, we meet, as Cunningham has well
pointed out, alternate strata of fascial and muscular
tissue, forming seven layers in all, viz. : (1) Superficial
fascia ; (2) superficial perineal muscles ; (3) triangular
ligament (ant. layer) ; (4) compressor urethrse imiscle ;
(5) triangular ligament (post, layer) ; (6) levator ani
'muscle ; (7) capsule of prostate.

Lateral lithotomy.- — The first incision is from
two to three inches in length, is commenced just to
the left of the middle line and just behind the central
point of the perineum, i.e., about one and a quarter

35o SURGICAL APPLIED ANATOMY. [Chap. xvm.

inches in front of the anus. The incision is carried
downwards and outwards into the left ischio-rectal
fossa, and ends at a point between the tuber ischii and
posterior part of the anus, and one-third nearer to the
tuberosity than to the gut. In the early part of this
incision the staff may just be touched, as it lies in the
membranous urethra, the incision becoming more and
more shallow as the knife is withdrawn. "The parts cut
in the first incision are : (1) Skin and superficial fascia;
(2) transverse perineal muscle, artery and nerve; (3) the
lower edge of the anterior layer of the triangular
ligament ; (4) the external hsemorrhoidal vessels and
nerve.

In the second incision the knife, guided by the fore-
finger of the left hand, is passed upwards behind the
triangular ligament, is engaged in the groove on the
staff as it lies in the membranous urethra, and then,
having its edge turned towards the left tuber ischii, is
steadily carried along the groove into the bladder. In
this incision the parts divided are : (1) Membranous and
prostatic portions of urethra ; (2) posterior layer of tri-
angular ligament; (3) compressor urethrse; (4) anterior
fibres of levator ani and left lateral lobe of prostate.
The finger is then introduced along the staff into the
bladder, the staff is removed, and, the forceps being
inserted, the stone is extracted, .traction being made in
the proper axis of the pelvis.

Parts that may be wounded. — (a) In the first in-
cision : (1) the bulb, or the artery to the bulb. These
parts can be avoided by commencing the incision well
behind the " central point/' and by causing the
holder of the staff to draw it, the scrotum, and the
penis well up. The staff should be held as close
up under the pubes as possible. The bulb is very small
in children, large in adults, and largest in old men.
(2) The rectum may be cut if much distended, or if
the incision be made too vertical or carried too far

Chap, xviii.] THE PERINEUM. 351

back. In all cases the gut should be well emptied by
enema before the operation. (3) The pudic vessels
can hardly be wounded unless the incision is
very carelessly made, and the knife carried almost
against the bone as it is being withdrawn, (b) In the
second incision the knife may be passed beyond the
prostate, and may so incise the visceral layer of the
pelvic fascia as to open up the pelvic cavity. It wil
be understood that the lateral lobe of the prostate may
be cut freely without this cavity being endangered.
The gland is enveloped by the pelvic fascia, but the
incision made into the prostate is well below the su-
perior reflection of the membrane. The incision in the
neck of the bladder, therefore, must be strictly limited
to the prostate. The prostatic plexus of veins cannot
avoid being wounded. The left ejaculatory duct
would be cut if the prostatic incision be carried too far
backwards.

In children the pelvis is relatively narrower than
in the adult, the bladder is more an abdominal than
a pelvic organ, and the neck of the bladder, therefore,
is high up. The viscus, moreover, is very movable,
and has less substantial attachments than has the
adult's bladder. It thus happens that in forcing the
linger into the bladder after the second incision, the
viscus has actually been torn away from the urethra.
In children the prostate is rudimentary, and thus more
of the actual neck of the bladder itself has to be cut.
From the small size of this gland, also, it happens that
in some cases the knife has passed too far beyond the
prostatic area, and has opened up the pelvic fascia.

Median lithotomy. — In this operation the
knife is entered in the middle line, just in front of the
anus. The staff has a central groove, and the point of
the knife should hit the instrument as near as possible
to the apex of the prostate. As the knife is withdrawn,
the whole of the membranous urethra is incised, and

352 SURGICAL APPLIED ANATOMY. [Chap. xvm.

a wound made in the median raphe of about one inch
and a quarter in length. The incision is made by
cutting upwards. A probe is then introduced into the
bladder, and, the staff being removed, the finger is
passed into that viscus by steady dilatation of the
parts, with some laceration of the prostate. The object
in this operation is to enter the bladder with the least
amount of cutting, and by dilatation rather than
incision.

Parts divided. — (1) Skin and superficial fascia;
(2) sphincter ani ; (3) central point of perineum ; (4)
lower border of triangular ligament; (5) whole
length of membranous urethra ; (6) compressor
urethrse.

Advantages. — (1) The bleeding is much less than
in the lateral operation, the slight vascularity of the
raphe being well known. (2) The pelvic fascia is much
less likely to be wounded if the bladder be entered by
dilatation rather than by incision, as in the lateral
procedure.

Disadvantages. — (1) The bulb is in great risk of
being wounded. It must, however, be noted that
wounds of the bulb in the middle line do not bleed
readily, as a rule. (2) The amount of space obtained
for the removal of the stone is very slight. (3) In
children the operation in its integrity is scarcely pos-
sible, since the prostate is quite rudimentary, and the
slight attachments of the parts are such, that, in using
forcible dilatation, the bladder may readily be torn from
the urethra. If tbe incision be made upwards, and
one finger be retained in the rectum, the risk of
wounding the gut is not great.

In lithotomy, and in other operations for reaching
the neck of the bladder through the perineum, it
should be remembered that the bladder lies at a depth
of from two and a half to three inches from the surface
when the body is in lithotomy position.

Chap, xviii.] THE BLADDER. 353

The bladder. — When empty the bladder is
triangular in shape as seen in an antero-posterior
vertical section, having its apex at the symphysis,
and its base resting against the rectum or vagina.
When moderately distended it is of rounded outline;
when completely distended it assumes an oval outline,
and rises out of the pelvis. As distension of the
bladder increases, the summit of the viscus is brought
more and more in contact with the anterior abdo-
minal wall, the organ becoming also more convex:
on its posterior than on its anterior surface. This
tendency for the summit of the distended bladder to
press itself against the anterior parietes is of good
service in tapping the organ above the pubes. When
greatly distended it may reach the umbilicus and may
even touch the diaphragm. The usual capacity of the
organ is about one pint, but when fully occupied it may
hold some quarts. When it is empty the anterior
wall of the abdomen is lined with peritoneum down
to the symphysis. As the distended bladder ascends
above the pubes it dissects the serous membrane from
the parietes, and the layer so lifted off forms a
cul-de-sac or fold of peritoneum between the upper
part of the anterior surface of the bladder and the
parietes. When the apex of the bladder is midway
between the umbilicus and the pubes there will be
about two inches (vertical) of the anterior abdominal
wall in the middle line and immediately above the
nymphysis, devoid of peritoneal lining. Thus it
happens that the distended viscus may be tapped
above the pubes without the peritoneum being
wounded. Between its anterior surface and the
symphysis, and shut in by the peritoneum above, is a
loose layer of connective tissue. The looseness of
this connective tissue permits the bladder to readily
alter its dimensions without disturbing the con-
nections of the organ. In injuries to the pelvis
x

354

SURGICAL APPLIED ANATOMY. [Chap. XVIIL

Fig. 37.— A Vertical Antero-posterior Section of the Male Pelvis
(Braune).

and to the front of the bladder, a diffuse inflam-
mation may be set up in this tissue and assume
serious proportions. I have reported a case where an

Chap, xviii.] THE BLADDER. 355

extensive suppuration in this area followed upon
aspiration of the bladder above the pubes, and led to
death. In rupture of the anterior wall of the viscus
the mine escapes into this district of cellular tissue; a
limited suppuration may follow and recovery ensue.

The bladder, although fairly fixed, has been found
in inguinal, femoral, and vaginal hernise. In the
erect position its neck (in the male) lies on a
horizontal line drawn from before backwards through
a point a little below the middle of the symphysis,
and is placed about one and a quarter inches (3 cm.)
behind that articulation (Tillaux).

Relations to the peritoneum. — The anterior
surface is entirely devoid of peritoneum, while the
superior surface is entirely covered by that membrane.
At the sides there is no peritoneum in front of, or
below, the obliterated hypogastric arteries. On the
posterior aspect of the bladder the serous membrane
extends down as far as a transverse line, uniting the
upper parts of the two seminal vesicles, so that the
upper ends of the vesicles, as well as the ureters,
where they enter the bladder, are covered by peri-
toneum. This recto-vesical pouch of peritoneum
extends to within about three and a half or four
inches of the anus, and does not reach below a line
one and a quarter inches above the base of the
prostate.

Puncture of the bladder per rectum.—
The base of the bladder is adherent to the rectum by
dense areolar tissue over a triangular area, the apex of
which is formed by the prostate, the sides by the
diverging seminal vesicles, and the base by the recto-
vesical fold of peritoneum. This triangle is equi-
lateral, and in the dissected specimen measures about
one and a half inches on all sides. It corresponds to
the trigone on .the inner surface of the viscus. It is
through this triangle, and as near as possible to the

356 SURGICAL APPLIED ANATOMY. [Chap. xvm.

prostate, that the bladder is tapped when the opera-
tion is performed per rectum. The recto-vesical fold
of peritoneum is raised, and is carried still farther
from the anus when the organ is distended.

Rupture of bladder. — The bladder may be
ruptured by violence applied to the anterior abdo-
minal wall apart from pelvic fracture or external
evidence of injury. Such a rupture cannot, however,
happen to the empty bladder, which must be full or
distended at the time. It is very rare for the rupture
to be on the anterior surface only. As a rule, the
tear involves the superior or abdominal surface, and
implicates the peritoneum. The injury, therefore, is
very fatal (five recoveries out of seventy-eight cases).
In some cases of vesical rupture the surgeon has
opened the abdomen and has endeavoured to stitch up
the rent in the viscus. Such attempts have, however,
not as yet been successful, the great difficulty de-
pending upon the depth at which the organ is placed
when approached from the abdomen, and the impossi-
bility, therefore, of entirely closing the tear. The
bladder may be torn by fragments of bone in fractures
of the pelvis, or by violence applied through the
rectum or vagina. A case, for example, is reported
(Holmes' " System of Surgery >;) of a man who fell
upon a pointed stake fixed in the earth. The stake
passed through the anus, pierced the rectum, and
entered the bladder near the prostate. The patient
recovered, the wound having been made in the tri-
angular area on the fundus of the bladder alluded to
above, and therefore outside the peritoneum. The
viscus may be ruptured by an accumulation of urine,
as seen in cases of congenital closure of the urethra in
some infants. In the museum of the Royal College
of Surgeons is a preparation of " the bladder of a
woman which burst near the entrance of the ureter in
consequence of neglected retention of urine." In

Chap. xviii.] THE BLADDER. 357

neglected cases of stricture in the male the urethra
gives way rather than the bladder, and an extravasa-
tion of urine into the perineum follows. A small
puncture of the bladder, as, for example, that made by
a fine trochar, is at once closed by the muscular con-
traction of its wall.

The mucous membrane of the bladder is very
lax, to allow of its accommodating itself to the varying
changes in the size of the viscus. Over the trigone,
however, it is closely adherent, and were it not so the
loose mucous membrane would be constantly so
prolapsed into the urethral orifice during micturition
as to block up the neck of the bladder. The trigone
is bounded by three orifices, for the urethra and
the two ureters, and forms an equilateral triangle,
measuring about one and a half inches on all sides.
It is here that the effects of cystitis are most evident,
and the unyielding character of the mucous membrane
over the trigone serves in part to explain the severe
symptoms that follow acute inflammation of that struc-
ture. Since the orifice of the urethra forms the
lowest part of the bladder in the erect posture, it
follows that calculi gravitate towards the trigone, and
are very apt to irritate that part of the interior. The
same remark applies to foreign bodies in the viscus.
The mucous membrane about the trigone and neck is
very sensitive, whereas the interior of the remainder
of the bladder appears to be singularly defective in
common sensation. This can be well noted in using
sounds and catheters.

In the muscular coat of the viscus the fibres
are collected into bundles which interlace in all
directions. When the bladder becomes hypertrophied
these bundles are rendered very distinct, and produce
the appearance known as " fasciculated bladder."
This simply means that the muscle of the bladder,
having been unduly exercised to overcome some

35 8 SURGICAL APPLIED ANATOMY. [Chap. xvm.

obstruction to the escape of urine, increases in
size, as do other much exercised muscles, and
that increase serves to demonstrate the arrange-
ment of the individual bundles. In a fasciculated
bladder the muscular bundles present much the appear-
ance of some of the columnae carnese in the heart.
It will be understood that the bladder wall between
the muscular bundles is comparatively thin, and
may yield when the viscus is distended. By such
distension the mucous membrane becomes bulged out
between the unyielding muscle bundles, so that sacculi
are formed, and the appearance known as " sacculated
bladder " is produced. In these sacculi urine may lodge
and decompose, phosphatic deposits may collect, and
calculi may develop (encysted calculi). In some cases
the parietes yield, especially at one part, and one
large saccule is produced. In this way a sacculus may
be formed which in time may become almost as large
as the bladder itself, and give rise to the erroneous
descriptions of " double bladder," etc. The ureters
run for three-quarters of an inch in the muscular wall
of the viscus, and their oblique course, together with
the action of the muscular tissue about them, tends to
prevent regurgitation of urine. In cases of retention
the ureters become distended ; but this is due rather
to accumulation of urine within them than to its
reflux from the bladder.

In cases of great distension of the bladder, the
neck of the viscus is opened up by the pressure from
within, and the patient exhibits the feature of over-
flow of urine. .

The female bladder is less capacious than that
of the male. Its neck is situate a trifle nearer to the
symphysis than it is in the male, and lies in a horizontal
line continued back from the lower border of the
symphysis. There being no prostate, the neck of the
bladder is very distensible, and this fact, taken in

chap, xviii.] THE PROSTATE. 359

connection with the shortness and dilatability of the
urethra, allows of most stones being extracted by
forceps without cutting. By simple dilatation, stones
of a diameter of three-quarters of an inch have been
removed. The intimate relation of the bladder to the
vagina allows it to be examined well from the latter
passage, and the comparative thinness of the dividing
wall serves to explain the frequency of vesico-vaginal
fistulse. Strange foreign bodies have been introduced
into the female bladder, such as hair-pins, crochet
hooks, sealing-wax, penholders, and the like.

The bladder in the child is oval, and its ver-
tical axis is relatively much greater than it is in the
adult. It can hardly be said that there is any base
or fundus to the child's bladder. The viscus is
situated mainly in the abdomen, the pelvis being
small and very shallow. Its wall is so thin that
in sounding for stone it is said that a " click " may
be elicited by striking the pelvis through the parietes
of the viscus.

The prostate. — The prostate is situated about
three-quarters of an inch below the symphysis pubis,
and rests upon the rectum in front of the bend
between the second and third segments of that viscus.
It is, therefore, placed within one and a half to two
inches from the anus, and can be readily examined
from the bowel.

The secretion from the gland is discharged through
a number of long and very narrow ducts. In certain
forms of prostatic irritation, little white opaque
threads, very much like short pieces of cotton, are
found in the urine, and are actual casts of the pro-
static ducts.

The prostate is enveloped in a firm capsule de-
rived from the pelvic fascia, and it is to this fascia
that we look for an explanation of the course of
prostatic abscess.

360 SURGICAL APPLIED ANATOMY. [Chap. xvm.

The prostatic abscess usually bursts into the
urethra, that being the direction in which least re-
sistance is encountered. If it does not enter the
urethra, it will probably open into the rectum, there
being only one layer of the pelvic fascia, and that layer
not a thick one, between the two organs. Indeed, the
posterior part of the prostatic capsule, and the anterior
part of the sheath of the rectum, are continuous.
Failing these two points of exit, the abscess may
progress towards the perineum. This course, however,
is not very usual, the advance of the abscess being
resisted by the dense posterior layer of the triangular
ligament, with the lower edge of which the prostatic
capsule is continuous. If the abscess reaches the
perineum, it will do so by running along the side
of the rectum. The abscess cannot make its way into
the pelvic cavity, its movement in that direction being
resisted by the pubo-prostatic ligaments which form
one of the very densest portions of the pelvic fascia.
This encasement of the gland in an unyielding mem-
brane will serve to in part explain the severe pain felt
in acute prostatic abscess.

Hypertrophy of the prostate. — The average
measurements of the normal prostate are an inch
and a half across at its widest part, and an inch and
a quarter from before backwards, or from apex to
base. After the age of fifty-three the organ is very
apt to become hypertrophied ; and, according to Sir
Henry Thompson, this hypertrophy may be considered
to exist when the gland measures two inches from
side to side, or when it weighs one ounce. The usual
weight of the prostate is six drachms. If the enlarge-
ment mainly affect the lateral lobes, it will be imder-
stood that the hypertrophy may attain considerable
dimensions without retention of urine being produced.
On the other hand, a comparatively trifling enlarge-
ment of the middle lobe may almost entirely block

chap, xviii.] THE URETHRA. 361

the orifice of the urethra. If the affection be general,
the prostatic urethra is lengthened, and if one lateral
lobe be more enlarged than the other, the canal
deviates to one side. When the enlargement par-
ticularly affects the middle lobe, the prostatic urethra,
which is normally almost straight, becomes con-
siderably curved, the curve being sometimes very
abrupt.

It is important to note that enlargement of the
middle lobe alone can hardly be made out by rectal
examination.

Between the prostate and its capsule is an exten-
sive plexus of veins, the prostatic plexus, into which
enters the dorsal vein of the penis. Phlebolithes are
said to be more frequently met with in these veins
than in any other in the body. This plexus is cut in
lateral lithotomy, and it is through its vessels that
septic matter is probably absorbed in cases of pysemia
following that operation.

The male urethra is about eight and a half
inches in length, an inch and a quarter being devoted
to the prostatic urethra, three-quarters of an inch
to the membranous, and six and a half inches to
the penile or spongy portion. The canal may be
divided into a fixed and a movable part. The
fixed part extends from the neck of the bladder to the
posterior extremity of the penile urethra at the .point
of attachment of the suspensory ligament. The fixed
part describes an even curve, fairly represented by
the line of a " short-curve " metal catheter. The
two ends of the curve lie about in the same line, viz.,
one drawn across the lower end of the symphysis,
and at right angles to the vertical axis of that arti-
culation. The curve is formed around this line, its
summit corresponding to a prolongation of the vertical
axis of the symphysis, and to about the centre of the
membranous urethra. This part of the tube lies

362 SURGICAL APPLIED ANATOMY. [Ch*P. xvm.

about one inch below the pubic arch. The movable
portion of the urethra forms, when the penis is
dependent, a second curve in the opposite direction,
so that the whole canal follows somewhat the outline
of the letter S.

In introducing a catheter it must be noted that
while the instrument passes along the movable
urethra the canal accommodates itself to the catheter,
but while traversing the fixed segment the instrument
must accommodate itself to the unyielding canal. In
introducing a catheter in the recumbent posture the
penis is held vertically upwards, and in this way the
curve formed by the movable urethra is obliterated.
The instrument is best kept close to the surface of the
groin, and over and parallel to Poupart's ligament.
When the fixed urethra is reached, the handle of the
catheter is brought to the middle line, and then, being
kept strictly in the median plane of the body, is
depressed between the legs, so that the front of the
instrument may follow the natural curve of the
canal. The greatest difficulty in the introduction is
generally experienced at the point where the movable
and fixed parts of the urethra meet; or rather, in
practice, at a spot a little behind this point, viz., at the
anterior layer of the triangular ligament. At this
spot the tube becomes abruptly, not only very fixed,
but also very narrow, and a part of it is reached
where muscular tissue is very abundant, and where
resistance from muscular spasm is therefore likely to
be most marked.

It thus happens that when a false passage has
been made by a catheter in a case where no stricture
exists to offer a definite obstruction, the instrument
is usually found to have left the canal just in front of
the triangular ligament.

Some other points in connection with catheterism
will be noted subsequently.

Chap, xviii.] THE URETHRA. 363

The urethral canal must not be regarded as
forming an open tube like a gas-pipe. Except when
urine or an instrument is passing along it, the tube
appears on section as a transverse slit, the superior
and inferior walls being in contact. This fact should
be remembered in amputation of the penis by the
ecraseur. In the fossa navicularis the tube appears as
a vertical slit.

The prostatic part of the canal is the widest and
most dilatable portion of the whole urethra. It is
widest at its centre, having here a diameter of nearly
half an inch ; at the bladder end its diameter is about
one-third of an inch, while at the anterior extremity of
this part of the urethra the measurement is a little less
than one-third of an inch. When small catheters are
being introduced their points may lodge in the orifice
of the utricle, unless the tip of the instrument be
kept well along thereof of the canal. The ejaculatory
ducts open into the prostatic urethra, and thus it
happens that inflammation of this part of the canal
may spread back along those ducts to the seminal
vesicles, and from thence along the vas deferens to
the epididymis. It is by spreading along these parts
that inflammation of the testicle is set up in
gonorrhoea, involving the prostatic urethra, and it will
be understood that a like inflammation may follow
lateral lithotomy, impacted stone in the prostatic
urethra, prostatic abscess, and the like. Stricture
never occurs in this part.

The membranous urethra is, with the exception
of the meatus, the narrowest part of the entire
tube. Its diameter is about one-third of an inch.
It is fixed between the two layers of the triangular
ligament, and is the most muscular part of the canal.
It is at this spot, therefore, that what is known as
" spasmodic stricture " usually occurs. In any case,
the contraction of the compressor urethras often offers

364 SURGICAL APPLIED ANATOMY. [Chap. xvm.

an appreciable amount of resistance to the passage of
a catheter or sound.

The penile urethra is dilated at either end ;
viz., at the parts occupying the bulb and the glans
penis respectively. The diameter of the bulbous
urethra is midway between that of the prostatic and
membranous segments of the canal, while that of
the greater part of the penile urethra is midway
between that of the bulbous and membranous portions.
It is in the bulbous urethra that organic stricture is
the most commonly met with. The meatus measures
from one-fifth to one-fourth of an inch, and therefore
if a catheter will pass the meatus it will pass along
any part of the canal if normal. Its aperture is very
resisting, and has often to be incised to allow the
larger instruments to pass.

The narrowest parts of the urethra, therefore, are
at (1) the meatus, and (2) in the membranous segment,
especially at its anterior end. It is at these points
that calculi passed from the bladder are most apt to
lodge. The widest portions of the canal, on the other
hand, are at (1) the fossa navicularis, (2) the bulbous
part of the urethra, and (3) the centre of the prostatic
portion.

The mucous membrane presents, in addition
to many mucous glands, several lacunae, the orifices of
which for the most part open towards the meatus.
These lacunae are most numerous in the bulbous
urethra, and occupy the floor rather than the roof of
the canal. In passing small catheters, therefore, the
point of the instrument should be kept along the
upper surface of the tube, so that it may not become
engaged in any of these spaces. The largest lacuna,
the lacuna magna, is situate in the roof of the fossa
navicularis, and may readily engage the point of a
small instrument.

Otis has endeavoured to show that a definite

Chap, xviii.] THE PENIS. 365

relation exists between the circumference of the penis
and the circumference of the urethra, a relation
represented by the proportions 2-25 : 1, and makes
use of instruments of large size, which, when passed,
seem to demonstrate rather the dilatability of the canal
than any certain anatomical relationship.

The urethra may be ruptured by the patient
falling astride of some hard substance. In such an
injury it is crushed between the hard substance
and the pubic arch. The part of the canal, there-
fore, that is most often damaged is the membranous
segment, and the posterior part of the penile
division. The more the body is bent forwards at the
time the perineum is struck, the greater is the length
of penile urethra that may be crushed against the
pubes.

The female urethra is about one and a half
inches in length, and has a diameter of from a quarter
to one-third of an inch. It is capable, however, of
great distension. In the erect position the canal is
nearly vertical, and in the recumbent posture almost
horizontal.

Penis. — The skin covering the bulk of the organ
is thin and fine, and the subcutaneous tissue is scanty
and lax. It follows, from the looseness of this tissue,
that the skin is very distensible and movable. The
latter fact should be borne in mind in circumcision,
for in performing that operation the skin of the penis
can be so readily drawn forwards over and beyond the
glans, that if it is excised as far back as possible the
greater part of the organ may be left bare. This
applies, of course, mainly, to children. The laxity of
the subcutaneous tissue permits the organ to become
enormously swollen when O3dematous, or when extra-
vasated urine finds its way into the part. Over the
glans penis the mucous membrane is so adherent
that there is practically no subcutaneous tissue. It

366 SURGICAL APPLIED ANATOMY. [Chap. xvm.

happens, therefore, that when Hunterian chancres
appear on this part they can never be associated with
other than the most trifling induration, there being no
tissue in which the thickening can develop. At the
corona, on the other hand, the submucous tissue is
lax and plentiful, so that the induration can readily
form, and it is about this spot, therefore, that the
syphilitic sore attains often its most characteristic
development. The vascularity of the penis, and the
rapid engorgement that ensues when the return of its
venous blood is impeded, serve to explain the ready
and extensive swelling of the organ that follows when
any constricting band is placed about it. This should
be borne in mind in tying in a catheter by securing it
by tapes around the penis. The penis is often the
seat of arrests of development, presenting a variety
of appearances. Among them may be mentioned
hypospadias, where the inferior wall of the urethra
and corresponding part of the corpus spongiosum
are wanting, and epispadias, where the superior wall
of the canal and corresponding parts of the corpora
cavernosa are more or less entirely deficient.

Scrotum. — The skin of the scrotum is thin and
transparent, so that in bruising of the parts the dis-
coloration due to the extravasation of blood beneath
the surface is readily and distinctly seen. It is also
very elastic, and allows of great distension, as is seen
in large scrotal hernise and testicular tumours. The
integument of the part is indeed redundant, and the
excision of a portion of it will hardly be missed. Even
in gangrene of the scrotum, when both testicles have
been exposed, the parts have been entirely restored
without any inconvenient shrinking or contraction.
The rugae on the surface of the scrotum favour the
accumulation of dirt, and the irritation set up by such
accumulation may be the exciting cause of the epi-
theliomata that are not uncommon in this part. When

Chap, xviii.] THE SCROTUM. 367

the surface is sweating, the rugae tend to favour a
retention of the moisture between their folds ; from
this and other circumstances it happens that the
scrotum is liable to eczema and to those syphilitic
skin disorders that are often localised by irritation.
The rugae are a sign of health, since they depend
upon the vigorous contraction of the muscle fibres in
the dartos tissue. In the enfeebled, or under the
relaxing effects of heat, the scrotum becomes smooth
and pendulous. In lacerated wounds, especially when
portions of the skin are torn away, the dartos is of
great value in assisting to close the gap by its contrac-
tion, and in thus covering the exposed parts. To pro-
mote such contraction the wound is dressed with cold
applications. In a simple incised wound, as in castra-
tion, the dartos is apt to turn in the edges of the skin
and cause some difficulty in applying the sutures.
This difficulty may be avoided by relaxing that tissue
for a while by the application of a warm sponge to the
wound.

The subcutaneous tissue is lax and very extensive,
and permits of considerable extravasations of blood
forming beneath the surface. It is unadvisable, there-
fore, to apply leeches to the scrotum itself, since they
may lead to an undesirable outpouring of blood beneath
the skin, and to the appearance of a considerable
ecchymosis. Leeches in testicular affections had
better be applied over the region of the cord.

The scrotum, from its dependent position, and
from the looseness and extent of its cellular tissue, is
often the first part of the body to become oedematous
in dropsy, and is apt to show that redema in a marked
degree. The scrotum also is the part most fre-
quently the seat of elephantiasis, which is due
essentially to a connective tissue change. The vitality
of the scrotum is not considerable, and it there-
fore not unfrequently sloughs in parts when

368 SURGICAL APPLIED ANATOMY. [Chap. xvm.

severely inflamed. For this reason strapping should
be applied with some care over the enlarged
testis, for against the hard mass of the affected
gland the integument of the scrotum can be
subjected to considerable pressure when the strap-
ping is tightly applied. In such a case I have seen
the whole of one side of the scrotum slough from an
indiscreet use of this familiar method of treatment.

The laxity of the subcutaneous scrotal tissues is an
essential feature in those operations for the radical
cure of inguinal hernia where the fundus of the sac is
invaginated, through an incision in the scrotum, into
the orifice of the inguinal canal. Lastly, the great
mobility of the scrotum affords an admirable source
of protection to the testicle ; for when the part is
struck or squeezed the testis can slip about within
the scrotum, as a smooth ball would within a loose
indiarubber bag, and so very often eludes all injury.

The testicle may be retained within the abdomi-
nal cavity, or may lodge for varying periods of time, or
for life, in the inguinal canal. It may, on the other
hand, pass beyond the scrotum into the perineum, or
may miss the inguinal canal altogether and escape
through the femoral canal and saphenous opening on
to the thigh. The testis proper is entirely invested
by the visceral layer of the tunica vaginalis, except
over a small part of its posterior border where the
vessels enter. The epididymis is entirely covered
with the serous membrane at its sides, is more or less
so covered in front, but is free or uncovered along the
greater part of its posterior border. It is about the
posterior border of the epididymis that the visceral
layer of the tunica vaginalis joins the parietal layer.
It is mainly by this uncovered part of the epi-
didymis, and by the vessels, etc., that enter there, that
the testicle is fixed, for were the whole organ to be
entirely enveloped by the serous membrane, it would

chap, xviii.] THE TESTICLE. 369

lie more or less loosely in the serous cavity as lies the
small intestine in the abdomen. The more intimate
and extensive connection of the serous tunic with the
testis or gland proper serves in part to explain
the greater frequency with which hydrocele appears
in inflammation of this part of the organ, as compared
with its occurrence when the epididymis is alone in-
flamed. It is owing to the reflections of the tunica
vaginalis that in cases of common hydrocele the testicle
remains firmly set at the lower and posterior part of
the swelling, and yet so extensively is the organ sur-
rounded by that membrane that the position of the
gland in the larger hydroceles is often difficult to deter-
mine. In some cases the testicle occupies the front of
the scrotum, the epididymis being placed anteriorly,
and the body of the gland being located behind it.
The vas deferens descends also along the front of the
cord. In these cases the testicle is just in the position
it would occupy if it had been turned round upon its
vertical axis. The condition is known as inversion of
the testicle, and should be sought for in cases of hydro-
cele, as in several instances the testis has been pierced
by the trochar when tapping collections in which the
inversion existed.

The proper gland tissue is invested by a very dense
membrane, the tunica albuginea. The epididymis, on
the other hand, lacks any such firm fibrous investment.
The unyielding character of the tunica albuginea serves
in great part to explain the intense pain felt in acute
affections of the testis proper, a degree of pain which
is not reached when the less tightly-girt epididymis is
alone involved. It will be understood also that in in-
flammation of the epididymis the part swells rapidly
and extensively, while in a like affection of the body
of the gland the swelling is comparatively slow to
appear.

The tunica albuginea must also for some time

Y

370 SURGICAL APPLIED ANATOMY. [Chap. xvm.

resist the growth of testicular tumours. When the
testicle suppurates and matter finds an escape through
the skin, it is the unyielding character of the tunica
albuginea that is mainly answerable for any "fungus"
that may form. This fungus merely means the escape
of swollen, softened, and inflamed structures through a
hole in a more or less rigid membrane, and were that
membrane yielding no such protrusion would form.
A " fungus " never develops in connection with
suppuration of the epididymis alone ; at the most
an abscess of that part will lead to a troublesome
sinus.

It should be borne in mind that the lymphatics
of the scrotum go to the inguinal glands, those of the
testicle to the lumbar.

The spermatic cord. — The structures in the
cord are (1) the vas deferens, (2) the cremaster
muscle, (3) the spermatic and (4) cremasteric arteries,
and (5) the artery to the vas deferens, (6) the sper-
matic plexus of veins, (7) the genito-crural nerve, (8)
sympathetic nerve-fibres, and (9) lymphatics. The vas
deferens lies along the posterior aspect of the cord, and
can be readily detected by the firm, cord-like sensation
which it gives when pinched between the thumb and
finger. Mr. Birkett (Holmes' " System ") gives three
cases of rupture of the vas deferens during severe and
sudden exertion. The duct appears to have in each
case given way within the abdomen at some point
between the internal ring and the spot where it ap-
proaches the ureter. The injury is followed, as may
be supposed, by atrophy of the corresponding testicle.
The size of the cremaster muscle depends mainly upon
the weight it has to suspend. In atrophy of the tes-
ticle it almost entirely disappears, while in cases of
large slow-growing tumours of the gland it attains
considerable proportions. If in children or young
adults the skin over the middle of the thigh just

chap, xviii.] THE SPERMATIC CORD. 371

below Poupart's ligament be tickled the testicle of the
same side will usually be seen to be suddenly drawn
upwards. ' The tickling concerns the crural branch of
the genito-crural, while the motor nerve of the cre-
master is the genital division of the same trunk. The
interval of time that elapses between the irritation of
the skin and the movement of the testicle has been
appealed to as affording evidence of the state of nerve
health and of the readiness with which nerve impulses
are conducted. The three arteries of the cord are
divided in castration, and may all require ligature.
It is advisable to secure them separately, rather than,
adopt the clumsy plan of involving the whole cord
in one common ligature. The veins of the spermatic
or pampiniform plexus are very frequently varicose,
and then constitute the affection known as varico-
cele. Many anatomical causes render these veins
liable to this affection : they occupy a dependent
position, and the main vein is of considerable length,
and follows a nearly vertical course ; the vessels are
very large when compared with the corresponding
artery, and so the vis a tergo must be reduced to
a minimum ; they occupy a loose tissue, and are
lacking in support and in the aid afforded to other
veins (as in the limbs) by muscular contraction ; they
are very tortuous, form many anastomoses, and have
few and imperfect valves ; they are exposed to pres-
sure in their passage through the inguinal canal. The
left veins are more frequently affected than the right.
This may be explained by the facts that the left tes-
ticle hangs lower than the right; the left spermatic vein
enters the left renal at a right angle, while the right
spermatic vein passes obliquely into the vena cava ;
the left vein passes beneath the sigmoid flexure, and
is thus exposed to pressure from the contents of that
bowel. The relation between constipation and left-
sided varicocele is well known.

372 SURGICAL APPLIED ANATOMY. [Chap. xvm.

The female generative organs require but
little notice in the present volume. The labia majora
have the same pathological tendencies as has the
scrotum, to which, indeed, they anatomically correspond.
They are liable to present large extravasations of
blood, are greatly swollen when cedematous, are prone
to slough when acutely inflamed, and are the usual seats
of elephantiasis in the female. A hernia may present
in one or other labium (pudendal hernia), the neck of
the sac being between the vagina and the pubic ramus.

The vagina is lodged between the bladder and
rectum, while the upper fourth of its posterior surface
is covered with peritoneum, and is therefore in relation
to the abdominal cavity. Thus it happens that the
bladder, the rectum, or the small intestines, may pro-
trude into the vagina by a yielding of some parts of
its walls and thus produce a vaginal cystocele, recto-
cele, or enterocele.

The abdominal cavity may be opened through a
wound of the vagina. In one or two instances of such
injuries several feet of intestine have protruded
through the vulva. In one reported case an old
woman, the subject of a brutal rape, walked nearly a
mile with several coils of the small bowel hanging
from her genitals.

From the comparative thinness of the walls that
separate the vagina from the bladder and rectum, it
happens that vesico-vaginal and recto-vaginal fistulae
are of frequent occurrence. The vagina is very
vascular, and wounds of its walls have led to fatal
haemorrhage. . It is very dilatable, as can be shown
when the canal is plugged to arrest haemorrhage from
the uterus.

The unimpregnated uterus is very rarely wounded,
owing its immunity to the denseness of its walls, to
its small size, to its great mobility, and to its position
within the bony pelvis.

Chap, xviii.] THE RECTUM. 373

The rectum in the adult is situated entirely
within the true pelvis, and presents three marked
curves, one in the lateral and two in the antero-
posterior direction. In the infant, however, a good
deal of the rectum is in the abdominal rather than the
pelvic cavity, the gut is nearly straight, and occupies
a more or less vertical position. For these reasons
prolapsus ani is much more common in children than
in adults ; children being, besides, especially liable to
such exciting causes of prolapse as worms and rectal
polypi.

The rectum is about eight inches in length. Its
upper part, for some three inches, is entirely in-
vested by peritoneum. The serous membrane gra-
dually leaves its posterior surface, then its sides,
and lastly its anterior surface. Anteriorly the peri-
toneum, in the form of the recto- vesical pouch, extends
in the male to within three and a half or four inches
of the anus, while on the posterior aspect of the gut
there is no peritoneum below a spot five inches from
the anus. Thus, in excision of the rectum, more of
the bowel can be removed on the posterior than on the
anterior part of the tube. It will be seen, also, that car-
cinomatous and other spreading ulcers are more apt to
invade the peritoneal cavity when they are situated in
the anterior wall of the intestine.

By inserting the finger into the rectum the pro-
state and seminal vesicles can be readily felt and
examined, and that triangular surface of the bladder
explored through which puncture per rectum is made
(page 355).

It will be understood that the prostate, when en-
larged, may encroach upon the cavity of the rectum
and greatly narrow its lumen. The position of the
seminal vesicles with regard to the bowel is such that
in violent attempts at defsecation they may be pressed
upon by the rectal contents, and so in part emptied,

374 SURGICAL APPLIED ANATOMY, ichap. xvin.

producing a kind of spermatorrhoea. Defecation also
often causes much pain in inflammatory affections of
the prostate and adjacent parts.

The anterior surface of the rectum in the female
is in relation, so far as the finger can reach, with the
vagina, and in examining the lower part of the rectum,
it is convenient to protrude its mucous membrane
through the anus by means of the finger introduced
into the genital passage.

The rectum is dilated, and is very distensible just
above the anus. In fsecal accumulations it may be dis-
tended to a considerable size, and strange foreign bodies
of large dimensions have been found in the ampulla.
Among the latter may be mentioned a bullock's horn,
an iron match-box, and a glass tumbler. Experiment
has shown that when the rectum is distended in the
male, the recto-vesical fold of peritoneum is raised,
and the bladder is elevated and pushed forwards. In
the female the fundus uteri is raised and pushed
towards the symphysis. In connection with the
latter effect it has been suggested that the rectum
should be artifically distended in some cases of opera-
tion on the uterus and ovaries, so that those organs
may be placed within easier reach.

If the sphincter be very gradually dilated, the
entire hand, if small, may be introduced into the
rectum in both males and females. The circumference
of the hand should not exceed eight inches. By a
semi-rotary movement, and by alternately flexing and
extending the fingers, the hand can be insinuated
into the commencement of the sigmoid flexure.
( ) wing to the - mobility of this part of the bowel a
large extent of the abdomen may be explored through
the bowel wall. The structures that can be readily
felt are the kidney, the aorta, the iliac vessels, the
uterus and ovaries, the bladder and its surroundings,
the pelvic brim, the sacro-sciatic foramina, the ischial

Chap, xvni.] THE RECTUM. 375

spine, the sacrum, etc. " In some subjects even a
small hand cannot be passed beyond the reflection of
the peritoneum over the second part of the gut. In
such instances the peritoneum offers a resistance like a
tight garter, and prevents the farther advance of the
hand without great risk of laceration of the parts "
(Walsham).

Mr. Davy has invented a wooden " lever," by
which the common iliac arteries may be compressed
against the pelvic brim through the rectum. The
lever has proved of particular value in arresting
haemorrhage during amputation through the hip
joint.

The attachments of the rectum by means of the
pelvic fascia are not very firm ; since, in some severe
and rare cases of prolapse, all the walls of the gut
may be protruded at the anus. In excision of the
rectum, also, advantage is taken of this mobility.
In that operation the lower two inches or more
of the bowel may be removed, and the remaining part
of the tube drawn down so that its mucous membrane
can be stitched to the edges of the wound.

The mucous membrane is thick, vascular, and but
loosely attached to the muscular coat beneath. This
laxity, which is more marked in children, favours pro-
lapse, an affection in which the mucous membrane of
the lower part of the rectum is protruded at the anus.
The mucous membrane presents three prominent semi-
lunar folds, about half an inch in depth, which are
placed more or less transversely to the long axis of the
bowel. The first projects backwards from the fore
part of the rectum opposite the prostate, the second
projects inwards from the left side of the tube opposite
the middle of the sacrum, the third is near the com-
mencement of the bowel on the right side. These
folds, especially when the gut is empty, may offer con-
siderable resistance to the introduction of a bougie or

376 SURGICAL APPLIED ANATOMY. [Chap. xvm.

long enema tube, and their position should be therefore
borne in mind.

The vessels -, and especially the veins, at the lower
part of the rectum, are apt to become varicose and
dilated, and form piles. The tendency to piles can
in part be explained by the dependent position of the
rectum, by the pressure effects of hardened faeces
upon the returning veins, and by the fact that part
of the venous blood returns through the systemic
system (internal iliac vein) and part through the
portal system (inferior mesenteric vein). This con-
nection with the portal trunk causes the rectum to
participate in the many forms of congestion in-
cident to that vein. The veins of the rectum, also,
can be affected by violent expiratory efforts. For
the last four inches, moreover, of the bowel, the ar-
rangement of the vessels is peculiar, and is such as to
favour varicosity. The arteries, "having penetrated
the muscular coats at different heights, assume a longi-
tudinal direction, passing in parallel lines towards the
edge of the bowel. In their progress downwards they
communicate with one another at intervals, and they
are very freely connected near the orifice, where all
the arteries join by transverse branches of consider-
able size " (Quain). The veins form a plexus with a
precisely similar arrangement.

Anus. — The skin about the anus is thrown into
numerous folds, and it is in these that the ulcer
or fissure of the anus forms. The extreme painful-
ness of these ulcers is due to the exposure of a nerve-
fibre at their base, and to the constant contraction of
the sphincter muscle that they excite. Relief is given
by incising the base of the ulcer, so as to divide
some part of the sphincter ; or by violently dilating
the anus, so as to tear up the base of the ulcer and
paralyse for a while the action of the disturbing
muscle. A fine white line around the anus, at the

Chap. XVIIL] PELVIS AND PERINEUM. 377

junction of the skin and mucous membrane, indi-
cates the interval between the external and internal
sphincters (Hilton).

The anus may be torn during defsecation, when
the stools are hard. A case is reported of a woman,
who, during violent efforts at defsecation, felt something
give way, and discovered faeces in her vagina. The
recto-vaginal wall had ruptured two inches from the
anus. During labour, the child's head has passed into
the rectum, and has been delivered per anum.

As congenital defects, the anus and entire rectum
may be absent ; or the anus be not evident, and the
rectum be more or less complete ; or the anus and
lowest part of the rectum may be normal, and the
upper part of the bowel be quite wanting.

Nerves of pelvis and perineum. — The
pelvic viscera are supplied by the pelvic plexus of
the sympathetic. This plexus is joined by at least
three spinal nerves, the second, third, and fourth
sacral.

It is well known that in certain affections of the
bladder, rectum, prostate, etc., pain is felt along the
perineum, in the penis, over the buttock, and down
the thigh. These parts are supplied by the pudic
and small sciatic nerves, and the reason for the pain
is explained by noticing that the very spinal nerves
that join the plexus for the viscera give off also the
pudic and small sciatic nerves, the former from the
third and fourth sacral, the latter from the second
and third. Thus, the pelvic viscera, and the skin of
the buttock, perineum, and external genitals are all
kept in association by the same spinal nerves.
The upper part of the rectum is provided with but
little sensation, as illustrated by the passage of instru-
ments, by the comparative painlessness of malignant
and other growths high up in the bowel, and by the
little inconvenience felt when the gut is distended

378 SURGICAL APPLIED ANATOMY. [Chap. xvm.

with hardened faeces. From this apathy it has pro-
bably happened that, in the self-administration of
enemata, patients have thrust the tube through the
rectum into the peritoneal cavity. The last two
inches of the bowel, on the other hand, are extremely
sensitive.

The pain at the end of the penis felt in prostatic
affections, and in stone, or other maladies involving
the bladder neck, is probably explained by the fact
that the prostatic nerve plexus (that supplies both
the gland and the neck of the bladder) is continued
to the end of the penis as the cavernous plexus. It
terminates at the very spot where the penile pain is
mostly complained of, viz., at the posterior part of the
glans.

The nerve relations between the anus and the neck
of the bladder are very intimate. Painful affections of
the anus often cause bladder troubles, and retention
of urine is very common after operations upon piles.
Maladies, on the other hand, that involve the bladder
neck are often associated with tenesmus and anal dis-
comfort. This relation is maintained by the pelvic
plexus, but mainly by the fourth sacral nerve. This
nerve gives special branches direct to the neck
of the bladder, and then goes to supply the muscles of
the anus (the sphincter and levator) and the integu-
ment between the anus and the coccyx.

The mucous membrane of the urethra, the muscles
of the penis, and the greater part of the skin of the
penis, scrotum, perineum, and anus, are supplied by the
pudic nerve. Thus, it will be understood that irritation
applied to the urethra may cause erection of the penis
(as illustrated by chordee in gonorrhoea), or may pro-
duce contraction of the urethral muscles (as seen in
some forms of spasmodic stricture). The disturbance
caused by accumulated secretion beneath the prepuce
in young children may provoke great irritability of the

Chap. XVIII. ] PELVIS AND PERINEUM. 379

organ, and it is well known that painful affections of
the perineum and anus may be associated with
priapism. The presence of the inferior pudendal
nerve in the perineum will explain the pain about the
buttock and down the back of the thigh that is often *
complained of during the growth of perineal abscess
and in painful affections of the scrotum. This nerve
crosses just in front of the tuber ischii, and may be
so pressed upon by using a hard seat as to cause one-
sided neuralgia of the penis and scrotum. It is also
in close connection with the ischial bursa, and neu-
ralgia of the same parts has been met with in cases of
inflammation involving that structure.

The testicle is supplied mainly by the spermatic
plexus. This plexus comes off* from the renal,
and thus the testicle is brought into close relation with
the kidney. This is illustrated by the pain felt in the
renal region in neuralgia of the testicle, by the pain
felt in the testicle, and by the vigorous retraction of
that organ observed in certain affections of the kidney,
such- as in acute nephritis, and in the passage of renal
calculi. By means of the renal plexus the testicle is
brought into direct communication with the semi-
lunar ganglia and solar plexus. This communication
serves to explain the great collapse often noticed in
sudden injuries to the testicle, and especially the
marked tendency to vomit, so often observed in such
lesions. So far as its nerves arc concerned, the testicle
is nearly in as intimate relation with the great nerve-
centre of the abdomen as is a great part of the small
intestine, and one would expect a sudden crush of the
testis to be associated with as severe general symptoms
as would accompany a sudden nipping of the ileum
in a rupture. Such a resemblance in symptoms is
actually to be observed in practice.

380

tfatt U.

THE LOWER EXTREMITY.

CHAPTER XIX.

THE REGION OP THE HIP.

THIS region will be considered under the following
heads : 1. The buttocks. 2. The region of Scarpa's
triangle. 3. The hip joint. 4. The upper third of
the femur.

1. The buttocks. — Surface anatomy. — The
bony points about the gluteal region can be well
made out. The crest of the ileum is distinct, as is also
the anterior superior spine. The posterior superior
spine is less evident, but can be readily felt by follow-
ing the crest to its posterior termination. This spine
is on a level with the second sacral spine, and is
placed just behind the centre of the sacro-iliac articu-
lation. The great trochanter is a conspicuous land-
mark. It is covered by the fascial insertion of the
gluteus maximus. Its upper border is on a level with
the centre of the hip joint, and is somewhat obscured
by the tendon of the gluteus medius which passes over
it. The comparatively slight prominence of the tro-
chanter in the living subject, as compared with the great
projection it forms in the skeleton, depends upon the
completeness with which the gluteus medius and
minimus fill up the hollow between the trochanter and
the ileum. When these muscles are atrophied the
process becomes very conspicuous. In fat individuals

chap, xix.] THE BUTTOCK. 381

its position is indicated by a slight but distinct depres-
sion over the hip.

If a line be drawn from the anterior superior spine
to the most prominent part of the tuber ischii, it will
cross the centre of the acetabulum, and will hit the top
of the trochanter. This line, known as Nelaton's line,
is frequently made use of in the diagnosis of certain
injuries about the hip. For like diagnostic purposes
Bryant makes use of a " triangle." As the patient lies
in the recumbent posture, a vertical line is dropped
from the anterior superior spine. A second line is
drawn forwards from the same point to the top of the
great trochanter. The triangle is completed by a third
line joining the first two, and drawn at right angles
to the vertical line. A measurement of this third or
test line will show if any shortening has taken place
in the neck of the femur. It may be noted that the
top of the trochanter is nearly on a level with the
pubes.

The tubera ischii are readily felt. They are covered
by the fleshy fibres of the gluteus maximus when the
hip is extended. But when the hip is flexed, the pro-
cesses become to a great extent uncovered by that
muscle.

The muscular mass of the buttock is formed by
the gluteus maximus behind and by the gluteus medius
and minimus and tensor vaginae femoris in front. The
latter muscle can be seen when in action, i.e., when
the thigh is abducted and rotated in.

The fold of the buttock corresponds to the lower
border of the gluteus maximus. When the hip is fully
extended, as in the erect posture, the buttocks are
round and prominent, the gluteal fold is transverse and
very distinct. When the hip is a little flexed, the but-
tocks become flattened, the gluteal fold becomes oblique,
and to a considerable extent disappears. Among
the early symptoms of hip disease are flattening of

382 SURGICAL APPLIED ANATOMY. [Chap. xix.

the buttock and loss of the gluteal fold. These
symptoms depend upon the flexion of the hip, which is
practically constant in every case of the malady before
treatment. It is incorrect to say, as some books
still assert, that these changes are due to wasting of
the gluteal muscles, since they appear at too early
a period for any considerable muscular atrophy to
have taken place. It is true that these symptoms
are much exaggerated by the wasting of the muscle
that occurs later on in the course of the hip affection.

With regard to the vessels and nerves of the but-
tock, if a line be drawn from the posterior superior
spine to the top of the great trochaiiter when the thigh
is rotated in, a point at the junction of the inner with
the middle third of that line will correspond to the
gluteal artery as it emerges from the sciatic notch.
A line drawn from the posterior superior spine to the
outer part of the tuber ischii crosses both the posterior
inferior and ischial spines. The former is about
two inches and the latter about four inches below
the posterior superior process. The sciatic artery
reaches the gluteal region at a spot corresponding to
the junction of the middle with the lower third of this
line. The position of the pudic artery as regards the
buttock is not difficult to indicate, since it crosses over
the ischial spine in passing from the great to the small
sacro-sciatic foramen.

A line drawn from the point just given for
the sciatic artery down the back of the limb, so as to
lie about midway between the great trochanter and the
ischial tuberosity, will correspond to the course of the
great sciatic nerve.

The skin over the buttock is thick and coarse,
and is frequently the seat of boils. From the appear-
ance it presents in very fully injected specimens, it
would appear that its blood supply is not quite so free
as it is in many other parts of the surface.

chap, xix.] THE BUTTOCK. 383

The subcutaneous fascia is lax, arid contains a large
quantity of fat. It is to this fat rather than to mus-
cular development that the buttock owes its roundness
and prominence. The enormous buttocks of the so-
called " Hottentot Venus," whose model is in many
museums, depend for their unusual dimensions upon
the greatly increased subcutaneous fat. The amount
of adipose tissue normally in the part renders the
buttock a favourite place for lipomata. The laxity of
the superficial fascia permits large effusions both of
blood and pus to take place in the gluteal region, and
ecchymoses of the buttock can probably reach a greater
magnitude than is possible elsewhere.

The deep fascia of the buttock, a part of the
fascia lata of the thigh, is a structure of much
importance. This dense membrane is attached above
to the iliac crest, and to the sacrum and coccyx.
Descending in front over the gluteus medius, it splits
on reaching the anterior edge of the gluteus maximus
into two layers, one of which passes in front of the
muscle and the other behind. The gluteus maximus
is thus enclosed, like the meat in a sandwich, between
two layers of fascia, and the two lesser gluteal muscles
are bound down within an osseo-aponeurotic space,
which is firmly closed above, and only open below
towards the thigh, and internally at the sciatic
foramina. Extravasations of blood may take place
beneath this fascia without any discoloration of the
skin to indicate the fact, the blood being unable to
reach the surface through the dense membrane. Such
extravasations may be long pent up, and, as they
would fluctuate, may be mistaken for abscess.

Deep inflammations beneath this fascia, and
especially when beneath the gluteus medius, may be
associated with much pain, owing to the circumstance
that the inflammatory effusions will be pent up between
a wall of bone on one side and a wall of dense fascia

384 SURGICAL APPLIED ANATOMY. [Chap. xix.

and stout muscle on the other. Abscesses so pent up
may travel for a considerable distance down the thigh
before they reach the surface, and Farabeuf relates a
case where a gluteal abscess travelled to the ankle
before it broke.

Under other circumstances the gluteal abscess may
make its way into the pelvis through the sciatic
foramina, or a pelvic abscess may escape through one
of these foramina, and appear as a deep abscess of the
buttock.

The thickened part of the fascia lata that runs
down on the outer side of the limb, between the crest
of the ileum above and the outer tuberosity of the
tibia and head of the fibula below, is known as the
ilio-tibial band. This band is tightly stretched across
the gap, between the iliac crest and the great
trochanter, and if pressure be made with the fingers
between these two points, the resistance of this part
of the fascia can be appreciated. It is obvious that
in fracture of the neck of the femur, when the great
trochanter is made to approach nearer to the crest,
this band will become relaxed, and Dr. Allis (Agnew's
4 'Surgery," vol. i.) has drawn attention to this fascial
relaxation as of value in the diagnosis of fractures of
the femoral neck.

The lower free edge of the glutens maximus
forms the "fold of the buttock/' as already stated
(page 381).

It would appear that even this great muscle may
be ruptured by violence. Thus Dr. MacDonnell (Brit.
Med. Journ., 1878) reports the case of a robust man,
aged sixty-three, who, while trying to lift a heavy
cart when in a crouching position, felt something
give way in his buttock, and heard a snap. He fell,
and was carried home, when it was found that the
great gluteal muscle was ruptured near the junction
with its tendon.

chap, xix.] THE BUTTOCK. 385

At least three bursse exist over the great
trochanter, separating that process from the three
gluteal muscles respectively. The most important of
these is the bursa between the gluteus maximus and
the bone. When this sac is inflamed much difficulty
is experienced in moving the limb, and the thigh is
generally kept flexed and adducted. This position
means absolute rest from movement on the part of the
gluteal muscles, which, when acting, would extend
and abduct the limb, and bring pressure to bear upon
the tender bursa.

. The bursa is quite close to the bone, so close that
it is said that caries of the trochanter has followed
upon suppuration of the little sac (T. P. Teale).
There is a bursa over the ischial tuberosity that is
often inflamed in those whose employments involve
much sitting, the bursa being directly pressed upon in
that position. This sac is the anatomical basis of
the disease known in older text-books as * ' weaver's
bottom," or " lighterman's bottom." When enlarged
this bursa may press upon the inferior pudendal nerve
(page 345).

The arteries and nerves of the buttock.—
The gluteal artery is about the same size as the ulnar,
and the sciatic as the lingual. The former vessel
may sometimes be of much greater magnitude, and
has led, when wounded, to rapid death from haemorr-
hage. Wounds of the gluteal vessel will probably
involve only the branches of the artery, since the
greater part of the main trunk is situate within the
pelvis. Gluteal aneurisms are not very uncommon,
and with regard to the treatment of these tumours it
may be noted that the gluteal artery, or, better, the
internal iliac trunk, can be compressed through the
rectum. Compression so applied has been adopted
for the treatment of gluteal aneurism by Dr. Sands
of New York (Amer. Journ. Med. Sc., 1881), but
z

386 SURGICAL APPLIED ANATOMY. [Chap. xix.

without much effect. Aneurism of the commence-
ment of the gluteal artery could hardly fail to provoke
nerve symptoms, since the vessel runs between the
lumbo-sacral cord and first sacral nerve.

Both the gluteal and sciatic arteries have been
ligatured through the buttock, through incisions made
directly over the course of the vessels.

Henle has collected six cases where the femoral
artery ran down along the back of the thigh to the
popliteal space in company with the great sciatic
nerve. The abnormal vessel was in each case con-
tinued from a greatly enlarged sciatic artery.

The great, sciatic nerve is a continuation
downwards of the main part of the sacral plexus. It
is in this nerve that the form of neuralgia known
as sciatica is located. A reference to the immediate
relations of this nerve will show that it may readily
be exposed to many external influences. Thus, in the
pelvis it may be pressed upon by various forms of
pelvic tumour, and sciatica be produced in consequence.
Its anterior surface is in close relation with some of
the principal pelvic veins, and according to Erb one
form of sciatica may be traced to an engorged condition
of these vessels. Aneurism of certain branches of the
internal iliac artery within the pelvis, sciatic hernia,
and accumulation of fseces within the rectum, may all
cause neuralgia of this important trunk. ' It is said to
have been injured also by the pressure of the foetal
head during tedious labours, and to be affected by
violent movements of the hip, a circumstance readily
understood if the close relation of the nerve to the
hip-joint be borne in mind. The nerve is also near
enough to the surface to be influenced by external
cold, and to this influence many forms of sciatica are
ascribed. At the lower edge of the great gluteal
muscle the trunk is still nearer to the surface, and
this fact receives illustration in a case reported in

chap, xix.] THE BUTTOCK. 387

Ziemssen's Cyclopaedia, where paralysis of the nerve
followed its compression by the contracting scar of a
bed-sore.

Nerve stretching:. — The great sciatic nerve has
been frequently cut down upon and roughly stretched
for the relief of certain nervous affections of the limb.
In connection with this procedure it is important
to know how great an amount of traction may be
brought to bear upon this and other nerves without
the cord giving way. Trombetta, who has paid much
attention to this matter, gives the following weights
as those required to break the undermentioned nerves :
great sciatic, 183 pounds; internal popliteal, 114
pounds ; anterior crural, 83 pounds ; median, 83
pounds; ulnar and radial, 59 pounds; brachial
plexus in the neck, 48 to 63 pounds; and brachial
plexus in the axilla, 35 to 81 pounds. (In each
instance fractions have been omitted.) It must
be borne in mind, however, as pointed out by Mr.
Symington (Lancet, 1878), that in forcibly stretching
the great sciatic nerve the trunk may be torn away
from its attachments to the soft spinal cord before a
sufficient force has been applied to rupture the nerve
at the point stretched. The same observation applies
to other large nerve-cords, such as those of the brachial
plexus, that are stretched at a spot not far from their
spinal connections.

The skin of the buttock is well supplied with
nerves, and tactile sensibility is almost as acute in
this part as it is over the back of the hand, while it is
more acute than is like sensibility in such parts as
the back of the neck, the middle of the thigh, and the
middle of the back. The sensation of the gluteal
integument is derived from a number of different
nerves, and it may possibly interest a school-boy, who
has been recently birched, to know that the painful
sensations reached his serisorium through some or all

388 SURGICAL APPLIED ANATOMY. [Chap. xix.

of the following nerves : offsets of the posterior
branches of the lumbar nerves, some branches of the
sacral nerves, the lateral cutaneous branch of the last
dorsal nerve, the iliac branch of the ilio-hypogastric
nerve, offsets of the external cutaneous nerve, and
large branches of the small sciatic.

.It should be remembered that the pelvic viscera
can be readily reached through the sciatic foramina
from the buttock. I once saw a case at the London
Hospital of a man who was admitted with an.
apparently insignificant stab of the buttock. He died
in a few days, of acute peritonitis ; and the autopsy
showed that the dagger had passed through the great
sacro-sciatic foramen, had entered the bladder and
allowed urine to escape into the peritoneal cavity.
The rectum has also been damaged in injuries to the
buttock, and Anger records a case of an artificial anus
situate upon the buttock, that had followed a gunshot
wound, which, after involving the buttock, had opened
up the caecum.

2. The region of Scarpa's triangle. —
Surface anatomy. — The most important land-
marks in the region of the groin, the anterior superior
iliac spine, the spine of the pubes, and Poupart's
ligament, are readily made out. To the two spines
reference has already been made (page 263). Poupart's
ligament follows a curved line, with its convexity down-
wards, drawn between these two projections. It can
be felt in any but stout persons, its inner half more
distinctly than its outer, and even in very fat indivi-
duals its position is indicated by a slight furrow. The
ligament is relaxed, and rendered less distinct when
the thigh is flexed and adducted, or when it is
rotated in.

The line, often called " Holden's line," is thus
described by that surgeon : i i When the thigh is even
slightly bent, there appears a second furrow in the

chap, xix.] SCARPA'S TRIANGLE. 389

skin, below that at the crural arch. This second
furrow begins at the angle between the scrotum and
the thigh, passes outwards, and is gradually lost
between the top of the trochanter and the anterior
superior spine of the ileum. It runs right across the
front of the capsule of the hip-joint. For this reason
it is a valuable landmark in amputation at the hip-
joint. The point of the knife should be introduced
externally where the furrow begins, should run
precisely along the line of it, and come out where it
ends ; so that the capsule of the joint may be opened

with the first thrust Effusion into the joint

obliterates all trace of the furrow, and makes a
fulness when contrasted with the opposite groin."
It must be confessed that this line is not always so
distinct as Mr. Hclden's description would lead us to
believe, and in many subjects it is quite impossible to.
make it out at all.

The sartorius muscle is brought into view when
the leg is raised across the opposite knee, and the
adductor longus is rendered distinct when the thigh
is abducted, and the individual's attempts to adduct
the limb are resisted. Even in the obese the clear
edge of this muscle can be felt when it is in vigorous,
action, and the fingers can follow its border up to
the very origin of the muscle, just below the pubic
spine.

The lymphatic glands in this region can sometimes,
be felt beneath the skin, especially in thin children.
The femoral ring lies on a horizontal line drawn from
the pubic spine to the top of the great trochanter, at
about one inch to the outer side of the first-named
process; or its position may be indicated by noting the
pulsations of the femoral artery against the pubes ;
and then, by allowing half an inch to the inner side of
that vessel for the femoral vein, the site of the femoral
ring will be reached. The position of the saphenous

39° SURGICAL APPLIED ANATOMY. [Chap. xix.

opening is sometimes indicated by a slight depression
in the integuments. It lies just below Poupart's
ligament, and its centre is about one and a half inches
below and external to the pubic spine. In thin
subjects the long saphenous vein can be often made
qut, passing to the saphenous opening.

Jf a. line be drawn from the middle of Poupart's
ligament to the tubercle for the adductor magnus, on
the inner condyle of the femur, it will correspond
in the upper two-thirds of its extent to the position
of the femoral artery. Just below Poupart's ligament
the femoral vein lies to the inner side o£ the artery,
whjle the anterior crural nerve runs about one-
fourth of a.n inch to its outer side. The profunda
femoris arises about one and a half inches below
Poupart's ligament, and the internal and external
circumflex vessels come off about two inches below
that structure.

The head of the femur lies close below the
ligament, and just to the outer side of its central
point. In very thin subjects this part of the bone
can be indistinctly felt through the soft parts when
the thigh is extended and rotated outwards.

The skin over Scarpa's, triangle is, unlike that of
the buttock, comparatively thin and fine. The loose-
ness of its attachment, also, to the parts immediately
beneath, permits it to be greatly stretched, as is seen
in cases of large femoral hernise, and in certain inguinal
tumours of large size. It may even give way under
severe traction, as occurred in a case reported by
Berne. The patient in this case was a child aged 11,
the subject of hip disease. The thighs were flexed
upon the abdomen, and, forcible extension being
applied to relieve the deformity, the skin gave way
just below the groin, and separated to the extent of
some two and a half inches. Contracting scars in the
region of the groin may produce a permanent flexing

Chap, xix.] SCARPA'S TRIANGLE. 391

of the hip, and this result is not uncommon after deep
and severe burns of this neighbourhood. It may at
the same time be noted that horizontal wounds about
the groin can be well adjusted by a slight flexion of
the thigh.

Instances are recorded where a supernumerary
mammary gland, provided with a proper nipple, has
been found located in the groin. Jessieu relates the
case of a female who had a breast so placed, and who
suckled her child from this part. In a few cases the
testicle, instead of descending into the scrotum, has
escaped through the crural canal, and made its
appearance in Scarpa's triangle. It has even mounted
up over Poupart's ligament after the manner of a
femoral hernia, being probably urged in that direction
by the movements of the limb.

The superficial fascia in this region is not
very dense, and has little or no influence upon the
progress of a superficial abscess. This fact receives
extensive illustration, since the glands in Scarpa's
triangle frequently suppurate, and yet the pus in the
great majority of the cases readily reaches the surface,
in spite of the circumstance that the denser layer of the
superficial fascia (for in this region it is divided into
two layers) covers in those glands, and should hinder
the progress of pus towards the surface. Although
the subcutaneous fat is not peculiarly plentiful in this
region, yet Scarpa's triangle is a favourite spot for
lipomata. It is in this place that the fatty tumour
often exhibits its disposition to travel, and several
cases are reported where such a tumour has started at
the groin, and travelled some way down the thigh.
The journey is always in the direction of gravity, and
is rendered possible by the lax capsule of the tumour,
by the looseness of the tissue in which it is embedded,
and by the fluidity of fat at the normal temperature
of the body.

392 SURGICAL APPLIED ANATOMY. [Chap. xix.

The fascia lata completely invests the limb,
being, so far as the front of the thigh is concerned,
attached above to Pou part's ligament, to the body and
rarrms of the pubes, and the ramus of the ischium.
Its integrity is interrupted only by the saphenous
opening. This fascia exercises some influence upon
deep abscesses and deep growths. Thus a psoas
abscess reaches the thigh by following the substance
of the psoas muscle, and finds itself, when it arrives at
Scarpa's triangle, under the fascia lata. In a great
number of cases it points where the psoas muscle
ends, but in other and less frequent instances its
progress is decidedly influenced by the fascia lata, and
it moves down the limb. Thus guided, a psoas
abscess has pointed low down in the thigh, and even
at the knee, and Erichsen reports a case where such
an abscess (commencing, as it did, in the dorsal spine),
was ultimately opened by the side of the tendo
Achillis.

The ilio-psoas muscle being stretched, as it were,
over the front of the hip joint, and participating in
many of the movements of that joint, is peculiarly
liable to be sprained in violent exercises. Between
this muscle and the thinnest part of the hip capsule is
a bursa, which often communicates with the joint.
When chronically inflamed, this bursa may form a large
tumour on the front of the thigh that may, accord-
ing to Nancrede, attain the size of a child's head. To
relieve this bursa from pressure when inflamed, the
thigh always becomes flexed, and a train of symptoms
is produced that are not unlike those of hip disease.
The bursa is quite close to the pelvic bones, and in one
case at least suppuration of this bursa led to necrosis
of those bones (Nancrede). The sartorius is a muscle
that, from its length, peculiar action, etc., one
would hardly expect to find ruptured from violence,
yet in the Musee Dupuytren there is a specimen of such

Chap, xix.] SCARPA'S TRIANGLE. 393

a rupture about the middle of the muscle united by
fibrous tissue. The adductor muscles, and especially
the adductor longus, are frequently sprained or even
partially ruptured during horse exercise, the grip of
the saddle being for the most part maintained by
them. " Rider's sprains," as such accidents are
called, usually involve the muscles close to their pelvic
attachments. Much blood is often effused when the
fibres are ruptured, and such effusion, may become
so dense and fibrinous as to form a mass that has,
been mistaken for a detached piece of the pubes
(Henry Morris). The term " rider's bone " refers to.
an ossification of the upper tendon of the adductor
longus or magnus, following a sprain or partial
rupture. Cases are reported where the piece of bone
in the tendon was half an inch, two inches, and even
three inches long.

Blood-vessels. — The femoral artery occupies so
superficial a position in Scarpa's triangle, that it is not
infrequently wounded. The vessel also has been
opened up by cancerous and phagedaBnic ulcerations of
this part, the occurrence leading to fatal haemorrhage.
Pressure is most conveniently applied to the artery at
a spot immediately below Poupart's ligament, and
should be directed backwards, so as to compress the
vessel against the pubes and adjacent part of the hip
capsule. Lower down, compression should be applied
in a direction backwards and outwards, so as to bring
the artery against the shaft of the femur, which lies
at some distance, to its outer side. Pressure rudely
applied by a tourniquet may cause phlebitis by
damaging the vein, or neuralgia by contusing the
anterior crural nerve.

From the near proximity of the artery and vein,
it happens that arterio- venous aneurisms following
wound have been met with in this situation. Aneu-
rism is frequent in the common femoral, and many

394 SURGICAL APPLIED ANATOMY. [Chap. xix.

reasons can be given why that vessel should be attacked.
It is just about to bifurcate into two large trunks, its
superficial position exposes it to injury, it is greatly
influenced by the movements of the hip, and its coats
may even be damaged by those movements, if excessive.

Phlebitis of the femoral vein has in many cases
followed contusion of the vessel in its upper or more
superficial part, and a like result has even followed
from violent flexion of the thigh. The long saphenous
vein is often varicose, and one form of the varicosity
is said to depend upon constriction of the vein by an
unduly narrow saphenous opening. One sometimes
meets with cases in out-patient practice that may
probably be due to this cause; but the evidence is not
sufficiently weighty to sanction the operation proposed
for such cases, viz., an enlargement of the saphenous
opening itself.

The anterior crural nerve lies on the ilio-psoas
muscle, and it is said that neuralgia and even para-
lysis of the nerve may follow upon inflammation of
that muscle and upon psoas abscess. The superficial
position of the trunk exposes it to injury. The
genito-crural nerve (the nerve that supplies the
cremaster muscle) gives a sensory filament to the
integument of the thigh in Scarpa's triangle. Irri-
tation of the skin over the seat of this nerve, which is
placed just to the outer side of the femoral artery,
will cause, in children, a sudden retraction of the
testicle. The same result is often seen in adults
also on slight irritation, and is nearly always provoked
by severe stimulation.

The lymphatic glands in this region are
numerous, and as they are frequently the seat of
abscess, it is important to know from whence they
derive their efferent vessels. They are divided into a
superficial and deep set. The superficial set, averaging
from ten to fifteen glands, are arranged in two clusters,

Chap, xix.] SCARPA'S TRIANGLE. 395

one parallel and close to Poupart's ligament (the
horizontal series), the other parallel and close to the
long saphenous vein (the vertical series). The deep
set, about four in number, are placed along the femoral
vein, and occupy the crural canal.

The inguinal glands receive the following lymphatics ;

Superficial vessels of lower limb — vertical set of
superficial glands.

Superficial vessels of lower half of abdomen —
middle glands, of horizontal set.

Superficial vessels from outer surface of buttock =
external glands of horizontal set.

From inner surface of buttock = internal glands
of horizontal set. (A few of these vessels go to the
vertical glands).

Superficial vessels from external genitals = hori-
zontal glands, some few going to vertical set.

Superficial vessels of perineum — vertical set.

Deep lymphatics of lower limb = deep set of glands.

The lymphatics that accompany the obturator,
gluteal, and sciatic arteries, and the deep vessels of
the penis, pass to the pelvis and have no concern
with the inguinal glands.

One of the deep glands lies in the crural canal
and upon the septum crurale. Being surrounded by
dense structures, it is apt to cause great distress when
inflamed, and great pain when the hip is moved. In
some cases, by reflex disturbance, it has produced
symptoms akin to those of strangulated hernia. Some
branches of the anterior crural nerve lie over the
" inguinal lymph glands, and Sir B. Brodie reports a case
in which these branches were stretched over two en-
larged glands, like strings of a violin over its bridge,
so that violent pain and convulsive movements were
set lip in the limb.

Elephantiasis Arabum is more common in the
lower limb than in any other part, and leads to an

396 SURGICAL APPLIED ANATOMY. [Chap. xix.

enormous increase in the size of the extremity (Co-
chin or Barbacloes leg). Its pathology is intimately
concerned with the crural lymphatics. " Elephantiasis
appears to consist primarily in an inflammatory hyper-
plasia of the cellular elements of the connective tissue,
in connection with which (according to Yirchow) there
is reason to believe that the roots, of the lymphatic
vessels are specially involved. Inflammatory over-
growth of the elements of the lymphatic glands next
ensues, with obstruction to the passage of lymph
through them. Then this fluid stagnates in the lym-
phatic vessels, which sometimes dilate even to their
radicles in the cutaneous papillae, and accumulates in
the interstices of the affected tissues, adding to their
bulk, and at the same time stimulating them to over-
growth .... In some cases of elephantiasis,
especially those in which the genital organs or adjoin-
ing parts of the thigh or abdomen are implicated,
groups of vesicles appear here and there on the affected
surface, which are really dilated lymphatic spaces, and
which, on rupturing .... discharge consider-
able quantities (sometimes several pints at a time) of
lymph (Dr. Bristowe).

The hip joint. — The hip joint is an articulation
of considerable strength. This strength depends not
only upon the shape of the articulating bones, which
permits of a good ball and socket joint being formed,
but also upon the powerful ligaments that- connect
them, and the muscular bands that directly support
the capsule. These advantages, however, are to some
extent counterbalanced by the immense leverage that
can \)e brought to bear upon the femur, and the nu-
merous strains and injuries to which the joint is
subjected, as the sole connecting link between the
trunk and the lower limb.

The acetabidum is divided into an articular and a
non-articular part. The former is qf horse-shoe shape,

chap, xix.] HIP JOINT. 397

and varies from one inch to half an inch in width.
The bone immediately above the articular area is
very dense, and through it is transmitted the superin-
cumbent weight of the trunk. The non-articular part
corresponds to the area enclosed by the horse-shoe, and
is made up of very thin bone. In spite of its thinness
it is very rarely fractured by any violence that may
drive the femur up against the pelvic bones, since no
ordinary force can bring . the head of the thigh-bone
in contact with this segment of the os innominatum.

Pelvic abscesses sometimes make their way into
the hip joint through the non- articular part of the
acetabulum, and an abscess in the hip joint may reach
the pelvis by the same route. But both such circum-
stances are rare. In some cases of destructive hip
disease the acetabulum niay separate into its three
component parts. Up to the age of puberty these
three bones are separated by the Y-shaped cartilage.
At puberty the cartilage begins to ossify, and by .the
eighteenth year the acetabulum is one continuous mass
of bone. The breaking up of the acetabulum by disease,
therefore, is only possible before that year.

The manner in which the various movements at
the hip are limited may be briefly expressed as follows.
Flexion, when the knee is bent, is limited by the con-
tact of the soft parts at the groin, and by some part
of the ischio-femoral ligament ; when the knee is ex-
tended the movement is limited by the hamstring
muscles. Extension is limited by the ilio-femoral or
Y ligament. Abduction by the pectineo-femoral
ligament. Adduction of the flexed limb is limited
by the ligameiitum teres and ischio-femoral ligament,
and of the extended limb by the outer fibres of the
ilio-femoral ligament and upper part of the capsule.
Rotation outwards is resisted by the ilio-femoral
ligament, and especially by its inner part, during
extension, and by the outer limb of that ligament and

398 SURGICAL APPLIED ANATOMY, [chap. xix.

the ligamentum teres during flexion. Rotation inwards
is limited during extension by the ilio-femoral ligament,
and during flexion by the ischio-femoral ligament and
inner part of the capsule.

Hip joint disease. — Owing to its deep position
and its thick covering of soft parts, this articulation is
able to escape, to a great extent, those severer injuries
that are capable of producing acute inflammation in
other joints. Acute synovitis is indeed quite rare in the
hip, and the ordinary disease of the part is of a dis-
tinctly chronic character. It follows also, from the
deep position of the articulation, that pus, when it is
formed in connection with disease, remains pent up,
and is long before it reaches the surface. Suppuration
in this region, therefore, is often very destructive.
When effusion takes place into the joint, the swelling
incident thereto will first show itself in those parts
where the hip capsule is the most thin. The thinnest
parts of the capsule are in front and behind ; in front,
in the triangular interval between the inner edge of
the Y ligament and the pectineo-femoral ligament,
and behind, at the posterior and lower part of the
capsule. It is over these two districts that the
swelling first declares itself in cases of effusion into
the joint, and as these parts are readily accessible to
pressure, it follows that they correspond also to the
regions where tenderness is most marked and is
earliest detected.

In chronic hip disease, certain false positions are
assumed by the affected limb, the meaning of which
it is important to appreciate. These positions may
be arranged as follows, according, as nearly as possible,
to their order of appearing.

(1) The thigh is flexed, abducted, and a little
everted ; and associated with this there is (2) apparent
lengthening of the limb and (3) lordosis of the
spine ; (4 ) the thigh is abducted and inverted, and

chap, xix.] HIP JOINT. 399

incident to this there is ( 5) apparent shortening of
the limb ; (6) there is real shortening of the limb.

1. The first position depends upon the effusion
into the joint. If fluid be forcibly injected into a
hip joint the thigh becomes flexed, abducted, and
a little everted. In other words, the articulation
holds the most fluid when the limb is in this
position, and the patient places it there to relieve
pain by reducing the tension within the capsule
to a minimum. Flexion is the most marked feature
in this position. Its effect is pronounced. It relaxes
the main part of the Y ligament, which, when the
limb is straight, is drawn as an unyielding band across
the front of the joint. Abduction relaxes the outer
limb of this ligament, and the eversion slightly relaxes
the inner limb. The latter movement is the least
marked, since eversion, even in the flexed position of
the joint, is resisted by the outer part of the Y liga-
ment. Any but a moderate degree of abduction would
be limited by the pectineo-femoral ligament, especially
as that band is rendered most tense when abduction is
combined with flexion and rotation outwards.

2. The apparent lengthening is due to the tilting
down of the pelvis on the diseased side, and is the
result of the patient's attempts to overcome the effects
of the position just described. The limb is shortened
by flexion and abduction, and to bring the foot again
to the ground and to restore the natural parallelism of
the limbs, the pelvis has to be tilted clown on the
affected side. Thus, an apparent lengthening of the
limb is produced, which is noticeable when the patient
lies upon a bed, and the abduction is made to entirely
disappear. Some real lengthening of the limb may be
produced in this disease by the effusion into the joint
separating the femur from the acetabulum, but it
must be so slight that it is doubtful if it could be ap-
preciated. By forcible injection into the joint Braune

400

SURGICAL APPLIED ANATOMY, [chap. xix.

could only separate the' articulating surfaces about

one-fifth of an inch.

3. The lordosis, or curving forwards of the

spine, occurs in the dorso-lumbar region. It depends

upon the flexion of the limb, and is the result

of an attempt to con-
ceal that false posi-
tion, or at least to
minimise its incon-
veniences (Fig. 38).
When the thigh is
flexed at the hip by
disease, the lower
limb can be made to
appear straight by
simply bending the
spine forwards in the
dorso - lumbar region
without effecting the
least movement at the
disordered joint. In-
deed, the movement
proper to the hip is in
this case transferred
to the spine. A

the dotted line) straight, and spine , • , -,-1 n j

normal. B, The flexion concealed or patient With a flexed

SSpfSySJW^*'1*?1 the hip as the result of

disease can lie on his

back in bed, with both limbs apparently perfectly
straight, he having concealed the flexion, as it were, by
producing a lordosis of the spine. If the lordosis be
corrected, and the spine be made straight again, then
the flexion of the hip reappears, although all the time
the hip joint has been absolutely rigid. This lordosis
generally appears a little late in the disease, and after
the limb has become more or less fixed in the false
.positions by contraction of the surrounding muscles.

Fig. 38. — Diagram to show the Mode of
Production of Lordosis in Hip Disease.

A, Femur flexed at hip, pelvis (represented by
the dotted line) straight, and spine

chap, xix.] THE HIP JOINT. 40 j

4. Sooner or later, in hip disease, the thigh
becomes adducted and inverted, while it still remains
flexed. This position has been variously accounted
for. According to one theory, it is due to
softening and yielding of some parts of the inflamed
capsule. This view is set forth by Mr. Barker, in
his admirable monograph on joint disease in Holmes'
" System of Surgery," in the following words :
"As the inflamed capsule commences to soften, its
weakest part yields first, i.e., the posterior inferior
This now admits of more flexion still. . . . The hori-
zontal posterior fibres, which in the distended condition
of the capsule help in the e version, are the next to
stretch, admitting of inversion, which is now the more
possible, as the Y is relaxed by flexion, and its inner
limb has no strain to be taken off by eversion. Finally,
the upper and outer anterior fibres yield, and adduction
then takes place." This explanation is a little
unsatisfactory ; and it is more probable that this false
position, and especially the adduction, depends upon
muscular action. The muscles about the joint are in a
state of irritability. They are contracted by a reflex
action that starts from the inflamed articulation, and
since the adductor muscles are supplied almost solely
by the obturator nerve, it is not unreasonable to
expect them to be especially disturbed if the
large share that the obturator nerve takes in the
supply of the hip be borne in mind. The adductors
are also rotators outwards, but this latter movement
would be resisted by the strong outer limb of the Y

-ligament, as well as by the ligamentum teres, both of
which are rendered tense by rotation outwards during
flexion. The whole matter, however, requires further
investigation.

5. Apparent shortening of the limb is due to
tilting up of the pelvis on the diseased side, and
bears the same relation to adduction that apparent

A A

402

SURGICAL APPLIED ANATOMY. [Chap, xix,

lengthening bears to abduction. To overcome the
adduction, and to restore the natural parallelism of the
limbs, the patient tilts up one side of his pelvis (Fig.
39). It thus happens that a patient with his femur

Fig. 39.— A, Parts in Normal Position. B, Femur Adducted. c, The
Adduction Corrected by Tilting up the Pelvis.

ac, Line of pelvis; ab, limb on diseased side; cd, limb on sound side; e, the
spine. It will be found that in Figs. B and c, the angle at a is the sameiu
the two cases.

flexed and adducted by disease may lie in bed with
both limbs quite straight and parallel, but with one
limb obviously shorter than the other. The flexion in
such a case is concealed by lordosis, and the adduction

Chap, xix.] THE HIP JOINT. 403

by the tilting of the pelvis. In some cases of simul-
taneous disease in both hip joints that has been in-
differently treated, both thighs may remain ad ducted.
The limbs are unable, of course, to remedy their posi-
tion by the usual means, when the disease is double,
and consequently one limb is crossed in front of the
other, and the peculiar mode of progression known as
" cross-legged progression " is produced.

6. The real shortening depends upon destructive
changes in the head of the bone, or to dislocation of
the partly-disintegrated head on to the dorsum ilii,
through yielding of the softened capsule and the
crumbling away of the upper and posterior margin of
the acetabulum.

When hip disease commences in bone it usually
involves the epiphyseal line that unites the head of
the femur to the neck. This line is wholly within
the joint, and the epiphysis that forms the head unites
with the rest of the bone about the eighteenth or
nineteenth year.

When the bone is primarily involved the posi-
tion of flexion and abduction with e version may
not be observed at all, there being no effusion at first
into the joint. In such cases the limb becomes at
once flexed and adducted, and this posture is probably
due solely to muscular spasm, and to an attempt
to prevent the head of the femur from pressing
against the acetabulum, and so causing pain.

It is well known that patients with hip disease
often complain of pain in the knee. This referred
pain may be so marked as to entirely withdraw
attention from the true seat of disease. Thus I once
had a child sent to my out-patient department with a
sound knee carefully secured in splints, but without
any appliance to the hip, which was the seat of a
somewhat active inflammation. This referred pain is
easy to understand, since the two joints are supplied

404 SURGICAL APPLIED ANATOMY. [Chap. xix.

by branches of the same nerves. In the hip, branches
from the (1) anterior crural enter at the front of the
capsule ; (2) branches from the obturator at the lower
and inner part of the capsule; and (3) branches from
the sacral plexus and sciatic nerve at the posterior
part of the joint. In the knee, branches from the
(1) anterior crural (nerves to vasti) enter at the front
of the capsule ; (2) branches from the obturator at
the posterior part of the capsule ; and (3) branches
from the internal and external popliteal divisions of
the great sciatic nerve at the lateral and hinder
aspects of the joint.

Pain, therefore, in the front of the knee, on one
or both sides of the patella, has probably been re-
ferred along the anterior crural nerve, and pain at
the back of the joint along the obturator or sciatic
nerves.

In hysterical individuals joint disease may be
imitated by certain local nervous phenomena, the
articulation itself being quite free from structural
change. This affection most commonly shows itself
in the hip or knee, and the " hysterical hip," or
"hysterical knee," takes a prominent place in the
symptomatology of hysteria. It is not quite easy to
understand why these two large joints should be so
frequently selected for the mimicry of disease. Hilton
has endeavoured to explain the fact upon anatomical
grounds, having reference to the nerve supply of these
joints in relation to the nerve supply of the uterus.
The uterus is mainly supplied by an offshoot from the
hypogastric plexus, and by the third and fourth sacral
nerves. Now, the hypogastric plexus contains fila-
ments derived from the lower lumbar nerves ; and from
the same trunks two nerves to the hip and knee
(the anterior crural and obturator) are in great part
derived. The great sciatic also contains a large
portion of the third sacral nerve. This common

Chap, xix.] THE UPPER END OF FEMUR. 405

origin of the joint and the uterine nerves forms the
basis of Hilton's explanation of the relative frequency
of hysterical disease in the large articulations of the
lower limb. The explanation, however, is unsatisfac-
tory, since the uterus receives many of its nerves from
the ovarian plexus, and the theory is founded upon
the unwarranted supposition that all hysterical dis-
orders are associated with some affection of the
uterus or its appendages.

Fractures of the upper end of tiie femur
may be divided into (1) fractures of the neck wholly
within the capsule ; (2) fractures of the base of the
neck not wholly within the capsule ; (3) fractures of
the base of the neck involving the great trochanter ;
(4) separations of epiphyses. It must be scarcely
possible, apart from gunshot injuries, to fracture
the neck of the femur by direct violence, owing to
the depth at which the bone is placed, and the
manner in which it is protected by the surrounding
muscles. The violence, therefore, that causes the
lesion is nearly always applied indirectly to the bone,
as by a fall upon the feet or great trochanter, or by a
sudden wrench of the lower lirnb.

M. Rodet, by a series of experiments, concludes
that the situation of the fracture can be predicated
by a knowledge of the direction in which the violence
has acted. " Thus, a force acting vertically, as in
falling on the feet or knees, will produce an oblique
intracapsular fracture ; a force acting from before
backwards, a transverse intracapsular fracture ; one
from behind forwards, a fracture partly within and
partly without the capsule, and a force applied
transversely, a fracture entirely without the capsule."
(Quoted by Henry Morris; Holmes' "System of
Surgery.")

1. The true intracapsular fracture may involve
any part of the cervix within the joint, but is most

40 6 SURGICAL APPLIED ANATOMY. [Chap. xix.

usually found near the line of junction of the head
with the neck. This fracture is most common in the
old, in whom it may be produced by very slight
degrees of violence. The liability of the aged
to this lesion is explained upon the following
grounds. The angle between the neck and shaft
of the femur, which will be about 130° in a
child, tends to diminish as age advances, so that in
the old it is commonly about 125°. In certain aged
subjects, as a result probably of gross degenerative
changes, this angle may be reduced to a right angle.
This diminution of the angle certainly increases the
risk of fracture of the neck of the bone. There is
often also, in advanced life, much fatty degeneration of
the cancel lous tissue of the cervix with thinning of
the compact layer. Dr. Merkel (Amer. Journ. Med.
Sc., 1874) also asserts that in old persons there is an
absorption of that process of the cortical substance
which runs on the anterior part of the neck between
the lesser trochanter and the under part of the head.
This process he calls the " calcar femorale," and
maintains that it occupies the situation at which the
greatest pressure falls when the body is erect. These
fractures are but rarely impacted; but when impacted,
the lower fragment, represented by the relatively
small and compact neck, is driven into the larger and
more cancellous fragment made up of the head of the
bone. The fracture may be subperiosteal, or the
fragments may be held together by the reflected
portion of the capsule. These reflected fibres pass
along the neck of the bone from the attachment of
the capsule at the femur to a point on the cervix
much nearer to the head. " These reflected fibres
occur at three places, one corresponding in position to
the middle of the ilio-femoral ligament, another to the
pectineo-femoral, and the third on the upper and back
part of the neck " (Henry Morris). Fractures of this

Chap, xix.] THE UPPER END OF FEMUR. 407

part very rarely indeed unite by bone. Blood is brought
to the head of the bone by the cervix, the reflected
parts of the capsule, and the ligamentum teres. When
the first two sources of blood supply are cut off by
the fracture the third does not appear to be sufficient
to allow of great reparative changes taking place
in the upper fragment. The fractures that heal by
bone are probably either impacted, or subperiosteal,
or not wholly intracapsular.

2. With regard to fractures at the base of the
neck, it must be remembered that a wholly extra-
capsular fracture of the neck of the femur is an
anatomical impossibility. If the fracture is wholly
without the capsule, then it must involve a part
of the femoral shaft, and cannot be entirely through
the cervix. In the front of the bone the capsule is
attached to the femur along a part of the inter-
trochanteric line, and strictly follows the line of
junction between the cervix and the shaft. Behind,
the capsule is inserted into the neck some half of an
inch in front of the posterior inter- trochanteric
line. It is therefore possible for a fracture of
the neck to be extracapsular behind, but not in
front, and many of these lesions at the base of the
neck have this relation to the capsule. The Y ligament
is so thick, being in one place about a quarter of
an inch in thickness, that a fracture involving the
base of the cervix may run between its fibres at their
attachment, and be neither extra- nor intra-capsular.
When fractures at the junction of the neck and shaft
are impacted, the upper fragment, represented by the
compact and relatively small cervix, is driven into the
cancellous tissue about the great trochaiiter and upper
end of the shaft. As a result of this impaction the
trochanter may be split up, and the bones may
become free again through the extent of thiy
splintering.

408 SURGICAL APPLIED ANATOMY. [Chap. xix.

With regard to the symptoms of a fracture
of the neck of the femur, the following may be
noticed : (a) The swelling often observed in the front
of the limb, just below Poupart's ligament, is due
either to effusion of blood into the joint, or to pro-
jection of the fragments against the front of the
capsule ; (6) the shortening is brought about by the
glutei, the hamstrings, the tensor vaginae femoris, the
rectus, sartorius, and ilio-psoas, the adductors, gracilis
and pectineus ; (c) the eversion, or rotation out-
wards of the limb, is mainly due to two causes : (1)
The weight of the limb, which causes it to roll
outwards, as is seen in persons insensible or asleep,
the line of gravity passing through the outer part
of the thigh ; (2) the fact that the compact tissue
on the posterior aspect of the neck is much more
fragile than that on the anterior aspect. Thus the
cervix is often more extensively fractured behind
than in front, or the fracture may be impacted behind
but not in front, and in either case the limb will tend to
become everted. As a third cause may be mentioned
the action of the ilio - psoas, the adductor and
pectineus muscles, and of the small rotators muscles,
all of which will tend to roll the femur outwards.

3. Fracture of the base of the neck, involving
the great trochanter. In this lesion the head, the
cervix, and a part of the great trochanter, are sepa-
rated from the shaft and rest of the trochanter.

4. Separation of epiphyses. There are three
epiphyses in the upper end of the femur, one for the
head, which unites between eighteen and nineteen ;
one for the lesser trochanter, which unites about
seventeen ; and one for the greater trochanter, which
unites about eighteen. The neck is formed by an
extension of ossification from the shaft. A few cases
are recorded where it is supposed that the caput
femoris was separated at the epiphyseal line by

Chap, xix.] DISLOCATIONS OF THE HIP. 409

violence, but the accident is, I believe, illustrated by
no actual specimens. Mr. Henry Morris has collected
five cases of separation of the epiphysis of the great
trochanter. This separation, if complete, could hardly
avoid being intracapsular in part, since the capsule is
attached to the anterior superior angle of the
trochanter itself.

Dislocations of the hip. — These injuries are
comparatively rare, on account of the great strength
of the articulation, and when they occur in a healthy
joint are always the result of a considerable degree of
violence. A dislocation of the hip may be congenital,
or may be spontaneously produced by muscular
efforts, as shown in a few rare cases, or may be the
result of disease of the articulation. We are, how-
ever, now concerned only with "regular" dislocations,
the result of violence.

Varieties. — The head of the bone may be found
displaced in four directions, producing the four regular
dislocations of the hip. In two the head of the femur
is posterior to a line drawn vertically through the
acetabulum, and in the other two it is found anterior
to that line.

(1) Backwards and upwards. Head rests upon
ileum, just above and behind acetabulum. The "dis-
location upon the dor sum ilii" (2) Backwards. Head
rests upon ischium, and, as a rule, about on a level
with the ischial spine. The " dislocation into the
sciatic notch" (3) Forwards and downwards. Head
rests on thyroid foramen. The " obturator or thyroid
dislocation" (4) Forwards and upwards. Head
rests upon the body of the pubes, close to its junction
with the ileum. The " dislocation upon the pubes."

The above arrangement represents also the order
of frequency of these luxations, No. 1 being the most
common dislocation of this part, and No. 4 the most
rare.

410 SURGICAL APPLIED ANATOMY. [Chap. xix.

General facts. — In all these dislocations of the
hip, (a) the luxation occurs when the limb is in the
position of abduction ; (6) the rent in the capsule is
always at its posterior and lower part ; (c) the head
of the bone always passes at first more or less directly
downwards ; (d) the Y ligament is untorn, while
the ligamentum teres is ruptured.

(a) It is maintained that in all luxations at the
hip, the pelvis and femur are in the mutual position
of abduction of the latter at the time of the accident.
The direction of the neck of the femur and of the
acetabulum, and the position of the cotyloid notch, all
favour dislocation in the abducted posture. The
lower and inner part of the acetabulum is very
shallow, and the lower and posterior part of the
capsule is very thin. In abduction, the head of the
bone is brought to the shallow part of the acetabulum;
it moves more than half out of that cavity ; it is
supported only by the thin weak part of the capsule, and
its further movement in the direction of abduction is
limited only by the pectineo- femoral ligament, a
somewhat feeble band. In abduction the round
ligament is slack, and in abduction with flexion both
the Y ligament and the ischio-femoral ligaments are
also relaxed. In the position of abduction, therefore,
no great degree of force may be required to thrust the
head of the bone through the lower and posterior part
of the capsule, and displace it downwards.

(b) The above being allowed, it will be understood
that the rent in the capsule is always at its posterior
and lower parts. " Generally the rupture is jagged
and irregular, but will be found to extend more or
less directly from near the shallow rim of the aceta-
bulum, across the thin portion of the capsule to the
femur near the small trochanter, and then to run
along the back of the ligament close to its attachment
to the neck of the bone " (Henry Morris).

chap, xix.] DISLOCATIONS OF THE HIP. 411

(c) If the position of the limb at the time of the
accident be considered, it will be seen that the femur
will in every case be displaced downwards. There is,
indeed, but one primary dislocation of the hip, a
luxation downwards. The four forms given above
are all secondary, the bone having in each instance
first passed downwards before it moved to any of
the positions indicated. This point has been ably
demonstrated by Mr. Henry Morris, whose account
of the anatomy of hip dislocations is most valu-
able. The head having left the acetabulum, its
ultimate destination will depend upon the character
of the dislocating force. "If the limb be flexed on the
pelvis, and rotated inwards, or the pelvis be corre-
spondingly moved on the thigh at the moment of
displacement, the head of the femur will take a
backward course, and rest on the dorsum ilii or some
part of the ischium. On the other hand, extension
and outward rotation will cause the head of the bone
to travel upwards and forwards, and what is called a

dislocation on to the pubis will occur If the

dislocation is neither accompanied nor followed by
rotation, or fixed flexion or extension, the head of the
femur will remain below the acetabulum, and will
occupy the foramen ovale, if it takes a slightly forward
direction in its descent, or some position near the
tuberosity of the ischium if it leaves its socket in a
backward and downward direction " (Henry Morris).

(d) The Y ligament is never torn in any "regular"
dislocation. It is saved by its great density, and the
circumstance that it is probably more or less relaxed
at the time of the luxation. The method of reducing
these dislocations by manipulation depends for its
success mainly upon the integrity of the Y ligament,
which acts as the fulcrum to a lever of which the
shaft of the femur is the long arm, and the neck the
short. In the backward luxations the head is behind

412

SURGICAL APPLIED ANATOMY. [Chap. xix.

the Y ligament, and in the forward displacements in
front of it.

The anatomy of eacli form.— Nos. 1 and 2.

The dislocations backwards. Here the femoral head,
having been displaced in the way indicated, is carried
towards the dorsum or sciatic notch by the glutei,

hamstring, and ad-
ductor muscles.
The bone having
taken a general
direction back-
wards, the height to
which it ascends de-
pends mainly upon
the nature of the
dislocating force,
and also upon the
extent of the rup-
ture in the capsule,
and the laceration
of the obturator
internus tendon
and other small
. external rotators.

Fig. 40. — Dislocation upon the Dorsum ilii m, , , , . ,

(Bigeiow). The dorsal disloca-

tion is, therefore,

a more advanced grade of the sciatic. The more
extreme the flexion and inward rotation at the time
of the accident the more likely is the dislocation to be
sciatic. More moderate flexion and inward rotation
will produce a luxation upon the dorsum. In the
dorsal luxation the head is above the obturator
internus tendon, while in the sciatic form it is below
it (Bigeiow). Morris has been able to find but one
case of direct dislocation of the femur backwards on
to the ischium. In every instance it passes first in a
downward direction, and then backwards.

chap, xix.] DISLOCATIONS OF THE HIP. 413

Bigelow states that there is no evidence to show
that the head of the femur has ever been actually
displaced into the sciatic notch.

In these backward dislocations the ilio-psoas
muscle is greatly stretched. The quadratus femoris,
the obturators, the gemelli, and the pyriformis are more
or less lacerated. The pectineus is often torn, and
the glutei muscles
even may be ruptured
in part. The great
sciatic nerve may be
compressed between
the femoral neck and
the rotator muscles,
or between the head
of the bone and the
tuber ischii. In both
of the backward lux-
ations there is shor-
tening, due to the
circumstance that the
line between the an-
terior superior spine
and the femoral
condyles is lessened

by the displacement Fig> 4i._Obturator or Thyroid Disloca-

back wards of the tion (Bigelow).

bone, with the addi-
tional shortening in the dorsal dislocation brought
about by the passing of the femoral head above the
level of the acetabulum. The adduction and in-
version in the main depend upon the position of
the head and cervix, which must follow the plane
of the bone upon which they lie. This position
is maintained by the tense Y ligament. The
damage done to the chief external rotators places
them also hors de combat. The flexion is due to

414

SURGICAL APPLIED ANATOMY. [Chap. xix.

the tension of the Y ligament, and of the ilio-psoas
muscle.

Nos. 2 and 3. The dislocations forwards. If the
head after leaving the acetabulum simply moves a

little forwards along
the inner edge of the
socket, the thyroid lux-
ation is produced. If
it goes farther and
moves upwards, the
pubic displacement will
result. The latter dis-
location is therefore
biit an advanced form
of the first - named.
Whether the head will
remain in the thyroid
foramen or ascend on
to the pubes depends
on whether extension
and rotation outwards
accompanies the dis-
placement. If these
occur the pubic form
is produced. In these
injuries the pectineus,
gracilis, and adductors
will be more or less torn, while the ilio-psoas, glutei, and
pyriform muscles are much stretched. The obturator
nerve may be stretched or torn, and in the pubic
luxation the anterior crural nerve may be involved.
The abduction and eversion of the limb noticed in
these luxations depend partly upon the position of
the head of the bone, fixed more or less by the
Y ligament, and partly upon the action of the gluteal
muscles and some of the small external rotators,
which are tightly stretched, The flexion of the

Fig. 42.— Dislocation upon the Pubes
(Bigelow).

Chap, xix.] DISLOCATIONS OF THE HIP. 415

limb is mainly due to the stretching of the ilio-
psoas muscle.

In the thyroid luxation the extremity is said to be
lengthened. This lengthening is, however, apparent,
and is due to the tilting down of the pelvis on the
injured side. In the pubic dislocation there is
shortening, the head being carried above the ace-
tabular level.

Of the modes of reducing these dislocations by
manipulation little can be said here. The more
usual proceedings may be briefly summarised as
follows : —

First. — Flex the thigh in the adducted \
position in luxations Nos. 1 i
and 2. f To relax the

Flex the thigh in the abducted ( Y ligament,
position in luxations Nos. 3 \
and 4. j

Secondly. — Circumduct out in ^ To bring back the head

Nos. 1 and 2. 'to the rent in the cap-

Circumduct in in f sule by the same route

Nos. 3 and 4. ) that it has escaped.
Thirdly. — Extend in all cases. To induce the head

to again enter the acetabulum.
In reducing dislocations of the hip it may be noted
that the internal coiidyle of the femur faces in nearly
the same direction as the head of the bone.

In amputation at the hip-joint by long
anterior and short posterior flaps the following parts
are divided. In the face of the anterior flap will be
seen sections of the tensor vaginse femoris, rectus, part
of the vasti, the adductors longus and brevis, and the
gracilis. Close to the acetabulum in front are sections
of the ilio-psoas and pectineus muscles, and behind
and to the inner side the obturator externus. In
this flap also, close to the angle between it and the
posterior flap, are small portions of the glutei to the

416

SURGICAL APPLIED ANATOMY. [Chap. xix.

outer side of the hip, and of the adductor magnus to
the inner side. The cut end of the sartorius is found
on the lower edge of the flap. The femoral and

Fig. 43. — Amputation at Hip Joint (Agatz).

«, Head of femur ; l>, acetabulum ; c, part of capsular ligament ; d, adductor
longus; e, adductor magnus; /, pectineus ; g, rectus; //, tensor vaginae
f emoris ; i, ilio-psoas ; j, sartorius ; k, femoral and prof unda vessels ; I, great
saphenous vein ; ra, anterior crural nerve.

profunda vessels, together with the saphenous vein
and the anterior crural and superficial nerves, are cut
in the lower edge of the flap. On the face of the flap
are branches of the profunda and external circumflex
vessels, while the trunk of the internal circumflex
artery is cut close to the acetabulum on its inner side.
The face of the posterior flap exposes the glutei
muscles, hamstrings, and adductor magnus. Deeper
in the flap are divided the small external rotators.

Chap, xx.] THE THIGH. 417

The sciatic nerves and vessels are cut on the lower
border of the flap, while on its face are divided
branches of the sciatic, perforating, and circumflex
arteries.

CHAPTER XX.

THE THIGH.

UNDER the term "the thigh" it will be convenient
to describe that part of the lower limb that extends
between the regions just described, and the districts
of the knee and popliteal space.

Surface anatomy. — In muscular subjects the
outline of the thigh is irregular, but in the less
muscularly developed, who are provided with a good
share of subcutaneous fat, the limb, in this section of
it, is more or less evenly rounded.

The prominence of the rectus muscle is noticeable
on the front of the thigh, especially when the muscle
is in action. To the inner side of this structure, and
conspicuous along the lower half of the thigh, is the
eminence formed by the vastus iiiternus. The mass
to the outer side of the rectus is composed of the
external vastus muscle, and occupies the greater part
of the limb in this region, being, however, more
conspicuous below.

Running down the anterior and inner aspect of
the thigh, from the apex of Scarpa's triangle, is a
depression which indicates the interval between the
quadriceps muscle and the adductors. Along this
groove the sartorius lies. Over the surface of the
vastus externus a longitudinal depression is often to
be observed formed by the pressure exercised by the
super-imposed ilio-tibial band of the fascia lata (Quaiii's

B B

4i 8 SURGICAL APPLIED ANATOMY. [Chap. xx.

" Anatomy"). The hamstring muscles cannot usually
be distinguished the one from the other above the
popliteal space, nor is their separation from the ad-
ductors indicated. The separation, however, between
them and the vastus externus is distinct, and corre-
sponds to the position of the external inter-muscular
septum. The line of the femoral vessels has already
been given. The long saphenous vein follows in the
thigh the course of the sartorius muscle, and may be
represented on the surface by a line drawn from the
region of the saphenous opening (page 390) to the
posterior border of the sartorius muscle at the level
of the inner condyle of the femur. The long saphenous
nerve follows the course of the femoral artery, lying
first to the outer side of that vessel, and then gradually
crossing it. In the lower fourth of the thigh the
nerve passes under cover of the sartorius muscle to
the inner side of the knee, and is accompanied by the
superficial branch of the anastomotic artery. A line
drawn down the back of the limb from a point midway
between the great trochanter and tuber ischii to the
middle of the ham will correspond to the great
sciatic nerve and one of its continuations, the internal
popliteal. The great trunk usually bifurcates a little
below the middle of the thigh.

The skin of the thigh is coarse on the outer side
of the limb, but internally it is thin and tine, and is
apt to be readily excoriated by ill-applied bandages or
splints. It is but loosely attached to the subjacent
parts, a circumstance that greatly favours the
performance of circular amputations in this region.
At one place, however, it is a little more adherent,
viz., along the groove that separates the vastus
externus behind from the hamstring muscles, and that
corresponds to the outer intermuscular septum. The
laxity of the subcutaneous tissue favours extensive
extravasations beneath the skin, and permits of large

chap, xx.] THE THIGH. 419

flaps of integument being torn up in cases of injury to
this part of the extremity.

The fascia lata invests the limb at all parts like
a tightly-fitting sleeve. It is thickest at its outer
side, where -it forms the dense ilio-tibial band. It is
thinnest at the upper and inner aspect of the thigh,
where it covers the adductor muscles. It increases
considerably in strength as it approaches the front of
the knee, and attaches itself to the tibia and lateral
margins of the patella. This fascia resists, especially
at its outer part, the growth of tumours and abscesses,
and limits deep extravasations of blood. It has
occasionally been ruptured in part by violence, and
through the rent so formed the subjacent muscle
has bulged, forming what is known as a hernia of
the muscle. This condition has been met with in the
case of the quadriceps muscle, and also of the adductor
longus. Such " hernise " are probably associated with
some rupture of the fibres of the muscles implicated.
Two deep processes of the fascia are attached to the
femur, and form the outer and inner intermuscular
septa. The outer septum separates the vastus
externus from the biceps, and the inner the vastus
internus from the adductors. Together with the
fascia lata, these septa divide the thigh into two
aponeurotic spaces, which can be displayed in a
transverse section of the limb. These divisions,
however, are of little surgical moment, and the inner
septum is often so thin and feeble that it could have
little effect in directing the course of an abscess.

In circular amputations of the thigh the muscles
are apt to retract a little unevenly, since some are
attached to the femoral shaft while others are free.
The muscles so attached are the adductors, vasti and
crureus, while the free muscles are the sartorius, rectus,
hamstrings, and gracilis.

In spite of its great strength the tendon of the

420 SURGICAL APPLIED ANATOMY. [Chap. xx.

quadriceps may be ruptured by muscular violence. A
good example of such an accident is recorded by Mr.
Bryant (Med. Times, 1878). A man aged forty -two
stumbled in the dark, and fell down a pit ten feet
deep. On examination the tendon was found to be
torn across, and the gap above the patella produced by
the rupture occupied no less extent than the lower third
of the thigh. A somewhat more remarkable accident
is reported to have happened to the sartorius muscle.
This muscle, just before its insertion into the tibia,
gives off an aponeurotic expansion from its anterior
border to the capsule of the knee-joint. In the case
alluded to (Lancet, 1873), this expansion is said to
have been ruptured, and the muscle itself to have been
found dislocated backwards in consequence. The
accident befell a man aged forty, who was squatting,
in the position assumed by tailors, upon the floor of a
wagon, when his companion tripped over him, and
fell across his bent knees. Something was felt to
have given way near the ham, and on examination the
above lesion was diagnosed.

The femoral artery may be ligatured at any part
of its course in the thigh, and the comparatively super-
ficial position of the vessel renders it very liable to be
injured. The thigh affords many instances of the
remarkable way in which isolated branches of a main
artery are often alone damaged. Thus, Langier relates
the case of a man-cook; who, in running round a table,
struck the upper and outer side of his thigh against
the corner of it. This led to a subcutaneous rupture
of the external circumflex artery. Unfortunately the
extravasation was cut into, and the patient, after
being subjected to many modes of treatment, died
from the effects of repeated haemorrhage. Dr. Butcher
(Dub. Journ. Med. Sc., 1874), gives the case of a man
who was stabbed in the thigh over the femoral vessels
during a scuffle. Profuse bleeding followed, and it was

Chap, xx.] THE THIGH. 421

found that the only vessel wounded was the internal
circumflex artery, just at its point of origin from the
profunda. The case was treated promptly and the
man did well.

Fractures of the femur. — The shaft of the
femur may be broken at any part, but the lesion is
most common at the middle third of the bone, and
least frequent at its upper third. If broken by direct
violence the fracture is usually transverse, and if by
indirect violence it is usually oblique. The probability
of a fracture being due to direct violence diminishes
in the bone from below upwards, while the probability
of a lesion from indirect violence increases in the
same direction. Thus it happens that the fractures
of the upper third of the bone are usually oblique,
while those of the lower third are more commonly
transverse. In the middle third the numbers of the
transverse and oblique fractures are more nearly
balanced. The femur has often been broken by
muscular violence, but it is doubtful if this has ever
occurred in other than a diseased bone. In many of
these cases the amount of force that breaks the bone
is most insignificant. Thus Vallin reports the case of
a girl aged eighteen, described as robust, who broke
the femur about its middle while in the act of
mounting a table for the purpose of undergoing a
vaginal examination. In oblique fractures in the
upper third of the bone the line of fracture usually runs
downwards and inwards, while in oblique fractures of
the middle third the direction is more commonly
downwards and forwards, with a slight lateral inclina-
tion that is sometimes inwards and sometimes out-
wards. Fractures of the lower third of the bone are
discussed in connection with the region of the knee
(chap. xxi.).

With regard to fractures of the upper and middle
thirds, the displacement of the fragments depends

422 SURGICAL APPLJED ANATOMY. [Chap. xx.

greatly upon the obliquity of the fracture. As a rule
the lower fragment is drawn up behind the upper
one by the hamstrings, aided by the rectus, gra-
cilis, sartorius, tensor vaginae, and adductors, and is
carried a little to its inner side under the influence
of the last-named muscles. The lower end of the
upper fragment usually projects forwards and a little
outwards. This is produced by the agency of the
lower fragment, which tilts the upper piece of bone in
the direction named. In the fracture of the upper
third of the shaft the projection forwards of the upper
fragment is aided by the ilio-psoas muscle. Thus the
deformity produced in fractures of the femoral shaft
is usually angular in character. The e version of the
foot noted in fractures of the femur is due to the
weight of the limb, which causes the helpless member
to roll out, aided probably by the action of the
external rotator muscles.

Certain spiral fractures (helicoidal fractures of
Leriche) may be produced in the lower part of the
shaft as the result of torsion. M. Fere finds by
experiment that if the limb be carried forwards in
front of the opposite knee, and the foot rotated
outwards, a spiral fracture can be produced at the
junction of the lower and middle thirds of the femur.
A like fracture at the same level, but with the
direction of the spiral reversed, can be produced by
carrying the limb outwards and then rotating it
inwards.

Shortening of the limb after fracture. —
It is doubtful if a fracture of the shaft of the femur
can, after any treatment, become united without some
shortening resulting, except in a few exceptional cases.
It is important, in connection with this subject, to
remember that the lower limbs may be normally of
unequal length. Dr. Wight, of Brooklyn, has fully
investigated this matter, and has arrived at the

Chap, xx.] THE THIGH. 423

following conclusions : (1) The greater number of
normal lower limbs are of unequal length ; (2) the
left limb is oftener longer than the right; (3) the
average inequality of normal lower limbs is probably

Fig. 44.— Transverse Section through the Middle of the Thigh
(Braune).

a, Rectus femoris ; &, vastus externus ; c, crureus; d, vastus interims: e, short
head of biceps ; /, long head 9f biceps ; g, semitendinosus ; h, semimembra-
nosus ; i, adductor magnus ; j, gracilis ; k, adductor longus ; I, sartorius ; 1,
femoral artery ; 2, great sciatic nerve ; 3, great saphenous vein ; 4, middle
cutaneous nerve ; 5, external cutaneous nerve ; 6, perforating branches from
profunda; 7, small sciatic nerve.

about a quarter of an inch ; (4) the average amount of
shortening after a fracture of the femur that has been
well treated is about three-quarters of an inch ; (5) in
about one case in ten or eleven the two limbs will be
found to be of equal length after the union of the
fracture; (6) one limb can never be a certain standard
of length for the opposite limb. Dr. Garson, as a
result of the careful examination of some seventy
skeletons, states that both the lower limbs are of
equal length in only about ten per cent, of all cases.

424 SURGICAL APPLIED ANATOMY. [Chap. xxi.

He also found that the femur was more frequently the
seat of variation than the tibia.

Amputation of the tliigli. — The circular
operation is well adapted for the middle third of the
thigh, especially in muscular subjects. In a circular
amputation of the thigh about its middle the following
parts would be divided : the quadriceps, sartorius,
gracilis, long and great adductors, and the three ham-
string muscles ; the femoral and profunda vessels,
the descending branches of the external circumflex
artery, the lower perforating vessels, and the long
saphenous vein ; the main branches of the anterior
crural nerve (middle cutaneous, internal cutaneous,
and muscular, together with the long saphenous
nerve), the anterior branch of the external cutaneous
nerve, the obturator, and the great and small
sciatic nerves.

CHAPTER XXI.

THE REGION OF THE KNEE.

IN this chapter will be considered the articulation
of the knee, the soft parts about the joint, the
popliteal space, the lower end of the femur, the
patella, and the upper ends of the tibia and fibula.

Surface anatomy. — In the front of the knee
the patella can be distinctly felt and seen. Its inner
border is a little more prominent than the outer.
When the limb lies in the extended posture, with the
quadriceps relaxed, the patella can be moved to and
fro, and appears to be but loosely attached. When
the quadriceps is contracted the bone is drawn
upwards, and becomes firmly fixed against the femur.
In flexion of the joint the patella sinks into the

chap. XXL] THE REGION OF TPIE KNEE. 425

hollow between the tibia and the intercondyloid notch,
and is very firmly fixed. In this position some part
of the trochlear surface of the femur can be made out
above the patella. On each side of the knee-cap a
hollow exists which may be completely filled up with
fat in the obese.

When the limb lies in the extended posture the
ligamentum patellae is not to be very distinctly made
out. It becomes a little more conspicuous in the
flexed position, and is most prominent when the
quadriceps muscle is vigorously contracted.

On the inner side of the knee the following parts
can be felt from above downwards : the tubercle for
the adductor magnus, and the tendon of insertion of
that muscle ; the inner condyle of the femur, which
is very prominent, and forms the chief part of the
rounded eminence on this aspect of the joint ; and
below this the inner tuberosity of the tibia. Between
the two latter processes of bone the interarticular
line is easily to be felt. On the outer side of the
joint is the external condyle of the femur, which is
much less conspicuous than its fellow of the opposite
side, and below it is the corresponding tuberosity of
the tibia, forming a marked prominence. Immediately
in front of the biceps tendon the upper part of the
external lateral ligament can be felt when the joint is
a little flexed. Between the tendon and the patella,
the lower part of the ilio-tibial process of the fascia
lata can be detected as a prominent rounded band,
descending to the external tuberosity of the tibia. It is
most distinct when the knee-joint is forcibly extended
by muscular action, and often stands out conspicuously
beneath the skin. The tubercle of the tibia and the
head of the fibula are both to be readily felt, and are
nearly on the same level.

The popliteal space only appears as a hollow when
the knee is bent. In the extended limb the hollow is

426 SURGICAL APPLIED ANATOMY. [Chap. xxi.

replaced by an evenly rounded eminence. The crease
in the skin that passes transversely across the ham is
some way above the line of the knee-joint. On the
outer side of the space the biceps tendon can be very
readily felt, especially when the muscle is in action.
Just behind it, and along its inner border, lies the
peroneal nerve. It can be rolled under the finger as
it crosses the head of the fibula to pass beneath the
peroneus longus muscle. On the inner side of the
ham three tendons can be felt. Nearest to the middle
of the space is the long prominent tendon of the
semitendinosus. Internally to it is the larger and
less distinct semimembranosus tendon, and still more
to the inner side the gracilis may be made out.

The popliteal vessels enter the ham obliquely at
its upper and inner part, and under cover of the
semimembranosus muscle. The outer border of this
muscle is the guide to the upper portion of the artery.
The vessels in their descent reach a point behind
the middle of the knee-joint, and then pass vertically
downwards. The termination of the popliteal artery
is on a level with the lower part of the tubercle of
the tibia. When the limb is flexed, the pulsations of the
artery can be felt and the vessel compressed against the
femur a little below its point of entry into the popliteal
space. The upper articular arteries run transversely
inwards and outwards just above the femoral condyles.
The lower articular arteries are also placed trans-
versely, the inner vessels running just below the
internal tuberosity of the tibia, and the outer just
above the head of the fibula. The deep branch of
the anastomotica magna descends to the inner condyle
of the femur in the substance of the vastus internus,
and along the front of the adductor magnus tendon.
The internal saphenous vein passes up along the back
part of the internal condyle of the femur, and then
follows the sartorius muscle to the thigh. It is just

chap, xxi.] THE REGION OF THE KNEE. 427

below the interarticular line that the long saphenous
nerve usually joins the vein. The short saphenous
vein follows the middle line of the calf just below
the ham, and pierces the deep fascia at the lower part
of the popliteal space. This vessel is much less con-
spicuous than is the long saphenous vein, and is,
indeed, not often to be seen unless varicose.

The internal popliteal nerve descends in the
middle Hne, and continues the line that marks the
course of the great sciatic trunk.

In their normal condition the popliteal glands are
not to be felt.

The limits of the synovial membrane of the knee-
joint, and the position of the various bursse about
this articulation, will be dealt with in some of the
subsequent paragraphs.

The front of the knee. — The skin over the
front of the knee is dense and very movable. This
mobility affords considerable protection to the knee-
joint, especially in stabs with bluntish instruments,
and in any injury where the gliding movement of the
skin may direct the violence away from the articula-
tion. The comparative looseness of the integument
is of great value also in the operation of removing
so-called " loose cartilages" from the knee-joint. It
permits the incision into the joint to be very indirect,
and, the skin being dragged out of place during the
operation, it follows that, when the procedure is com-
plete, the surface wound and that in the knee capsule
no longer correspond. In flexion, the skin is drawn
tightly over the patella, and, as is the case elsewhere,
where integument lies more or less directly upon bone,
a contusion over the knee-cap may produce a lesion
precisely like an incised wound.

In the Lancet for 1877 is recorded the case of a
very stout woman, aged fifty-seven, who, stumbling
on a hard road, fell upon her bent knee. The skin

428 SURGICAL APPLIED ANATOMY. [Chap.xxi*

was burst across the front of the knee, and a wound
was produced that was seven inches in length, and
was as cleanly cut as if made by a scalpel.

There is but little subcutaneous fat in front of
the articulation, and thus it happens that in amputa-
tions through the knee-joint the anterior flap is very
thin, and is composed of little other than the simple
integument.

As blisters, and various forms of counter-irri-
tant, are often applied to the front of the knee in
cases of disease, it may be well to take note of the
blood-supply of this part, and of the relations between
the surface vessels and those of the joint. The
vessels that give branches to the front of the knee,
and that are concerned in the supply of the part to
which blisters are usually applied, are the anastomotic,
the four articular branches of the popliteal, and the
anterior tibial recurrent. Now of these arteries, and
especially of the anastomotica magna and superior
articular, it may be said that, shortly after their
origin, they divide into two branches, or two sets of
branches, one going to the surface and the other to
the articulation of the knee and deeper parts about
it. It may be supposed, therefore, that, in applying
a counter-irritant in front of the knee for the relief
of a joint affection, a greatly increased quantity of
blood is drawn into the superficial divisions of the
above-named vessels, and less blood is thereby left
to flow by their deeper branches to the seat of
disease.

The superficial lymphatics in the region of the
knee lie for the most part on the inner aspect of the
joint, and follow the course of the long saphenous
vein. Ulcers, and other inflammatory affections of
the skin over the articulation, are more apt to be
associated with lymphangitis and with enlargement of
the inguinal glands when situate on the inner aspect

chap. XXL] THE POPLITEAL SPACE. 429

of the joint than when placed in front or to the outer
side of it.

The Imrsse over the front of the knee. — (1) The
patellar bursa is a large sac placed in front of the
patella and upper part of the patellar ligament, and
separates those structures from the skin. It is very
often found enlarged in those who kneel much, in
housemaids, stone-masons, religieuses, etc. The parts
about are well supplied with nerves, and hence much
pain is usually associated with acute inflammation of
this sac. It is in close contact with the patella, and,
in one case reported by Erichsen, suppuration of the
bursa led to caries of that bone (Figs. 45, 46, and
49). (2) There is a small bursa between the
patellar ligament and the tubercle of the tibia
(Fig. 46). When inflamed, it causes more pain
than is observed in affections of the previous bursa,
since it is firmly compressed between two rigid struc-
tures, the ligament and the bone. It is separated
from the synovial cavity by the pad of fat that lies
behind the patella. It would appear, however, to
sometimes communicate with the joint, since Hamilton
has collected three cases where incision into this
bursa led to suppuration of the articulation. There
is a pad of soft fat between the ligament and the
tibia! tubercle, which often protrudes a little at either
side of the former structure, and has been mistaken
for an enlarged bursa. (3) The bursa between the
quadriceps tendon and the femur will be considered
in connection with the synovial cavity.

The popliteal space. — The skin over the
space is not so movable as is that over the front of
the knee. When destroyed by injury, by burns, or
by extensive ulceration, the contraction of the result-
ing cicatrix may lead to a rigidly-bent knee. The
skin in this place has also been ruptured by forcible
extension applied to the limb in cases of contracted

43° SURGICAL APPLIED ANATOMY. [Chap. xxi.

knee. Beneath the skin and superficial tissue is the
popliteal fascia, a dense membrane that covers in the
space. It is but a continuation of the fascia lata of
the thigh, and is continuous below with the fascia of
the leg. It passes without bony attachment over the
hamstring muscles that bound the ham. This fascia
limits, often in a very marked manner, the progress of
popliteal abscesses and growths towards the surface.
Its unyielding character is a prime cause in the pro-
duction of the severe pain with which such collections
and tumours are often associated. The popliteal
abscess, unable to reach the surface, is encouraged to
extend either up into the thigh or down the leg. The
ham may hold a very considerable quantity of pus.
Yelpeau has seen a case where a litre (1 pint, 15 ozs.)
of pus was evacuated from this region in a patient
who presented before the operation but an insignificant
swelling in the site of the collection. Duplay records
two cases of ulceration of an abscess into the popli-
teal artery, and Ollivier an instance where the abscess,
unable to find a way to escape, ultimately entered
into the knee-joint.

Pus may reach the ham from the buttock or pelvis
by following the great sciatic nerve, or may extend
from the thigh through the opening in the great
adductor for the femoral vessels.

The hamstring muscles are frequently found
contracted in neglected cases of knee-joint disease, and
produce thereby more or less rigid flexion of the leg
upon the thigh. Among the reasons for this contrac-
tion may be mentioned the fact that these muscles
are all supplied by the great sciatic nerve, and that
the knee-joint derives its main nerve -supply from
the same trunk by means of its internal popliteal
branch.

Contraction of these muscles in knee-joint disease
tends not only to flex the knee but also to draw the

Chap, xxi.] THE POPLITEAL SPACE. 431

tibia backwards, and produce in some cases a partial
luxation.

The hamstring tendons may be ruptured by
violence, the tendon most frequently torn being that
of the biceps. The muscles are greatly stretched when
the trunk is bent forcibly forwards at the hip joint,
the knee remaining extended. Extreme movement in
this position has ruptured some of the fibres of this
muscle. The difficulty experienced in touching the
toes with the fingers while the knees are kept stiff
depends upon the resistance offered by the stretched
hamstrings. In tenotomy of the biceps tendon the
peroneal nerve is in great risk of being wounded. It
may be noted that contraction of the muscle tends to
increase the distance between the tendon and the
nerve, and to render the former more superficial. The
peroneal nerve is in still greater risk of being wounded
in resecting the head of the fibula, an operation, how-
ever, that is seldom performed.

The vessels of the ham. — The popliteal vessels
are, from their depth, but seldom wounded. It must
be borne in mind that the lower part of the artery may
be reached from the anterior aspect of the leg by an
instrument passing between the tibia and fibula.
Thus Spence reports the case of a farmer who received
a wound in front of the leg, just below the knee, from
the slipping of his knife while cutting a stick. It was
discovered subsequently that the knife had entered the
interosseous space and had wounded the popliteal
artery at its bifurcation. It had indeed nearly severed
the anterior tibial artery from the main trunk.

The popliteal artery has been ruptured by external
violence, as when a wheel has passed over the region
of the vessel. Mr. Harrison Cripps (Lancet, 1876)
believes that the rupture is, as a rule, the result of a
force acting in an oblique direction from below upwards
upon the lower expanded end of the femur. This

43 2 SURGICAL APPLIED ANATOMY. [Chap. xxi.

artery is more frequently the seat of aneurism than is
any other artery in the body, save only the thoracic
aorta. In 551 cases of spontaneous aneurism, col-
lected by Crisp, the popliteal vessel was the seat of the
disease in 137 instances, the thoracic aorta having
been affected in 175 of the cases. This marked
disposition to aneurism depends upon many factors.
The vessel is subjected to a great deal of movement,
and often to very violent movement. Experiments
upon the dead body show that the inner and middle
coats of the vessel may be ruptured by extreme
flexion of the knee, and that a like rupture may in a
smaller percentage of cases be brought about by
forcible extension. Moreover, except when the limb
is in the position of extension the popliteal artery is,
like the thoracic aorta, much curved. Then, again,
the vessel breaks up into two large vessels, and it is
well known that the point of bifurcation of an artery
is a favourite spot for aneurism. Lastly, the artery is
supported only by the lax tissue of the popliteal space,
and the support of strong muscles given elsewhere
to so many large vessels is practically absent. Some
popliteal aneurisms have been successfully treated by
flexing the knee and retaining the limb for some time
in that position. That flexion can have a direct effect
upon the lumen of the vessel is shown by the dimi-
nished pulse at the inner ankle produced by forcibly
bending the leg upon the thigh. The artery and vein
are so adherent that it is difficult to separate the two
when applying a ligature to the arterial trunk. This
adhesion must have been appreciated by any who
have taken pains to " clean " the artery in a dissection
of the ham.

The popliteal vein is a remarkably substantial
vessel, and has walls so dense and thick, that on
section they often look more like the tunics of an
artery. On the ground of this peculiarity, and of

chap, xxi.] THE POPLITEAL SPACE. 433

its close adhesion to its companion vessel, Tillaux
asserts that "it is unlike any other vein in the
economy." It is worthy of note that the vein,
although more superficial than the artery, is very
rarely ruptured by violence. As a rule, the artery
alone is torn. In a few cases both the vessels may
suffer ; but I can find no instance recorded of rupture
of the popliteal vein alone.

From the relations of the artery to the vein and
nerve it will be understood that a popliteal aneurism
may soon lead to oedema of the leg and to nerve
symptoms depending upon pressure on the internal
popliteal trunk. It has more than once also made its
way into the knee-joint, with the posterior ligament
of which the artery is in such close relation.

The short saphenous vein lies almost in the middle
line, and not being usually apparent through the
skin, may be divided in an incision made into the
lower part of the popliteal space. Herapat has
suggested that varices of this vein may depend
upon the narrowness of the opening in the fascia
lata through which the vessel passes to reach the
main trunk.

The lymphatic glands in the ham are from
four to five in number and are deeply placed about
the great vessels. When enlarged they have been
mistaken for aneurism and other popliteal tumours.
They receive the deep lymphatics of the leg. A
small gland is often met with beneath the fascia,
close to the point of entry of the short saphenous
vein. It receives some lymphatics that follow that
vessel.

The bursse about tlie ham are usually six in
number, two on the inner side of the space and four
on the outer. Inner side. — (1) A large bursa between
the internal condyle of the femur and the inner head
of the gastrocnemius and the semimembranosus.
c c

434 SURGICAL APPLIED ANATOMY. [Chap. xxi.

This is the largest bursa in the space, and after adult
life it usually communicates with the joint. It is, of
all the bursse in this region, the one most often
enlarged, and when affected may attain great size.
In one reported case the sac measured 5 inches by 3*5
inches. In the extended position of the limb the
enlarged bursa feels firm and resisting, but on flexion
it becomes flaccid and can often be made to entirely
disappear. Probably the slit - like communication
between the bursa and the joint is closed when the
posterior ligament is tightened by extension, and is
opened when it is relaxed on bending the knee. In
the latter posture the contents of the bursa can be
reduced into the cavity of the knee-joint, and so the
tumour disappears. (2) A little bursa between the
semimembranosus tendon and the tuberosity of the
tibia. It never communicates directly with the joint,
but has sometimes an opening into the bursa just
described. Outer side. — (1) A bursa between the
popliteus tendon and the external lateral ligament
that does not usually communicate with the joint.
(2) One between the popliteus tendon and outer
tuberosity of the tibia, that is merely a diverticulum
from the synovial membrane. This sac may open
into the tibio-fibular articulation, and so bring that
cavity in connection with the knee-joint. (3) A bursa
between the outer head of the gastrocnemius and the
femoral condyle. It is not constant and is not con-
nected with the articulation. (4) A bursa between
the biceps tendon and the external lateral ligament.
The peroneal nerve runs across this sac, a circum-
stance that may explain some of the pain experienced
when the bursa is enlarged.

It is not improbable that wounds of bursse in
this region containing fluid have been mistaken for
wounds of the joint, and the escaping serum for
synovia.

chap, xxi.] THE KNEE JOINT. 435

The knee-joint. — This articulation is the largest
in the body. The joint owes its great strength to the
powerful ligaments that unite the two component bones,
and to the muscles and fasciso that surround it. It
derives no strength from the shape of the articular
surfaces, since they are merely placed in contact with
one another. In spite of its frequent exposure to in-
jury, dislocations "at the knee are extremely rare. The
lateral ligaments are comparatively feeble, are tense in
extension and relaxed in flexion. The laxity of these
ligaments is such that partial luxations of the tibia
are possible without rupture of these bands, especially
in cases where the joint is found slightly flexed after
the accident. The crucial ligaments are very power-
ful, and are more or less tense in all positions of the
joint. The anterior of these ligaments especially
resists extension, forward displacement- of the tibia,
and rotation inwards of the leg. The posterior band
resists flexion and displacement backwards of the
tibia. In the movement of extension the tibia slides
a little forwards and is rotated a little outwards. In
flexion that bone glides backwards and rolls a little
inwards. Extension generally is limited by the
crucial and posterior ligaments ; flexion by the liga-
mentum patellae and anterior part of the capsule in
addition to the crucial ligaments. The thinnest
part of the posterior ligament is the portion below
the oblique fibres derived from the semimembra-
nosus. If pus finds its way from the joint into the
ham, it will probably escape through this part of the
ligament.

In the contracted knee associated with fibrous
anchylosis, the chief contraction, so far as the joint
tissues are concerned, is in the posterior ligament, in
the lateral ligaments, and in the fibrous and fatty
tissue between the former ligament and the posterior
crucial band.

436

SURGICAL APPLIED ANATOMY. [Chap. xxi.

The synomal membrane of the knee-joint extends
upwards as a large cul-de-sac above the patella and
beneath the extensor tendon. This cul-de-sac reaches
a point an inch or more above the upper margin of the
trochlear surface on the femur, and is rendered very

Fig. 45.— Vertical Section of Normal Knee-joint (Braune).

a, Quadi'iceps ; 6, semiraembranosus ; c, gastrocnemius ; d, posterior crucial
ligament ; e, liganientum patellse ; /, bursa between quadriceps and femur.

distinct when the joint is distended with fluid (Fig.
46). When the knee is bent, the cul-de-sac is drawn
down, and therefore this position of the limb is
advised when operations are about to be performed
upon the lower end of the femur. Above the sy no vial
pouch is a bursa that separates the quadriceps tendon
from the femur, and is usually over an inch in its
vertical measurement (Fig. 45). From the exami-
nation of two hundred and sixty knee-joints in both
infants and adults Schwartz found that this bursa

Chap, xxi.] THE KNEE JOINT. 437

communicated with the synovial cavity in seven cases
out of ten in young children, and in eight cases out of
ten in adults.

It will thus be seen that when this communica-
tion exists, a stab over the femur, about two inches
above the trochlear surface of the bone, or about
the same distance above the top of the patella,
when the limb is extended, will practically open the
knee-joint.

Cases are reported of extravasation of blood into
this bursa, that, although at first limited to the sac,
have, on rough handling, extended into the knee-
joint, a circumstance leading to the supposition that
in some cases the orifice of communication may be
very small.

The crucial ligaments, although more or less com-
pletely invested by the synovial membrane, are yet
entirely outside the synovial cavity.

The upper third of the patellar ligament is in
relation to the synovial membrane, from which, how-
ever, it is separated by a pad of fat. The lower two-
thirds of the ligament are in relation to the bursa and
fatty tissue that intervene between the band and the
tibia. A knife passed horizontally backwards at the
apex of the patella, would, when the limb is extended,
just miss the joint line between the femur and tibia,
and would hit the latter bone (Fig. 45). If, how-
ever, there be any effusion in the joint, or the limb be
a little flexed, a knife so introduced would pass
between the two bones (Fig. 46).

Joint disease. — Owing to its superficial position,
the knee-joint is the articulation that is most frequently
the seat of inflammations due to injury and exposure
to cold. When distended with fluid, the effusion soon
shows itself above and at the sides of the patella, by
bulging forward the synovial sac, which is here more
nearly in relation to the surface than it is elsewhere.

433

SURGICAL APPLIED ANATOMY. [Chap. xxi.

Fluctuation is soon to be detected, and tlie patella,
being pushed away from the femur, is said to " float "
upon the distending fluid (Fig. 46).

The inflamed knee-joint, if left to itself, almost

Fig. 46.— Vertical Section of Knee-joint distended with Fluid
(Braune).

a, Vastus externus ; 6, crureus ; c, short head, and d, long head, of biceps ; e, plan-
taris : /, gastrocnemius; g, popliteus ; h, soleus; i, tibialis posticus ; j, bursa
patellae; k, ligamentum patellae ; I, ligamentum imicosum ; in anterior crucial
ligament; n, external semilunar cartilage; 1, external popliteal nerve;
2, popliteal artery.

invariably assumes the flexed position. This may be
explained upon three hypotheses, and it is probable
that each of the three reputed factors takes part in
producing this position in cases of disease.

(1) The capacity of the joint is increased on

Chap, xxi.] THE KNEE JOINT. 439

flexion. The pain of acute synovitis is due mainly
to the increasing distension of the joint with fluid,
and it is natural that the patient should in-
stinctively place the limb in the position in which
the joint will hold the greatest amount of fluid,
and in which the interarticular tension is reduced
to a minimum. It cannot be said, however, that the
greater the degree of flexion the greater the capa-
city of the joint cavity. By experimental injections
into the knee_, Braune found (a) "that the capacity of
the synovial cavity reaches its maximum in a definite
degree of flexion, and that the angle at which this
happens is twenty-five degrees ; " (b) that "the mini-
mum of the capacity of the synovial cavity coincides
with the maximum of flexion." Thus it happens that
the tension within an inflamed knee will be greater in
extreme flexion than it is in full extension.

(2) By flexing the limb, the more powerful liga-
ments (such as the ligamentum posticum, the posterior
crucial and lateral ligaments) are relaxed, while the
ligaments rendered tense by the position are the
patellar and the anterior part of the capsular, the
latter of which is but a yielding membrane.

(3) The sensory nerves of the joint being disturbed,
contraction of muscles may be anticipated from reflex
action, and of the muscles so excited the flexors may
be expected to have the advantage, as being the more
powerful and the more favourably placed for acting
upon the articulation.

Dislocation of the semi-lunar cartilages.—
One or other of these cartilages may be displaced from
its attachments to the tibia, and become nipped or
locked between that bone and the femur. The result
is a sudden pain in the limb associated with a fixing of
the knee in the ' flexed position. The accident is
usually brought about by a twist given to the leg when
the knee -joint is more or less bent. It may be noted

44° SURGICAL APPLIED ANATOMY. [Chap. xxi.

in connection with the causation of the lesion, that in
flexion and extension the two cartilages move with the
tibia upon the femur, but in the rotation movements
of the leg the discs are fixed, and the tibia rotates
beneath them. The luxated cartilage may be displaced
either inwards towards the tibial spine, or inwards and
backwards, or outwards so as to slip beyond the mar-
gins of the two articulating bones. Although statistics
are wanting that would show which cartilage is the
more often luxated, anatomical facts would point to the
outer disc as the one the more likely to be displaced.
This disc is much more movable than its colleague.
The internal cartilage and its coronary ligament are
adherent to both the posterior and internal lateral
ligaments by extensive attachments j while the outer
cartilage has only a somewhat feeble connection with
the ligamentum posticum and the hinder of the crucial
bands.

Geim-valgiim, or knock-knee. — In this affection,
owing to changes in and about the joint, the tibia
and femur are bent laterally, and the angle formed by
the outer borders of the thigh and leg becomes more
or less conspicuously diminished. The appearances
produced by this affection are familiar. When a
person stands erect with the feet together, the tibiae
are practically vertical, and the femora meet them at a
certain angle. The degree of this angle depends, in
normal subjects, to a great extent upon the relative
wiclfch of the pelvis. The greater this width the less
is the angle between the outer sides of the femur and
leg. Compared with men, many women, on account
of the relatively greater width of their pelves, may be
said to be in a sense knock-kneed. In actual genu-
valgum, the tibiae cease to be vertical in the erect
position ; their lower ends deviate more and more from
the middle line, until the distance between the two
malleoli becomes considerable when the individual

chap, xxi.] THE KNEE JOINT. 441

stands upright and when he is not concealing any of
the deformity by rotating the limb.

The progress of genu-valgum may be divided into
three stages. In the first stage there is a yielding or
elongation of the internal lateral ligament, and of the
fascial structures on the inner side of the joint. That
the yielding of this ligament alone will permit of a
lateral movement at the articulation being accomplished
is illustrated by cases of sprains of the knee, where the
ligament has been torn, and where much lateral bend-
ing has been in consequence permitted. It is probable
that the crucial ligaments yield also a little, and it is
upon the posterior band attached to the internal con-
dyle that the strain possibly first comes. In the
second stage there is a contraction of the tissues on the
outer side of the joint, that have been relaxed by the
new position of the limb. These structures are the
ilio-tibial band of the fascia lata, the external lateral
ligament, and the biceps tendon. This contraction
tends to give permanency to the deformity. In the
third stage the bones become changed. On the outer side
of the joint the external condyle and the outer tuber-
osity of the tibia are pressed together, and through these
bones the greater part of the weight of the body will
be transmitted. As a result of the continual pressure
the parts waste a little, and by their atrophy contribute
not only to the extent of the deformity but also to its
permanency. On the inner side the internal condyle
tends to become separated from the tibia, and an
interval to develop between the two bones as the
deformity advances. This interval is prevented
from actually existing by the development of the
condyle, which enlarges, and so still maintains its con-
tact with the tibia. Mikulicz has pointed out that
" the alteration in length on the inner side of the
femur arises not from alteration of the epiphysis, but
is confined to the lowest part of the diaphysis." This

442

SURGICAL APPLIED ANA TOMY. [Chap. xxi.

is shown in the diagram (Fig. 47), where it will be
seen that the enlargement of the internal condyle
is due almost entirely to increased growth in the
diaphysis.

The patella.— Fractures.— This bone is more
often broken by muscular violence than is any other
in the body. Although the patella may be fractured

Fig1. 47. — A, Normal femur ; B, femur in an advanced case of knock-knee,
showing the enlargement of the internal condyle. The dotted line
in each case represents the line of the epiphysis.

by both muscular and direct violence, it would appear
that the former is the agent that most often pro-
duces the lesion. Thus, in 127 cases of simple trans-
verse fracture collected by Hamilton, he considers that
muscular action was the cause of the injury in 106 in-
stances. The form of fracture due to muscular violence
is very uniform. It is nearly always transverse, simple,
and through the centre of the bone, or just above that
point or just below it. Fractures due to direct violence
may present the same appearance, but they are more
often starred, or oblique, or even longitudinal. Ex-
periments upon the cadaver show that a simple trans-
verse fracture about the centre of the bone cannot be
produced with any degree of certainty by a direct
blow. The position of the knee that most favours

Chap, xxi.] THE REGION OF THE KNEE. 443

fracture by -muscular action 'is that Oi nbxlcri. "When
the knoe is bent, the patella rests upon the femoral
condyles' nlpn£ rts transverse kxiH only. Nieady the
whole of its4 upper" half is unsupported behind, and
the extensor muscle acts in a line nearly at right
angles to the vertical axis of the bone. Thus, by
violent contraction of the quadriceps, the patella may
be snapped across the condyle
as a stick is snapped across
the knee (Fig. 48). As the
fracture usually causes the
patient to fall, it has been sup-
posed that the contact with the
ground, rather than any pre-
vious muscular action, may
have caused the lesion. But,
as Hamilton has pointed out, Fig. 48.-Diagram to show

if a person falls UDOll the beilt Mechanism of Fracture of
i -i ,1 !• i i • the Patella "by muscular

knee when the limb also is action.

fl^vorl nTkr»™ fV»a 4 -mm IT- f"Ko a> ^ne °f action of quadriceps
Upon tne trunK, tne muscle ; &, femur ; c, tibia.

part that comes in contact

with the ground is not the patella, but the tubercle

of the tibia.

In the great majority of cases, the lesion not only
involves the bone, but also the cartilage and fibrous
structures that cover it respectively behind and in
front ; the synovial membrane also is torn, and the
patellar bursa opened up. Thus the synovial contents
may come in actual contact with the skin. "It is
anatomically possible, if the fracture involve only the
lower and non-articular portion of the. patella, and if
the amount of separation of the fragments is slight,
that the fatty tissue behind the apex of the patella,
over which the synovial membrane is reflected, may
save the latter from injury " (Henry Morris). In all
cases where there is much separation of the fragments,
the fibrous expansion attached to either side of the

444 SURGICAL APPLIED ANATOMY. [Chap. xxi.

patella irjiisi* Jbe -JiQm through. : 'Ind^ed/^one but a
slight separation of the parts is possible until that ex-
pansion is .ruptu/ed- Braune has 'tfemonef.r&ted this
by experiment, fy sawing through fche patella without
damage to the lateral ligameiitous structures, and
noting that but trifling separation of the fragments
was possible until these structures had been divided.
In stellate fractures, due to direct violence, these
fibrous expansions from the extensor tendon may be
uninjured, and no separation of any magnitude be per-
mitted between the portions of the broken bone.

The patella is more readily broken by muscular
violence than is either the extensor tendon or the liga-
mentum patellae. In the flexed position it will be seen
(Fig. 48) that the bone is placed at a considerable
disadvantage when compared with the two other
structures. Bichet reports a case where violent con-
traction of the quadriceps caused the tubercle of the
tibia to be torn away from the bone without any other
lesion of the parts immediately concerned being
produced.

Dislocation of tlie patella. — This bone may
be dislocated outwards or inwards, or turned upon its
edge so that its anterior and posterior surfaces are
placed laterally. The luxation outwards is by far the
most common. This depends upon the fact that the
quadriceps, the patella, and the ligamentum patellae do
not, when the muscle is contracted, follow the lines of.
the femur and tibia. They are more nearly in a
straight line, that passes to the outer side of the angle
formed by the femur with the leg at the knee-joint.
Muscular contraction, therefore, tends to draw the
knee-cap outwards, a tendency that is in all normal
circumstances corrected by the increased prominence
of the external condyle. The vastus externus also is
said to be more powerful than the internus.

Dislocations of this bone are usually due to

chap, xxi.] THE REGION OF THE KNEE.

445

rfr

muscular action, and are most apt to occur in the ex-
tended position of the limb, the position in which the
patella is not fixed and its ligament and the anterior
part of the joint
capsule attached
to the bone are
the most lax. The
lateral luxations are
usually incomplete,
but may be com-
plete. In the
former case the an-
terior part of the
capsule need not be
torn, but in the
latter form it can
scarcely escape ex-
tensive rupture.

In the disloca-
tion of the patella

n-nrm it<a prlo-P tVi^ Fig. 49.— Transverse Section of left Knee-
eage, tne through the centre of the' Patella

inner border of the (Braune).
bone usually pro-
jects for wards, while
the outer is placed
between the con-
dyles. But little
is known as to the mechanism of this dislocation.

In dislocations of the knee, which are very
rare, the tibia may be displaced outwards, inwards,
forwards, or backwards. The two lateral luxations
appear to be more common than the antero-posterior.
The former are nearly always partial, the latter usually
complete. Considerable violence is required to produce
these luxations, owing to the great strength of the
ligaments and the great width of the bones involved.
Direct violence to the tibia or femur, associated often

a, Patellae bursa; 6, internal lateral ligament and
inner condyle ; c, external lateral ligament
and outer condyle; d, biceps; e, semimeni-
branosus; /, senritendinqsus; g, gracilis
tendon ; h, sartorius ; 1, internal popliteal
nerve ; external popliteal nerve ; 3, internal
saphenous vein.

446 SURGICAL APPLIED ANATOMY. [Chap. xxi.

with a twisting of the former bone, is the common
cause of the lesion. It is probable that in all luxa-
tions of the knee, the crucial ligaments are torn.
The lateral ligaments also are usually ruptured, but in
the partial luxations they may be sometimes found to
be intact. The tendinous expansion of the vasti in
front of the knee seldom escapes some laceration, even
in the partial dislocations. The projection of the spine
of the tibia between the femoral condyles offers an
obstruction to lateral luxation. In the antero-posterior
displacements, the tibia is more often luxated forwards
than backwards. In these injuries, not only are the
crucial and lateral ligaments torn, together with the
anterior part of the capsule, but the posterior ligament,
the gastrocnemius, the biceps, and less often the semi-
membranosus, suffer more or less extensive laceration.
The popliteal vessels and nerves are much compressed,
and appear to be more severely injured by the femur
in the forward dislocation than by the tibia in the
backward displacement.

The lower end of the femur. — The condylar
part of the femur is composed almost wholly of can-
cellous bone, with but a slight layer of compact tissue.
It is so spongy that it may be pierced by a bullet, as
pointed out by Legouest, without any splintering of
the bone being produced, and without damage to the
articulation. The fractures that may be met with in
the lower end of the bone are the following: (1) A
fracture of the shaft above the condyles ; (2) a sepa-
ration of the lower epiphysis ; (3) a fracture separating
either the outer or inner condyle ; (4) a T-shaped
fracture, i.e., a transverse fracture above the condyles
with a vertical one between those processes. These
lesions are, as a rule, due to well localised direct vio-
lence. Fractures Nos. 1 and 4 may be produced by in-
direct violence, as by a fall upon the feet from a height.
Henry Morris states that lateral flexion, or force

chap, xxi.] THE REGION OF THE KNEE. 447

applied in a lateral direction, is best calculated to pro-
duce a separation of the epiphysis. Hamilton reports
a strange case in a man aged 21, whose outer condyle
was fractured by the twist of the leg, which happened
while he was undressing himself to bathe. The only
fracture that requires special notice in this place is the
fracture of the shaft just above the condyles. The
lesion is situated generally about two inches above the
line of the epiphysis, and corresponds to the spot
where the compact shaft joins the softer and more
cancellous tissue of the lower end of the bone. It is
near the place, also, where the femoral artery crosses
the bone to reach the ham, and it has thus happened
that the vessel has been wounded by splinters in this
particular injury. The fracture is usually oblique,
from behind, downwards, and forwards. The lower
fragment will be drawn upwards by the same muscles
that produce shortening in other fractures of the shaft
(page 422), and its sharp upper end is very apt to be
pulled forcibly into the popliteal space by the gastroc-
nemius muscle. This latter displacement is difficult to
remedy. If the limb be extended, the fragment is
only drawn the more into the ham, and it is therefore
possible for the limb to appear straight, and yet have
the knee-joint much bent. In three cases of this
injury I divided the tendo Achillis, and then placed
the limb upon a straight splint, following a practice
suggested by Mr. Bryant. The effect upon the posi-
tion of the fragments was in each case very good
(Brit. Med. Jour., 1883).

The upper end of the tibia is sometimes the
seat of fracture, although of all parts of this bone
the upper third is the part least often broken. One
or other of the tuberosities may be broken off, or
there may be a transverse or oblique fracture of the
upper end of the shaft associated with a vertical
one running up into the joint between the two

448 SURGICAL APPLIED ANATOMY. [Chap. xxi.

tuberosities. Such accidents are the result, in nearly
every instance, of great direct violence. Dr. Hutton
reports a case, probably unique, in which the spine of
tibia, the central part of the head of the bone, and a
considerable portion of the left articular surface, were
torn from the rest of the tibia. The anterior crucial
ligament was attached fco the fragment. The patient
had been wrestling while in a state of intoxication,
and had been heavily thrown. Madame Lachapelle
reports a case of separation of the upper epiphysis of
the tibia caused by traction during parturition ; but I
am not aware of any reported case of separation of
this epiphysis due to violence or under circumstances
other than this.

The spongy tissue in the head of this bone and in
the lower end of the femur is, par excellence, the
favourite seat for myeloid sarcomata.

In excising the knee-joint through an inci-
sion commencing at the back of one condyle, and
continued across the joint, just below the patella, to
the back of the other condyle, the following structures
are divided : Skin, fascia, patellar plexus of nerves
(formed by the middle and internal cutaneous and
the patellar branch of the long saphenous), bursa
patellae, anterior part of the capsule, ligamentum
patellae, synovial membrane, lateral and crucial liga-
ments, the superior and inferior articular arteries,
the anastomotica magna, and the anterior tibial
recurrent vessel.

The incision over the inner condyle need not be
made so far back as to divide the internal saphenous
vein and nerve. In sawing the femur it is most
important that the exact inclination of the joint
surface of the bone be reproduced. If improperly sawn
the patient would be bow-legged or knock-kneed. The
rule, therefore, is that the saw be applied parallel to
the articular surface and perpendicular to the shaft.

chap. XXL] THE REGION OF THE KNEE.

449

In young subjects care must be taken that the
saw-cut do not pass beyond the epiphyseal line. The
upper limit of the femoral epiphysis will be repre-
sented by a horizontal line drawn across the bone at
the level of the tubercle for the adductor magnus.
If the whole of the trochlear surface be removed in the
excision, the whole of the epiphysis will have been
taken away. A single nucleus appears in this
epiphysis shortly before birth, and joins the shaft
about the twentieth year. The limits of the tibial
epiphysis are represented behind and at the sides by a
horizontal ]ine that just marks off the tuberosities.
It includes, therefore,
the depression for the
insertion of the semi-
membranosus, and also
the facet for the fibula.
In front the epiphyseal
line slopes downwards ^
on either side to a
point on the upper end
of the shin, so as to en- *|
close the whole of the .
tubercle of the tibia.
The centre joins the
main bone at the twen-
ty-first or twenty-second
year. The popliteal
artery runs some risk
of being wounded in
this procedure. The
vessel is separated by
some little distance from
the popliteal surface of
the femur (Fig. 49),
but is in very close relation to the tibia, the pos-
terior ligament alone intervening at the upper level of

D D

Fig. 50.— Disarticulation at the Knee-,
joint by single Anterior Flap
(Agatz).

a, Int. cotidyle ; 6, ext. condyle ; c, inter-
condyloid fossa; d, lig. patellae: e, sar-
torius;/, gracilis ; <j, seniitendmosus ;
h, ext. lat. ligament ; i, popliteus : j,
plantaris ; k, semimernbranosus ; I and
m, inner bead of gastroenemius ; n, outer
head of gastrocnemius; o, l>iceps ; pt
popliteal vessels ; </, int. pop. nerve.

450 SURGICAL APPLIED ANATOMY. [Chap. xxn.

the bone. It thus happens that the risk of wounding
the artery is greater when the tibia is sawn than
when the lower part of the femur is being removed.
Amputation through the knee-joint. — By

single anterior flap. In fashioning the anterior flap
(which is composed only of integument), and in
opening the joint, the patellar plexus of nerves, the
superficial branches of the plexus of arteries, the
ligamentum patellae, and the anterior part of the cap-
sule will be cut. Nearer the condyles of the femur the
anastomotic and the two superior articular arteries
will be divided. The long saphenous vein and nerve
will be divided at the inner angle of the flap. On the
cut surface made by the posterior incision will be found
divided the sartorius, gracilis, and semitendinosus, the
semimembranous, both heads of the gastrocnemius,
the popliteus, plantaris, and biceps. The popliteal
vessels, the sural arteries, the short saphenous vein,
the internal and external popliteal nerves, the external
saphenous and the small sciatic nerves will also be
found divided in the same incision.

CHAPTER XXIL

THE LEG.

Surface anatomy. — The anterior border of the
tibia can be felt in its entire length, forming, as it does,
the prominence of the shin. It should be remembered
that this border presents a somewhat flexuous course,
being curved outwards above and inwards below. The
broad internal surface of the bone is subcutaneous,
and the internal border can be followed from the
tuberosity to the malleolus. The head of the

chap, xxii.] THE LEG. 451

fibula can be distinctly made out, but the upper
half of the shaft of the bone is lost beneath the
mass of muscle on the outer side of the limb. The
lower half of the fibular shaft can be felt, and the
bone just above the malleolus becomes subcutaneous
in the interval between the peroneus tertius and the
two other peroneal tendons. Between the tibia and
fibula the outline of the tibialis anticus muscle can be
well defined when it is in action. To its outer side is
the less conspicuous and narrower eminence formed by
the extensor communis digitorum. In well developed
limbs the groove that separates these two muscles is
very distinct, and forms the best guide to the anterior
tibial artery. In the lower third of the leg these
muscles become tendinous, and between them the
extensor longus pollicis can be felt as it comes to the
surface. The long arid short peroneal muscles can be
defined, and their tendons followed behind the
malleolus. When in active contraction the interval
between the two muscles is often well marked. The
gastrocnemius muscle and the more superficial parts
of the soleus are brought well into view when the
body is raised upon the toes. The two heads of the
former muscle are then quite conspicuous, and it can
be seen that the inner head is the larger and descends
lower in the leg.

The popliteal artery bifurcates on a level with the
lower part of the tubercle of the tibia. The course of
the posterior tibial vessel is represented by a line
drawn from the middle of the limb at the lower part
of the ham to a spot midway between the inner
malleolus and the prominence of the heel. The
artery becomes superficial in the lower fourth of the
leg, where it may be felt pulsating between the tendo
Achillis and the tibia. The peroneal artery arises
about three inches below the knee, follows the posterior
surface of the fibula, and ends behind the outer

45 2 SURGICAL APPLIED ANATOMY. [Chap. xxn.

malleolus. The position of the anterior tibial artery
may be indicated by a line drawn from a point midway
between the outer tuberosity of the tibia and the head
of the fibula to the centre of the front of the ankle
joint. Both the saphenous veins can often be made
out in the leg. The inner or larger vein passes in
front of the malleolus and ascends just behind the
internal border of the tibia. With it runs the long
saphenous nerve. The short saphenous vein lies
behind the outer malleolus, and passing up the middle
of the calf ends at the ham. It is accompanied by
the external saphenous nerve.

The leg. — The skin is somewhat more adherent to
deeper parts in the leg than it is in the thigh. The
difference in the degree of this adhesion is obvious
when skin-flaps are dissected up from the two parts
in cases of amputation. Over the internal surface of
the tibia and the greater part of the shin, the
integument lies directly upon the periosteum and
bone, nothing intervening save a scanty amount of
subcutaneous fascia. Thus blows and kicks over these
parts of the leg are apt to be associated not only
with much pain but also with much bruising or
tearing of the integument. A " graze on the shin "
is one of the commonest of lesions, and is produced by
a degree of violence that upon a well -covered part
would have little or no effect. It will be understood
that ulcers over these feebly protected parts may,
if they spread in depth, readily expose the bone and
lead to some disease of its substance, or to at least
some inflammation of its periosteum. Scars left by
deep ulcers or burns are also often found to be
quite adherent to the bone.

The aponeurosis of the leg invests it like a
cightly-drawn buskin, being lacking only over the sub-
cutaneous surfaces of the bones. It is attached to the
head and the anterior and inner borders of the tibia,

Chap, xxii.] THE LEG. 453

the head of the fibula, and the two malleoli. It is
continuous above with the fascia lata, and below with
the fascia of the foot and the annular ligaments. It
is thicker in front than behind, and is especially thick
at the upper part of the leg just below the knee.
Here the fascia offers great resistance to the growth
of tumours springing from the head of the tibia.
From the deep surface of the aponeurosis two
septa pass inwards to be attached to the an-
terior and external borders of the fibula. They
serve to isolate the two larger peroneal muscles
from the other muscles of the limb, and form a
closed space which might form a definite and well
localised cavity for pus. Beneath the gastrocnemius
and soleus a layer of fascia extends between the two
bones and covers in the deep layer of muscles. It
is thin above but denser below, and would have some
influence in directing the progress of a deep abscess.

In the upper third of the leg there is a septum be-
tween the tibialis anticus and extensor communis
digitorum, which must be found in the operation for
ligaturing the upper part of the anterior tibial artery.
I have never had the good fortune to see the very
distinct "white line" that many text-books describe
as indicating the position of this septum.

In the substance of the soleus muscle there is a
tendinous expansion connected with the border of the
tibia, that runs backwards and towards the middle
line. In cutting through the soleus to apply a liga-
ture to the posterior tibial artery, this intersection
may be mistaken for the aponeurosis on the deep
surface of the muscle.

Several cases are reported of rupture of some part
of the gastrocnemius muscle during violent exertion.
The tendo Achillis has been ruptured under like cir-
cumstances. It is said that the plantaris tendon is
also not infrequently torn across, producing a sudden

454 SURGICAL APPLIED ANATOMY. [Chap. xxn.

sharp pain in the calf during exertion, to which the
French give the name " coup de fouet."

Vessels. — The large arteries of the leg, being all
in near proximity with the bones, are apt to be in-
jured by sharp fragments in fractures of the limb.
This especially applies to the peroneal artery, which
runs along the fibula, and is in considerable risk of
being wounded in fractures about the middle of that
bone. It is at the point of bifurcation of the popliteal
artery that emboli are peculiarly apt to lodge. They
plug the vessel and practically block the three main
arteries of the leg. Gangrene therefore not infre-
quently follows the occurrence. Billroth states that
in all the cases of gangrene of the leg due to embolism
that he has met with, the ping was found situated
at the bifurcation of the popliteal trunk (" Clinical
Surgery," 1881). According to some French surgeons,
aneurism of the commencement of the posterior tibial
artery is more often associated with gangrene of the
leg than is a popliteal aneurism. The reason they
assign is the following : The aneurism on the former
vessel not only interferes with the passage of the
blood into the posterior tibial and peroneal arteries,
but also compresses the anterior tibial vessel and with
it the anterior tibial recurrent, an artery that is of
so great importance in establishing the collateral
circulation.

Varicose veins are more commonly met with in
the leg than in any other part of the body, save, per-
haps in the hsemorrhoidal and spermatic veins. This
depends upon the great length of the veins of the lower
limb, the large columns of blood their valves have to
support, their vertical position, the liability of the
great trunks (iliac) into which they ultimately enter,
to be compressed, and upon the fact that the superficial
veins, being outside the fascia, lose that assistance to
the circulation derived from muscular contraction. The

chap, xxii.] THE LEG. 455

use of garters especially affects the long saphenous vein,
which lies close to the bone at the spot about which
these contracting bands are usually applied. Between
the two layers of the muscles of the calf Yerneuil
describes a venous plexus, which he believes to be
more often the seat of varices than are the vessels of
the surface. A varicose condition of these deeply-
placed veins may explain the "aching legs" complained
of by those who stand a great deal. The intra-mus-
cular veins are very large. Callender
showed that the six chief veins which
pass from the soleus muscle alone to I
enter into the posterior tibial and pero-
neal trunks have a united diameter of
not less than one inch. Yarix would
appear to commence most often at points
where the deep veins join the superficial
vessels. There is good reason for this, Fig. 51.
for at these points three forces meet,
the general directions of which are shown in the
annexed diagram (Fig. 51). There is the weight
of the superincumbent column of blood (a) acting
from above, the resistance offered by the next
valve below the point of entry of the deep vein
acting from below (6), and the force with which
the blood is driven by the contracting muscles out of
the deep vein into the superficial trunk acting at an
angle to both these lines of force (c). Unfortunately for
the subjects of varices, the two principal veins (the
saphenous) are accompanied by sensory nerves, and
there is no doubt that much of the pain incident to
varicose veins in the leg depends upon pressure on
these nerves.

With reference to pain in the leg it must be re-
membered that the nerves that bring sensation to the
part arise at a considerable distance from their points
of termination, and that the causes of pain in the limb

45 f> SURGICAL APPLIED ANATOMY. [Chap. xxn.

may be situated far away from the seat of trouble.
Thus Sir B. Brodie mentions the case of a gentleman
who suffered from severe pain in the left leg, from the
foot to the knee, in the course of the peroneal nerve.
No cause could be found for it. At the patient's
death, however, a large tumour was found attached to
the lumbar spine, which had evidently compressed the
left great sciatic nerve.

There would appear to be little connection be-
tween disease in the rectum and a pain in the leg,
yet in one case at least that connection was marked.
" Only recently," writes Mr. Hilton, " I saw a
gentleman from South Wales, who was the subject
of stricture of the rectum from malignant disease.
He suffered pain in the knee-joint and in the back
part of the leg. This led me to suspect, what really
turned out, upon careful examination, to be the
case, that a large mass of cancer was involving the
nerves on the anterior part of the sacrum, and also, no
doubt, the obturator nerve."

Fractures of tlie leg". — Of the bones of the leg
the tibia and fibula are more often broken together
than singly, and of separate bones the fibula is
more often fractured than is the larger bone.

1. The tibia and fibula. As regards the resistance
it offers to violence the fibula presents about the same
degree of strength in all its parts, save at the malleo-
lus and at its upper extremity. Its great length and
the manner of its attachment to the tibia (its two ends
being fixed and its main part being unsupported)
render it a slender bone, and but for the efficient
protection it derives from the thick pad of muscles that
surrounds it would no doubt be very frequently broken.
This is all the more likely to be the case, since the bone
is placed upon the more exposed aspect of the limb.

The shaft of the tibia presents various degrees of
strength according as we regard its upper, middle, or

chap, xxii.i THE LEG. 457

lower third. According to Dr. Lericlie the average
transverse diameter of the adult tibia just below the
tuberosities is a little over If inches. The transverse
diameter at the base of the malleolus is a little less
than If inches, and that of the narrowest part of the
bone is a little more than one inch. This narrow
part is at the junction of the lower with the middle
third of the shaft and is the weakest point in the bone.
The relation of the compact to the cancellous
tissue is about the same in all parts of the shaft; but
according to MM. Fayel and Duret the spongy
tissue is arranged in two independent vertical columns,
one occupying the upper two-thirds and the other
the lower third of the bone. The minimum
of resistance (these authors assert) is at the point
where these two systems meet. Thus it happens
that the most common spot for a fracture of the tibia
is at the junction of the middle with the lower third
of the shaft. It is here that the bone yields when
broken by indirect violence, while the lesions de-
pending upon direct violence may be at any part of
the shaft. Owing to the thin covering of soft parts,
and the slight barrier interposed between the frac-
turing force and the bone, it comes to pass that
fractures of the leg are more often compound and
comminuted than are those of any other bones of the
extremities. If the fracture be oblique (as is commonly
the case when the violence is indirectly applied), the
line of breakage usually extends from behind, down-
wards, forwards and a little inwards. The lower
fragment, with the foot, is drawn up behind the rest
of the bone by the muscles of the calf, and is usually
displaced also outwards by the obliquity of the
fracture line. Often the lower fragment is slightly
rotated outwards by the rolling over of the foot, a
rotation produced by the simple weight of the limb. If
the fracture be transverse there may be little or no

458 SURGICAL APPLIED ANATOMY. [Chap. xxn.

displacement. The fibula is usually broken at a higher
level than the tibia, and its lower fragment follows, of
course, with absolute precision the corresponding
fragment of the larger bone. A remarkable spiral
fracture (fracture helico'ide), involving the lower third
of the tibia, has been described by French surgeons.
It is associated with a more or less vertical fissure
that involves the ankle-joint, and with a fracture of
the fibula high up. MM. Leriche and Tillaux have
shown that this injury is due to torsion, especially to
some twisting of the leg while the foot is fixed.

2. The fibula alone. Fractures of this bone in
its lower fourth are usually due to indirect violence,
and will be dealt with in connection with the
ankle-joint. When broken in any other part the
fracturing force is usually directly applied, the lesion
transverse, and the displacement insignificant, or
scarcely obvious. The tibia acts as an efficient splint.

3. The tibia alone. The malleolus may be broken
by a blow, or the lower epiphysis separated. The
latter comprises the whole of the inner malleolus,
and the facet with which the fibula articulates. It
joins the shaft during the eighteenth or nineteenth
year. Fractures of the tibia alone are nearly always
due to direct violence, and whilst most common in the
lower third of the bone, become more rare as the
knee is approached. When transverse there may be
no visible displacement, the fibula acting as a splint.
Thus Mr. H. Morris mentions the case of a woman
who walked into and out of a hospital with a trans-
verse fracture of the tibia that was not detected on
examination, and was not indeed discovered until
two days after the accident. When the fracture is
just above the ankle the lower fragment may be moved
in whatever direction the foot is forced, such displace-
ment being resisted and limited by the inferior tibio-
fibular ligaments.

Chap. XXII.]

THE LEG.

459

In rickets the tibia is, of all the bones of the
extremities, the one that most frequently becomes
bent. It yields at its weakest part (the lower third),

Fig. 52.— Amputation of Leg at junction of Upper with Middle Third
by single Posterior Flap (Agatz).

a, Tibia; 6, fibula; c, tibialisanticus: d. ext. com. digit; e, peron. Ion.?. ; /, tib.
post. ; g, soleus with flex. long, digit ; h, gastrocnemius ; i, anterior tibial
vessels; j, post, tibial and peroneal vessels; k, int. saphen. vein; it post.

and there the bone will be found to have developed a
curve forwards and a little outwards.

Amputation of the leg" at the junction of the
upper with the middle third. This operation is often
performed by antero-posterior flaps, the anterior flap

460 SURGICAL APPLIED ANATOMY. [Chap. xxn.

being fashioned by cutting, and the posterior, which
is a little the longer of the two, by transfixion. In
the anterior flap the following structures would be
cut : Skin, cutaneous nerves, fascia, tibialis anticus,
extensor coinmunis digitorum, and a little of the

Fig. 53.— Transverse Section through the Lower Third of the Leg
(Braune).

a, Tibialis anticus ; 6, extensor longus pollicis; c, extensor communisdigitorum;
dt peroneus brevis ; e, peroneus longus; /, tibialis posticus : g, ik-xor longus
digitorum ; h, flexor longus pollicis ; i, gastrocnemius and soleus ; j, short
gapbenous nerve and vein ; k, anterior tibial vessels and nerve; I, peroneal
vessels ; m, posterior tibial vessels and nerve ; n, musculo-cutaneous nerve.

extensor proprius pollicis, the peroneus longus, and a
small part of the upper extremity of the peroneus
brevis, the anterior tibial vessels and nerve, and the
musculo-cutaneous nerve. In the posterior flap the
following would be the parts divided: Skin, external
and internal saphenous veins and nerves, fascia, gastroc-
nemius, plantaris, soleus, tibialis posticus, flexor longus
digitorum, a little of the upper end of the flexor
longus pollicis, the posterior tibial vessels and nerve,
and the peroneal vessels. Fig. 52 shows the stump
left after an amputation through the lower part of the

chap, xxiu.] THE ANKLE AND FOOT. 461

upper third of the leg, by means of a single flap cut
from the calf. It serves to show the relations of the
chief parts divided, and gives a good idea of the stump
that would be left in an amputation by an anterior
skin flap and a posterior transfixion flap cut from the
calf. In Fig. 53 is shown a transverse section of the
leg at the lower third, from which can be gathered an
idea of the number and position of the parts cut in
amputations through that part.

CHAPTER XXIII.

THE ANKLE AND FOOT.

Surface anatomy. — Bony points. — The outlines
of the two inalleoli can be very distinctly defined.
The external is somewhat the less prominent, descends
lower, and lies farther back than the internal process.
The tip of the outer malleolus is about half an inch
behind and below the tip of the corresponding bony
prominence. The antero-posterior diameter, however,
of the internal malleolus is such that its posterior
border is on a level with that of the outer process
behind.

On the dorsum of the foot the individual tarsal
bones are not to be distinguished, although the
astragalus forms a distinct projection upon that
surface when the foot is fully extended.

On the inner side of the foot the tuberosity of the
os calcis may be felt most posteriorly. In front of it,
and about one inch vertically below the inner malleo-
lus, is the projection of the sustentaculum tali. About
one and a quarter inches in front of the malleolus the
tubercle of the scaphoid can be distinctly made out.

462 SURGICAL APPLIED ANATOMY. [Chap. xxiu.

In the interval between it and the last-named process
lies the calcaneo-scaphoid ligament, and the tendon of
the tibialis posticus. Farther towards the front of
the foot can be felt the ridge formed by the base of
the first metatarsal bone, and between it and the
scaphoid tubercle lies the inner cuneiform bone. Lastly,
the shaft of the first metatarsal bone, its expanded
head, and the sesamoid bones that lie on the plantar
aspect of the metatarso-phalangeal joint can be more
or less distinctly defined. On the outer side of the
foot the external surface of the os calcis is subcutaneous
in nearly the whole of its extent. Less than an inch
below and in front of the malleolus is the peroneal
tubercle, with the short peroneal tendon above it and
the long one below it. Some two and a half inches
from the outer malleolus the projection of the base of
the fifth metatarsal bone is very evident, and extending
for an inch or so behind it lies the cuboid bone.

Joint lines. — The ankle-joint lies about on the level
of a point half an inch above the tip of the inner
malleolus. Immediately behind the tubercle of the
scaphoid is the astragalo-scaphoid articulation, and a
line drawn transversely across the dorsum of the foot,
just behind this process, very fairly corresponds to the
mid-tarsal joint (the joint compounded of the astragalo-
scaphoid and calcaneo-cuboid articulations).

If the latter articulation be approached from the
outer side it will lie opposite a point midway between
the outer malleolus and the prominent base of the
fifth metatarsal bone.

The lines of the articulations between the first
and fifth metatarsal bones and the inner cuneiform
and the cuboid respectively are easily indicated, being
placed just behind the bases of the former bones.
The metatarso-phalangeal articulations are situated
about one inch behind the webs of the correspond-
ing toes.

chap, xxiii.] THE ANKLE AND FOOT. 463

Tendons. — The tendo Achillis stands out very
conspicuously at the back of the ankle, and between it
and the malleoli are two hollows which are evident in
even obese individuals. Over the front of the ankle
the tendons of the extensor muscles are readily to be
distinguished, especially when the joint is flexed.
From within outwards they are : the tendons of the
tibialis anticus, extensor longus pollicis, extensor
longus digitorum and peroneus tertius. Beneath the
tendons of the extensor of the toes, and on the outer
part of the dorsum of the foot, the prominent fleshy
mass formed by the extensor brevis digitorum can be
felt and, when in action, seen. Above and behind the
inner malleolus the tendons of the tibialis posticus and
flexor longus digitorum can be discerned, the former
lying nearer to the bone. Nearer to the middle line
runs the flexor longus pollicis. Behind the outer
malleolus the long and short peroneal tendons can be
felt, lying close to the edge of the fibula, the tendon of
the smaller muscle being the closer to it.

In the middle of the sole of the foot the resisting
plantar fascia can be felt, and some of its processes
made out when the toes are drawn up by the extensors.
The fleshy mass on the inner margin of the foot is
formed by the abductor and flexor brevis pollicis ; that
on the outer side by the abductor and flexor brevis
minimi digiti.

Vessels. — The anterior tibial artery and nerve are
placed opposite the ankle joint, between the tendons of
the extensor proprius pollicis and longus digitorum.
The dorsal artery runs from the middle of the ankle
to the interval between the bases of the first and
second metatarsal bones. It may be felt pulsating
against the bones along the outer side of the extensor
proprius pollicis tendon, which is the readiest guide
to it. The plantar arteries start from a point midway
between the tip of the malleolus interims and the

464 SURGICAL APPLIED ANATOMY. [Chap. xxm.

centre of the convexity of the heel. The internal
vessel follows a line drawn from this point to the
middle of the under surface of the great toe. The
external vessel crosses the sole obliquely to within a
thumb's breadth of the base of the fifth metatarsal
bone. From thence it turns more transversely across
the foot, running inwards over the bases of the meta-
tarsal bones to inosculate with the dorsalis pedis artery
at the back of the first interosseous space. On the
dorsum of the foot the subcutaneous veins may be seen
forming an arch convex towards the toes, and from
the ends of the arch vessels may be followed into the
internal and external saphenous veins.

The ankle and foot. — The skin about the
ankle and over the dorsum of the foot is thin and but
loosely attached to the subjacent parts. It becomes
readily excoriated, as is often the case where splints
or instruments have been improperly applied. Since the
skin over the malleoli lies directly upon the bone, while
that covering the dorsum of the foot is but slightly
separated from the bones of the tarsus, it follows that
the integuments in this region are readily contused,
and may suffer gangrene from an amount of pressure
that would cause but little trouble in other parts.
Over the sole the integument is dense and thick in all
those parts that come in contact with the ground. In
the normal foot, the heel, the outer margin of the foot,
and the line of metatarso-phalangeal joints are in
contact with the ground when the sole is placed flat
upon it. Along the inner margin of the foot the
integument is -thin and fine. The skin of the sole,
like that of the palm of the hand, is remarkably
adherent to subjacent parts. When cut it shows no
tendency to gape, and thus exploratory incisions made
into the part (as for the discovery of foreign sub-
stances) have often to be of greater dimensions than
would be needed elsewhere.

chap, xxiii.] THE ANKLE AND FOOT. 465

The subcutaneous tissue about the ankle and foot
varies greatly both in quantity and character. It is
abundant and well provided with loose fat in the
immediate neighbourhood of the tendo Achillis. Over
the front of the ankle and dorsum of the foot it is
very lax and fairly extensive, although possessing
but little adipose tissue in its meshes. In the
sole the subcutaneous tissue is most developed
where most pressure is received. Thus, beneath
the heel it is often three-quarters of an inch in
thickness, and is more extensively distributed along
the outer than along the inner margin of the foot.
It is here composed mainly of little lobules of fat
bound down and enclosed by numerous fibrous bands
that pass vertically from the skin to the deep fascia.
Over the centre of the sole it is more scanty, and
the union between the integument and the plantar
fascia is more direct. It very closely resembles the
subcutaneous tissue found in the palm and upon
the scalp. Beneath the heel it forms an actual pad or
cushion that must much diminish the force of shocks
transmitted to the body through the foot. The laxity
of the tissue upon the dorsum of the foot permits of
great swelling occurring in cases of diffuse inflammation
of the part, and in conditions producing oedema. In
the commencement of general dropsy the dorsum of
the foot is often the first part of the whole body to
show the morbid swelling. In the sole, on the other
hand, inflammatory affections and effusions of various
kinds can produce but little external change, owing to
the unyielding character of the parts concerned.
Collections of pus upon the dorsum may form readily
and extend rapidly, but in the sole of the foot and
in the heel the abscess remains small, is unable to
spread, and causes intense pain by reason of the dense
structure of the tissues involved.

The integuments of the foot are well supplied
E E

466 SURGICAL APPLIED ANATOMY. [Chap. XXIIL

with nerves, being furnished with branches from no
less than six nerve trunks, the musculo-cutaneous,
the anterior tibial, the two saphenous, and the external
and internal plantar.

Many Pacinian bodies are found upon these
cutaneous branches, and end-bulbs are met with in the
skin on the sole and dorsum. It must be remembered
that these nerves come from a considerable distance
(the long saphenous from the lumbar plexus, and the
remainder from the sacral) so that pain experienced
in the foot may be due to causes very remotely
situated. Thus, Sir B. Brodie mentions a case of
severe neuralgia of the foot, after each evacuation of the
bowels, caused by the descent and pressure of internal
piles. The integuments of the foot respond acutely
to sensations of pain, of pressure, of temperature, and
to certain unwonted forms of tactile impression, such
as tickling. Tactile sensibility, however, as measured
by the sethesionieter, is not acute, the dorsum of the
foot showing, in regard to this matter, no more sen-
sitiveness than does the skin of the buttock.

Over the "tread of the foot," and especially under
the ball of the great toe, the peculiar affection known
as " perforating ulcer " is most commonly met with.
This ulcer occurs as an occasional symptom in certain
nerve maladies, and particularly in locomotor ataxy.

The fascia; of I. lie foot and the tendons
about the ankle. — The fasciaB on the dorsum occur
in two layers, a superficial one that is continued from
the anterior annular ligament, and a deeper placed
over the extensor brevis and interossei muscles. These
membranes are both thin and insignificant, and exercise
no influence from a surgical point of view. The
plantar fascia is divided into three parts, a central or
main portion which is extremely dense and powerful,
and two lateral expansions which are thin and
surgically insignificant. The outer of the two lateral

Chap, xxiii.] THE ANKLE AND FOOT. 467

portions is, however, of some substance, and forms a
very thick band between the os calcis and fifth meta-
tarsal bone, that may become rigidly contracted in
some forms of talipes. The central expansion assists
greatly in supporting the antero-posterior arch of the
foot, which it tends to maintain in the manner that
the bowstring maintains the arch of the bow.

The sinking of the arch that occurs in "flat foot"
is associated with marked yielding of this fascia.
The plantar fascia is often found much contracted (as
a rule, secondarily) in certain forms of club-foot,
such as talipes equinus and congenital varus. The
term " talipes cavus " is applied to a deformity
that depends mainly or entirely upon a contraction
of the plantar fascia. The best place in which to
divide this membrane is at a spot about one inch in
front of its attachment to the os calcis. This is its
narrowest part, and the knife (which should be
introduced from the inner side) will be behind the
external plantar artery which runs beneath the ex-
pansion. An abscess situated beneath the membrane
will be very closely bound down, and will advance
in any direction other than through the membrane
itself so as to point in the centre of the sole. Such
deep collections cause intense pain, and often much
destruction, before they are discharged. They may
open upon the dorsum, or may extend up along the
tendons to the region of the ankle. There are certain
foramina or spaces in the substance of this layer
occupied usually by fat. Through one or more of
these an abscess will, in exceptional cases, extend, and
then spread out beneath the integuments. Such an
abscess will have, therefore, two cavities united by
a small hole, and will form the abces en bissac or
en bouton de chemise of the French. The plantar
fascia divides into slips near the roots of the toes, and
forms a series of arches, beneath which pass the

468 SURGICAL APPLIED ANATOMY. [Chap. xxm.

tendons, vessels, and nerves bound for the digits.
Two iritermuscular septa connected with the mem-
brane separate the flexor brevis digitorum from the
abductor pollicis on the one side, and the abductor
minimi digiti on the other. They are, however, mem-
branes of too feeble a structure to much affect the
progress of a deep plantar abscess.

The anterior annular ligament is divided into two
parts ; an upper band in front of the tibia and fibula,
and a lower band in front of the upper limits of the
tarsus. Beneath the former there is only one sy no vial
sheath, that for the tibialis anticus ; beneath the
latter are three sheaths : one for the peroneus tertius
and extensor com munis, one for the extensor proprius
pollicis, and a third for the tibialis anticus.

According to Holden, there is often a large
irregular bursa between the tendons of the extensor
longus digitorum and the projecting end of the
astragalus. This bursa sometimes communicates with
the joint of the head of the astragalus.

Beneath the internal annular ligament are three
sy no vial sheaths for the tendons of the tibialis
posticus, flexor longus digitorum, and flexor longus
pollicis. Inflammation involving the sheath for the
tibialis posticus may spread to the ankle joint, with
which the tendon is in close relation. Beneath the
outer annular ligament is the single synovdal sheath
for the long and short peroneal tendons.

In severe sprains of the ankle not only are the
ligaments about the joint more or less ruptured, but
the various synovial sheaths just named are apt to be
torn. The long abiding trouble in the part that often
follows severe sprains depends to a great extent upon
damage to these sheaths, and to extravasations of
blood, and subsequently of inflammatory material,
within them.

There are few Imrsae of any magnitude about the

Chap, xxiii.] THE ANKLE AND FOOT. 469

foot, save one between the tendo Achillis and os calcis,
and another over the metatarso-phalangeal joint of
the great toe. The first-named bursa rises up about
half an inch above the os calcis, and bulges out on
either side of the tendon. When inflamed it may
produce symptoms like those of ankle-joint disease,
and when suppurating may lead to caries of the
os calcis. The enlargement of the bursa over the
metatarso-phalangeal joint of the great toe consti-
tutes a 'bunion. This condition is generally brought
about by improperly-shaped boots, which force the
great toe outwards, place it obliquely to the long axis
of the foot (with which it should be parallel), and
render the metatarsal joint very prominent. The
result of this deformity is a great weakening of the
toe and adjacent part of the foot, a lengthening of
the internal lateral ligament of the little joint, and
a displacement outwards of the tendon of the
extensor proprius pollicis. Bursa3 are often de-
veloped over the malleoli in tailors, and especially
over the external process, the part most pressed
upon when sitting cross-legged. In club-foot, bursse
are found over any points that are exposed to undue
pressure.

The tendons about the ankle are not infrequently
ruptured by violence. Those that most frequently
are so injured are the tendo Achillis, and the tendons
of the tibia! is posticus and long and short peroneal
muscles. The tendo Achillis usually breaks at a
point about one and a half inches above its insertion,
where it becomes narrowed and its fibres are col-
lected into a very definite bundle.

In some forms of violence the synovial and fibrous
sheaths that bind down a tendon may be ruptured
and it be allowed to become displaced. This has hap-
pened to the tibialis posticus and peroneal muscles. In
each instance the dislocated structure comes forwards

470 SURGICAL APPLIED ANATOMY. [Chap. xxm.

upon or in front of the malleolus. No tendon in
the body is so frequently displaced as is that of the
peroneus longus.

The tendons about the ankle are frequently
divided by operation. The tendo Achillis is usually
cut about one inch above its insertion, the knife
being entered from the inner side to avoid the
posterior tibial vessels. The tibialis posticus tendon
is, as a rule, divided just above the base of the inner
malleolus. There is, however, enough room between
the annular ligament and the scaphoid bone to cut
it on the side of the foot. The anterior tibial
tendon may be divided readily either in front of the
ankle or at its insertion into the internal cuneiform
bone.

Blood-vessels. — The lines of the various arteries
have been already indicated. Wounds of the plantar
arch are serious, on account of the depth at which the
external plantar artery lies, and the impossibility of
reaching the vessel without making a large wound
in the sole that would open up important districts
of connective tissue, and do damage to tendons
and nerves. The arch is formed by the junction
of the external plantar artery with the dorsal
artery of the foot, a continuation of the anterior
tibial vessel. In cases, however, of bleeding from
the arch ligature of both the posterior and anterior
tibial vessels at or just above the ankle, would not
necessarily arrest the haemorrhage. After ligature
of these vessels blood would still be brought in-
directly to the arch by means of the peroneal artery.
By its anterior peroneal branch this vessel com-
municates with the external malleolar branch of the
anterior tibial artery, and with the tarsal branch of
the dorsalis pedis. By its terminal branch it com-
municates with the two last-named vessels, and also
with the internal calcaneal branches of the external

Chap, xxiii.] THE ANKLE AND FOOT. 471

plantar artery. As a matter of practice, however,
elevation of the limb, together with pressure upon the
wounded point, and compression of the main artery,
are sufficient to check most hsemorrhages from the
plantar arch.

It must be remembered that this arch can be
wounded by penetrating wounds inflicted upon the
dorsum of the foot ; and Dr. Delorme has shown how
readily various parts of the arch may be ligatured from
the dorsum after portions of one or other of the meta-
tarsal bones have been removed Thus by resecting
the upper part of the shaft of the fourth metatarsal
bone in one case, the main part of the shaft of the
third bone in another, and the upper part of the
shaft of the second bone in a third instance, he has
been enabled to expose and ligature the greater part
of the plantar arch from the dorsal aspect of the
foot.

The dorsalis pedis artery, from its superficial
position and its close contact with the bones of the
foot, is frequently divided in wounds, and ruptured in
severe contusions. The posterior tibial artery at the
ankle is well protected by the projecting malleolus,
the dense annular ligament, and the tendons that
run by its side.

The superficial veins of the foot, like those of the
hand, are found mainly upon the dorsum of the
member. The sole, as a part exposed to pressure, is
singularly free from them. About the malleoli, and
especially about the inner process, these veins form a
considerable plexus. Hence it is that appliances that
fit tightly around the ankle are apt to produce
oedema and pain in the parts beyond. The dull pain
in the feet that is often caused by tight elastic- side
boots is probably due to the same cause. It will be
understood that wounds and suppurations about the
dorsum of the foot are more apt to be attended by

472 SURGICAL APPLIED ANATOMY. ICH^P. xxm.

phlebitis tliaii are like lesions when situated upon the
sole. Venesection is sometimes performed in the
foot, the vein opened being either one of those forming
the dorsal plexus, or more usually the internal
saphenous vein just above the malleolus. The vessels
are rendered conspicuous by placing the foot in hot
water, and then applying a constricting band around
the leg.

The lymphatics form a very fine and elaborate
plexus in the coverings of the sole, from which vessels
arise that reach the borders and dorsum of the foot,
and principally the inner border. The main lymph
vessels of the part are found upon the dorsum and
about the radicles of the two saphenous veins. Those
on the inner side of the foot are by far the more
numerous ; they follow pretty generally the course of
the internal saphenous vein, and end in the inguinal
glands. The external vessels pass up along the outer
ankle and outer side of the leg. The bulk of them
pass obliquely across the ham to join the inner set
above the knee ; others reach the inner set by crossing
the front of the tibia, while a few follow the short
saphenous vein and end in the popliteal glands. Thus,
so far as the foot is concerned, lymphangitis is more
common after wounds of the dorsum than after
wounds of the sole, although in the latter locality the
frequent retention of pus beneath the dense fascia
greatly favours lymphatic inflammations. Since many
vessels cross the shin on their way from the outer to
the inner set of vessels, it will be seen that abrasions,
etc., of that part of the limb are very apt to be
followed by inflammation of the lymph canals. A
lesion on the inner side of the foot, and most lesions
on the dorsum, will be associated with enlargement of
the inguinal glands ; while a like mischief on the
outer border of the foot may affect either the inguinal
or the popliteal chain of glands.

Chap, xxiii.] THE ANKLE AND FOOT. 473

The ankle-joint is a very powerful articulation,
its strength being derived not only from the shape of
its component bones, but also from the unyielding
ligaments and many tendons that are bound about it
like straps. Of the ligaments, the two lateral are
very strong, and have an extensive hold upon the
foot. The anterior and posterior are extremely thin
and insignificant, although the latter is supported
by the tendon of the flexor longus pollicis, which
crosses it. When effusion takes place into the joint,
it first shows itself in front, beneath the extensor
tendons, and just in front of the lateral ligaments.
This is due to the feebleness of the anterior liga-
ment and the extent and looseness of the synovial
sac in relation with that structure, More extensive
effusions cause a bulging behind through yielding
of the thin posterior part of the capsule, and fluctua-
tion can then be obtained on either side of the tendo
Achillis. In no ordinary case can fluctuation be
detected distinctly beneath the unyielding lateral
ligaments. Moreover, the loose synovial sac of the
ankle-joint extends both in front and behind beyond
the limits of the articulation, while, at the sides, it is
strictly limited to the joint surfaces. The ankle is a
perfect hinge-joint, and permits only of flexion and
extension. The very slightest amount of lateral
movement is allowed in extreme extension, when the
narrower, or hinder, part of the astragalus is brought
into contact with the widest, or anterior, part of the
tibio-fibular arch. When obvious lateral movement
exists at the ankle, the joint must be the seat of
either injury or disease, and it is important not to
mistake the lateral movements permitted between
certain of the tarsal bones for movements at the
ankle-joint. Flexion is limited by the posterior and
middle parts of the internal ligament, by the poste-
rior part of the external ligament, by the posterior

474 SURGICAL APPLIED ANATOMY. [Chap. xxm.

ligament, and by the contact of the astragalus with
the tibia. Extension is limited by the anterior fibres
of the inner ligament, the anterior and middle parts
of the outer ligament, by the anterior part of the
capsule, and the contact of the astragalus with the
tibia.

Owing to its exposed position, this joint is very
liable to become inflamed from injury or other ex-
ternal causes. When inflamed, no distortion is, as a
rule, produced, the foot remaining at right angles
with the leg. It would appear that this position is
due to the circumstance that the flexor and extensor
muscles about balance one another, and it does not
seem that the capacity of the joint is affected by
the posture of the foot. The synovial cavity of the
ankle is in communication with the inferior tibio-
tibular articulation.

In connection with the subject of " referred pains,"
it should be remembered that the nerves supplying
the ankle-joint bring that articulation into relation
with two great plexuses, with the lumbar plexus
through the internal saphenous nerve, and with the
sacral plexus through the external division of the
anterior tibial nerve.

Dislocations at the ankle-joint. — The foot
may be dislocated at the ankle in five directions,
which, placed in order of frequency, are, outwards,
inwards, backwards, forwards, and upwards between
the tibia and fibula. These dislocations are nearly
always associated with fracture of either the tibia or
fibula, or of both bones.

1. The lateral dislocations: Outwards, inwards.
These luxations differ somewhat from those met with
in other joints. In the great majority of cases
they consist of a lateral twisting of the foot, of
such a kind that the astragalus is rotated beneath the
tibio-fibular arch. There is no great removal of the

chap, xxiii.] THE ANKLE AND FOOT. 475

upper surface of the astragalus from that of the
tibia, but rather is one or other edge of the former
bone brought in contact with the horizontal articular
surface of the latter. Although much deformity is
produced, the actual separation of the foot from the
leg is not considerable. In some rare cases a true
lateral dislocation in the horizontal direction has been
met with.

These injuries are due to sudden and violent
twistings of the foot, and are in nearly every instance
associated with fractures of the tibia or fibula. The
luxation outwards is due to forcible e version of the
foot, the luxation inwards to violent in. version.

It is of interest, in the first place, to note the re-
lation of the fibula to injuries at the ankle-joint,
especially as a fracture of the lower end of the
shaft of that bone may follow alike upon both
inversion and eversion of the foot. The lower three
or four inches of the fibula may be considered to
form a lever of the first kind (Fig. 54, A). The fulcrum
is at the inferior tibio-fibular articulation, one arm of
the lever is the malleolus below that joint, while the
other arm may be regarded as formed by the lower
two or three inches of the shaft of the bone, Now
the lower ends of the tibia and fibula are bound
together by very powerful ligaments, viz., the anterior
and posterior tibio-fibular, the transverse, and the
inferior interosseous. I would venture to parti-
cularly insist that in no ordinary lesion about the
ankle, whether fracture or dislocation, do these liga-
ments give way. If they should yield, then an
anomalous form of fracture or luxation will be pro-
duced. In forcible eversion of the foot, the internal
lateral ligament becomes stretched and tears, the
astragalus is rotated laterally beneath the tibio-
fibular arch and is brought into violent contact with
the end of the outer malleolus. This process is

476

SURGICAL APPLIED ANATOMY. [Chap. xxm.

pushed outwards, and acts as one end of a lever. The
fulcrum is secured by the unyielding tibio-fibular
ligaments, and the fibula breaks at the other end of
the lever, a, point some two to three in.ches above the

Fig. 54. — Diagrams to illustrate the Mechanism involved in Fractures
of the Lower End of the Fihula.

A, Parts in normal position; a, tibio-flbular ligaments; b, external lateral liga-
ment; c, internal lateral ligament; B, fracture of fibula due to eversion of
foot ; c, fracture of fibula due to inversion of foot.

end of the bone (Fig. 54, B). In forcible inversion of
the foot, the astragalus undergoes a little lateral rota-
tion in the opposite direction ; the external lateral
ligament is greatly stretched, and tends to drag the
end of the outer malleolus inwards. If the liga-
ment yields, the case will probably end as a sprained
ankle, or pass on to a dislocation inwards of the foot.
But, if it remains firm, the end of the fibular lever

Chap, xxiii.] THE ANKLE AND FOOT. 477

(the tip of the malleolus) is drawn towards the
middle line, the fulcrum is secured by the tibio-
fibular ligaments, and the shaft breaks at the other
end of the lever, some few inches above the end of
the bone (Fig. 54, c). It will be seen that in. the
fracture due to eversion the upper end of the lower
fragment is displaced towards the tibia, while, in the
lesion due to inversion, it is displaced from that bone.
From a careful examination of all the cases of frac-
ture of the lower end of the fibula admitted into the
London Hospital during the time I held the post of
surgical registrar there, I convinced myself that the
lesion is much more frequently due to eversion than to
inversion of the foot. I think it may be said that a
fracture of the lower end of the fibula due to simple
inversion of the foot is not possible unless the ex-
ternal lateral ligament remains entire.

In the outward luxation, better known as Pott's frac-
ture, the condition is such as has just been described in
connection with the effects of eversion of the foot upon
the fibula. That bone is always broken some two or
three inches above the malleolus, the deltoid ligament
is torn, or the tip of the inner malleolus wrenched off.
The astragalus is so rotated laterally that the foot is
much everted, its outer edge is raised, while its inner
edge rests upon the ground. The inferior tibio-
fibular ligaments remain intact. If they yield, an
unusual form of fracture or dislocation is produced,
as already stated. Boyer relates a case, considered
to be unique, where the foot was luxated outwards,
but without any fracture of the fibula. That bone,
however, had been forced upwards entire, and its
head dislocated from the articular facet of the tibia.
A horizontal dislocation outwards, without rotation of
the foot and without fracture of the fibula, is possible
if the inferior tibio-fibular ligaments are entirely torn.

In Dupuytrerfs fracture (a rare injury) the fibula

478 SURGICAL APPLIED ANATOMY. [Chap. xxm.

is fractured from one to three inches above the
malleolus, the inferior tibio - fibular ligaments are
entirely lacerated, or the portion of the tibia to
which they are attached is torn away, and remains
connected with the lower fragment of the fibula.
The foot is dislocated horizontally outwards, and is
drawn upwards, the extent of the upward displace-
ment depending upon the height at which the fibula
breaks.

In the inward luxation the external lateral liga-
ment is torn or the tip of the outer malleolus dragged
away, the deltoid ligament is intact, but the internal
malleolus is commonly broken by the violence with
which the astragalus is brought into contact with it.
That bone itself may be broken, and is in any case
rotated laterally, so that the foot is inverted, and its
inner border much raised. In all forms of this dis-
location, whether simple or complicated, the inferior
tibio-fibular ligament remains intact.

2. The antero-posterior dislocations — Backwards ;
forwards. These injuries are brought about by great
force applied to the foot while the leg is fixed, or
more commonly by sudden arrest of the foot during
some violent impulse given to the body, as on jumping
from a carriage when in motion. In the luxation
backwards the astragalus is displaced behind the tibia,
while the articular surface of the latter bone rests
upon the scaphoid and cuneiform bones. The anterior
and posterior ligaments are entirely torn, and a great
part also of the two lateral bands. The fibula is
broken some two or three inches above the malleolus,
and there is usually a fracture also of the inner
malleolus.

The luxation forwards is of extreme rarity. In
the few reported cases one or both malleoli were
broken. 11. W. Smith believes that the dislocation is
never complete.

Chap, xxii L] THE ANKLE AND FOOT. 479

3. The dislocation upwards. — In this rare accident
the inferior tibio-fibular ligaments are ruptured, the
two bones are widely separated at their lower ends,
and the astragalus is driven up between them. The
anterior and posterior ligaments are entirely rup-
tured, but the lateral ligaments usually escape with
but some slight aceration. The accident appears to
be generally caused by a fall, the patient alighting flat
upon the soles of the feet. Mr. Bryant records a case
in which both feet were similarly dislocated upwards.

The foot. — There are two arches in the foot, an
antero-posterior and a transverse.

1. The antero-posterior arch has its summit at the
astragalus and ankle-joint. It may be considered

Fig. 55.— Antero-Posterior Section of the Foot (Eiidinger).

1, Tibia; 2, astragalus; 3, oscalcis: 4, scaphoid; 5, int. cuneiform; 6, first
mctatarsal bone ; 7 and 8, phalanges of great toe.

as composed of two piers. The hinder pier contains
the posterior parts of the astragalus and os calcis, the
anterior pier the remainder of those bones with the
rest of the tarsus, the metatarsus, and the phalanges
(Fig. 55).

480 SURGICAL APPLIED ANATOMY. [Chap. xxui.

The foot rests upon the heel, the heads of the
metatarsal bones, and the outer margin of the foot.
The hinder pier is solid, is made up of two strong
bones, and contains only one joint. It serves to
support the main part of the weight of the body, and
gives a firm basis of attachment to the muscles of the
calf. The anterior part of the arch, on the other
hand, contains many small bones and a number of
complicated joints. It serves to give elasticity to the
foot, and to diminish the effect of shocks received
upon the sole of the foot. The comparative value of
the two piers of the arch in this latter respect can be
estimated by jumping from a height and alighting
first upon the heels and then upon the balls of the
toes. The inner part of the arch is much more
curved than the outer, and forms the instep.

2. The transverse arch is most marked across the
cuneiform bones. It gives much elasticity to the foot
and affords protection to the vessels of the sole.

These two arches result from the shape of the
component bones, and are maintained by the various
ligaments. The peroneus longus tendon, and nearly
all the ligaments which connect the first and second
rows of tarsal bones on both the plantar and dorsal
aspects, are inclined forwards and inwards, and by this
arrangement are well adapted to maintain the integrity
of the transverse as well as of the antero-posterior
arch.

The chief joints of the foot. — The articu-
lation between the os calcis and astragalus forms
a double joint. The posterior joint, that behind the
interosseous ligament, has a separate synovial sac,
while the anterior communicates with the synovial
cavity of the mid-tarsal articulation. The two bones
are held together not only by the interosseous, the
internal, external, and posterior calcaneo-astragaloid
ligaments, but are supported also by the external

Chap. XXIIT.] THE ANKLE AND FOOT. 481

calcaneo-scaphoid ligament, the two lateral ligaments
of the ankle, and the tendons about the part. The
articulation permits of adduction and abduction, and
of some rotation of the foot beneath the astragalus.
Adduction is associated with some turning of the toes
inwards, and abduction with some turning of them
outwards.

Dislocations of the astragalus. — This bone
is sometimes luxated alone, being separated from its
connections with the os calcis, the tibia, the fibula,
and the scaphoid bone. The displacement may be
either forwards, backwards, or laterally. The lateral
luxations are nearly always oblique, the bone passing
as a rule forwards as well as inwards or outwards.
The luxation forwards is by far the most common
lesion, and next in frequency being a luxation out-
wards and forwards. The backward displacement is
extremely rare. The dislocations are usually com-
plete, are very often compound, especially when in
the lateral direction, and are commonly associated
with fracture of the tibia or fibula, or of the astragalus
itself. A lateral complete dislocation is impossible
without fracture of one or other malleolus. In these
injuries the interosseous ligament between the os
calcis and astragalus is entirely torn, as are also
a greater part of the lateral ligaments of the ankle,
and the various bands that connect the astragalus
with the os calcis and scaphoid. In all instances the
malleoli are brought nearer to the sole. In the
antero-postevior luxations the foot as a rule undergoes
no rotation, but in the luxation of the bone forwards
and outwards it becomes inverted, and in the displace-
ment forwards and inwards everted.

Dislocation of the os calcis. — This bone,
although often fractured, is very rarely luxated.
When displaced, however, it is usually displaced
outwards, and is torn away from its attachments to

F F

4#2 SURGICAL APPLIED ANATOMY. [Chap. xxm.

the astragalus and cuboid, or from the former bone
alone.

Subastragaloid dislocations of the foot.

— In these lesions, which are not very uncommon, the
astragalus remains in position between the tibia and
fibula, while the rest of the foot is dislocated below
that bone. The luxation, therefore, concerns the
calcaneo-astragaloid and astragalo-scaphoid joints.
The foot may be displaced either forwards, backwards,
or laterally. The forward dislocation is extremely
rare, and the lateral luxations are nearly always
oblique. In the most usual displacement the foot is
dislocated outwards or inwards, and is at the same
time carried backwards. These luxations are often
compound, especially when lateral. They are, as a
rule, incomplete as regards the calcaneo-astragaloid
joint, while, on the other hand, the displacement of
the astragalus from the scaphoid is in nearly every
instance complete. In all cases the interosseous liga-
ment between the os calcis and astragalus must be
torn, and there will also be more or less laceration of
the astragalo-scaphoid ligament, and of one or both
of the lateral bands of the ankle joint. The malleoli
are very often fractured.

It is only necessary to notice 'in any detail the two
lateral luxations, as being the only common forms.
In the inward dislocation the foot is inverted, its
inner border is raised, is shortened; and rendered
concave, while its outer border is lengthened and
made convex. The deformity much resembles that of
talipes varus. The head of the astragalus with the
outer malleolus form a projection at the outer aspect of
the foot, while below them a deep hollow exists. The
inner border of the os calcis is very prominent at the
internal side of the limb, while the inner malleolus is
buried in the hollow left by the displacement of that
bone. The calcaneum and scaphoid are approximated.

chap, xxiii.] THE ANKLE AND FOOT. 483

In the outward luxation the foot is abducted, its
outer border is raised, and the deformity produced
is not unlike that of talipes valgus. The outer
malleolus is lost in the hollow caused by the eversion
of the foot, while the tibial malleolus and head of the
astragalus form a projection on the inner aspect of
the limb.

The medio-tarsal joint is composed of two
articulations, the astragalo - scaphoid and calcaneo-
cuboid. The ligaments supporting the former joint
are the external and inferior calcaneo-scaphoid and
the astragalo-scaphoid ; while the latter articulation
is maintained by the internal and dorsal calcaneo-
cuboid ligaments, and the long and short plantar.
Movement is somewhat freer in the astragaloid than
in the calcaneal segment of the joint. The move-
ments permitted in the articulation as a whole consist
of flexion and extension, with some rotation around an
aiitero-posterior axis whereby the sole can be turned
in or out. Flexion is associated with inward rotation
of the sole and adduction of the toes, extension with
outward rotation of the sole and abduction of the
toes. It should be noted that the movements of
turning the toes either in or out take place mainly at
the hip-joint ; while the turning of one edge of the
foot either up or down is a movement that mostly
concerns the medio-tarsal and calcaneo-astragaloid
joints. The chief deformities in club-foot take place
about the former articulation.

Club-foot* — It is usual to divide the various
forms of talipes, or club-foot, into four main divisions,
viz., (1) T. equinus ; (2) T. calcaneus; (3) T. varus;
and (4) T. valgus. Four secondary forms result from
combinations of these principal varieties, viz., T.
equino-varus, T. equino-valgus, T. calcaneo-varus, and
T. calcaneo-valgus.

1. Talipes equinus. In this deformity the heel is

484 SURGICAL APPLIED ANATOMY. [Chap. xxm.

drawn up, and the patient walks upon the balls of the
toes. The contracting muscles are those of the calf
attached to the tendo Achillis. In a well-marked
case the os calcis is much raised, and may even be
brought in contact with the tibia. The astragalus is
displaced downwards, and projects upon the dorsum.
The foot tends to become more and more bent at the
medio-tarsal joint, until at last the scaphoid may even
touch the os calcis. The ligaments of the sole are
usually much contracted.

2. Talipes cakaneus. In this form -of club-foot
the toes are drawn up, and the patient walks upon
the heel. The contracting muscles are the extensors
on the anterior aspect of the limb. The os calcis is
rendered more vertical, and the astragalus becomes so
obliquely placed that part of its upper articular
surface may project beyond the tibia in a backward
direction.

3. Talipes varus. This is the commonest form.
In a well-marked congenital case there is a four-
fold deformity: (1) The heel is drawn up by the
muscles attached to the tendo Achillis ; (2) the
foot is adducted ; and (3) its inner edge is drawn up-
wards by the contraction of the tibialis anticus and
posticus ; (4) the sole is contracted by the flexor
longus digitorum muscle and the shrinking of the
plantar fascia and ligaments. In this variety of
talipes the os calcis is drawn into a more vertical
position. The astragalus is displaced forwards and
downwards, so that some part of its upper articular
surface becomes superficial on the dorsum. The
scaphoid is displaced upwards and backwards, until
its inner border often touches the internal malleolus.
The three cuneiform bones follow the scaphoid, and
the cuboid becomes the lowest bone in the tarsus.

4. In talipes valgus the foot is abducted and its
ou ter border drawn upwards. The contracting muscles

chap, xxiii.] THE ANKLE AND FOOT. 485

are the two peronei. In a well-marked congenital
case the os calcis is found a little raised and the
astragalus is displaced forwards and downwards. The
scaphoid is so rotated that its inner part is depressed
and its outer raised. The internal portion of the
bone forms one of the two projections obvious on the
inner side of the foot, the other prominence being
formed by the head of the astragalus. The cuboid
is found to be a little rotated outwards. The arch of
the foot is lost, aiid all those ligaments are stretched
that serve to support and maintain that arch.

Of the mixed, or secondary, forms of talipes
nothing need be said. They are the results merely of
a combination of the primary varieties.

As trouble is often caused in talipes by pressure
being brought to bear upon an unusual part of the foot,
it is well to note upon what portion of the member
the patient treads in the different varieties of the
deformity. In varus the " tread " is mainly upon the
outer side of the fifth metatarsal bone ; in valgus
upon the internal malleolus and scaphoid ; in equinus
upon the bases of all the toes ; in equino-varus upon
the base of the little toe ; in equino- valgus upon the
base of the great toe ; in all forms of calcarieus upon
the heel.

Flat-foot, or splay-»foot, are the names given
to a deformity due probably to the yielding of certain
ligaments, whereby the arch of the foot is lost and
the sole becomes more or less perfectly flat. The
foot, at the same time, is abducted, and the outer
border is often a little raised, so that the patient
walks mainly upon the inner side of the foot. This
deformity is met with in those who stand a great
deal, and is the direct result of yielding of the tarsal
ligaments from long-continued pressure. When the
weight of the body is brought to bear on the foot
placed flat upon the ground, it will be transmitted in

486 SURGICAL APPLIED ANATOMY. [Chap. xxm.

an oblique direction from above downwards and in-
wards. The foot therefore tends to become abducted,
a tendency resisted by such powerful ligaments as the
internal lateral of the ankle and those connecting the
os calcis with the astragalus. In flat-foot these liga-
ments yield, and the toes consequently are turned out
or abducted. The ligament, however, that is mainly
affected in this deformity is the inferior calcaneo-
scaphoid. This strong band of fibres supports the
head of the astragalus and holds up the very key-
stone of the plantar arch. When it yields, the head
of the astragalus is pressed forwards, downwards,
and inwards by the superincumbent weight, and the
foot beyond becomes, as a consequence, over-extended
and rotated out. The long and short plantar liga-
ments also, which contribute so much to the main-
tenance of the arch of the foot, in time yield, and
allow of a still greater degree of deformity. In
neglected cases the distortion is rendered more or less
permanent by alterations in the shape of the tarsal
bones, and by a contraction of such ligaments as have
been relaxed by the deformity. The foot being
abducted, and its outer border a little raised, the
peronei muscles become relaxed, subsequently shorten
and contract, and so contribute to the permanency of
the disorder. It will be understood that the abnormal
pressure brought to bear upon the various tarsal
bones and articulations will cause severe pain to be
often associated with this affection.

It may be noted that the medio-tarsal joint, which
is so conspicuously involved in the distortion, is
supplied by the anterior tibial, musculo-cutaneous,
and external plantar nerves.

According to Duchenne (of Boulogne), flat-foot is
rather a muscular affection in the first instance, and
is due to a weakening of the peroneus longus, the
sinking of the plantar arch being subsequent thereto.

Chap, xxiii.] THE ANKLE AND FOOT.

4*7

The tarsal bones, owing to their spongy
character, are readily broken by direct violence, as in
e crushes. The soft parts that cover these bones
being scanty upon the dor-
sal aspect of the foot, it
follows that these accidents
are often compound and
associated with much lacer-
ation of the integuments.

The tarsal bone the
most frequently fractured
is the os calcis. This bone
may be broken by a fall
upon the heel, and in many
instances has been the only
one fractured by such an
accident. A few cases have
been recorded of fracture
of the calcaneuin by mus-
cular violence, the muscles

producing the lesion being

those attached to the tendo

Achillis. Thus, Sir A.

Cooper reports the case of

a woman, aged forty-two,

in whom a large fragment

of the posterior part of the

os calcis was torn away

by the muscles and drawn

some two and a half inches

away from the heeL The

accident was caused by her

taking a false step. Abel

has collected three cases

of fracture of the sustenta-

culum tali. He believes

that this injury may be

488 SURGICAL APPLIED ANATOMY. [Chap. xxm.

produced by falls upon the sole or by extreme supi-
nation (rotation outwards) of the foot, whereby the
astragalus is forced violently against the process.

The astragalus alone may be broken by a fall upon
the feet, and such accidents are often associated with
fractures of both that bone and the os calcis. It
must be noted, however, that in a fall, when the
patient alights upon the feet, the tibia and fibula are
much more likely to be broken than are the tarsal
bones, since the bones of the leg transmit the weight
of the body directly, whereas that weight is much
diffused and broken-up when passing through the foot
with its many bones and joints.

The metatarsal bones and phalanges are nearly
always broken by direct violence. I had, however,
under my care at the London Hospital a man who
had broken the shafts of the three outer metatarsal
bones by simply slipping off the edge of the curb.

With regard to the luxations of the foot not yet
considered, it may be said that the cuboid is never
dislocated only. Walker reports a case of dislocation of
the scaphoid alone, that structure being quite separated
from the astragalus and cuneiform bones. The acci-
dent was brought about by alighting upon the ball of
the foot when jumping, and the little bone was found
projecting on the dorsum. Mr. Bryant has mentioned
an instance of dislocation of the scaphoid inwards.
As a rule, however, this bone when displaced is
dislocated along with the astragalus.

Of the cuneiform bones the one most often lux-
ated alone is the internal. The attachment of the
tendons of the tibialis anticus and peroneus longus
about the internal cuneiform and first metatarsal
bones renders it common for the latter to follow
its tarsal colleague when dislocated. Mr. Luke
has recorded a case of incomplete luxation of
all three cuneiform bones upwards, and at least

Chap, xxiii.] THE ANKLE AND FOOT. 489

three cases have been described of dislocation of the
internal bone upwards and backwards, together with
a like displacement of all the metatarsals.

One or more of the metatarsal bones may be
luxated, or the entire series may be displaced upwards,
downwards, inwards, or outwards, the first-named
lesion being the most common. In rarer instances,
one bone has been thrown in one direction and its
fellow or fellows in another.

Dislocation of the first phalanx of the great toe
is often very difficult to reduce, as is also the case in
the corresponding luxation in the thumb. When the
displacement is dorsal, the difficulty is probably due
to the sesamoid bones, which in this joint take the
place of the glenoid ligament or fibro-cartilaginous
plate of the other toes. " Like the glenoid ligaments,
the sesamoid bones are much more firmly connected
with the phalanx than with the metatarsal bone, and
thus get torn away and shut back behind the head of
the metatarsal bone ; or it may be that the sesamoid
bones, retaining their connections with the lateral
ligaments of the joint as well as with the short flexor
tendons, are separated from one another, and so allow
the head of the metatarsal bone to pass forwards, and
thus become nipped, as it were, in a button-hole
between them " (Henry Morris).

There are six synovial cavities in the foot,
excluding that of the ankle-joint, viz., one for the
posterior calcaneo-astragaloid joint, a second for the
anterior calcaneo-astragaloid and astragalo-scaphoid
joints, a third between the os calcis and cuboid, a
fourth between the latter bone and the two outer
metatarsals, a fifth for the joint between the inner
cuneiform and first metatarsal bones, and a sixth for
the remaining articulations (Fig. 56). These synovial
cavities tend greatly to diffuse disease among the
various bones of the foot when once one bone has

49°

SURGICAL APPLIED ANATOMY. [Chap. xxm.

become inflamed. The best position, therefore, for
bone disease, with reference to the question of exten-
sion, would be in the hinder parts of either the

os calcis or astragalus,

/ ,,; and one of the worst

positions would be as-
sumed by disease in-
volving the scaphoid
bone.

The tarsal bones,
from their cancel lous
structure and exposure
to external influences
and injuries, are pecu-
liarly liable to become
the seat of caries or
necrosis.

Syme's ampu-
tation at the ankle.
In the heel-flap are
cut the integuments,
the external saphenous
nerve and vein, the
peroneus longus, pero-
neus brevis, tibialis
posticus, flexor longus
digitorum, flexor longus
pollicis, tendo Achillis,
and posterior tibial
vessels and nerves. In
the dorsal flap are cut

brevisT'T," peroneus" longus';" X "tendo the integuments, tibi-
Achillis; m, some muscles of the sole that i- o^fi^no. ovfone™*
are not usually left in this operation^.*, &11S ailtlCUS, extensor

communis digitorum,
extensor proprius pol-
licis, peroneus tertius, anterior tibial vessels and nerve,
musculo-cutaneous nerve, and internal saphenous

Fig. 57. — Syme's Amputation (Agatz).

a, Tibia; 6, fibula: c, tibialis anticus; d,
extensor proprius pollicis ; e, extensor
communis digitorum ; f, peroneus tertius;
g, flexor longus pollicis; h, tibialis posti-
cus ; ?', flexor longus digitorum ;j, peroneus

are not usually left in this operation ; n,
anterior tibial vessels ; o, posterior tibial
vessels ; pt posterior tibial nerve.

Chap, xxiii.i THE ANKLE AND FOOT. 491

nerve and vein. The position of the principal struc-
tures divided is shown in Fig. 57. It is not usual
to dissect up any of the muscular tissue of the sole
as shown in Agatz's plate.

It should be noted that the integuments of the
heel derive their blood-supply, which is very free,
mainly from the external calcaneal branch of the
posterior peroneal artery, and the internal calcaneal
from the external plantar. The supply of the part is
also aided by branches from the tarsal artery, by the
internal malleolar branch of the posterior tibial, and
the outer and inner malleolar vessels from the anterior
tibial trunk.

The nerves supplying the integuments of .the heel
are the calcaneal branch of the external saphenous
and the calcaneal and plantar cutaneous twigs from
the posterior tibial.

In PirogoflPs amputation, the parts divided
in the anterior flap are the same as in Syme's opera-
tion. In the heel or sole flap the same structures
also are cut as in the corresponding flap in a Syme,
with the exception that the tendo Achillis is not
divided, the flexor brevis digitorum, abductor pollicis,
abductor minimi digiti, and flexor accessorius are cut,
and the plantar vessels and nerves are divided in the
place of the posterior tibial.

Cliopart's operation, an amputation at the
medio- tarsal joint. In the dorsal flap are cut the
integuments, the extensor communis and brevis digi-
torum, extensor proprius pollicis, tibialis anticus,
peroneus tertius and brevis, the musculo- cutaneous,
anterior tibial, and two saphenous nerves, the dorsal
artery, and the dorsal plexus of veins. In the plantar
flap are found divided the integuments, plantar fascia,
flexor brevis digitorum, abductors of the great and
little toes, flexor accessorius, and tibialis posticus
tendon. If the flap be well dissected up from the

492 SURGICAL APPLIED ANATOMY. [Chap. xxm.

bones, parts of the short flexors of the great and little
toes, the adductor pollicis, and trans versus . pedis will
be found cut in the flap. The tendons of the long
/ flexors of the digits

and great toes, the
peroneus longus,
and the plantar
vessels and nerves
are also divided
(Fig. 58).

JL i s f r a n c ' s
operation, or am-
putation through
the tarso-metatarsal
line of joints. In
the dorsal flap the
same structures are
divided as are cut
in the correspond-
ing flap in Cho-

part's amputation.
Fig. 58,-CHoparf B Operation (Agatz). jn the kntar fl

a, Astraeralus ; b, os calcis; c, extensor pmprius i j_i T •

pollicis: d, tibialis anticus; e, extensor cum- also the parts dlVl-

niunis digitorum ; /, peroneus longus ; gt abduc- i i

tor minimi digit! ; h, flexor brevis digitorum ; Cted are the Same as

i, flexor longus digitorum;.;, abductor poHicis: ,1 , i

k, flexor longus pollicis; /.dorsalis pedis artery; in tnat procedure.

m, internal plantar artery ; n, external plantar •,-! ,1 ,.

artery. with the exception

that the flexor ac-

cessorius and the tendon of the tibialis posticus es-
cape section. In opening the line of joints it should
be noted that the articulations between the three outer
metatarsals and the corresponding tarsal bones form a
line sufficiently straight to be traversed by the knife
in one cut when once the blade has been introduced.

The joint also between the first metatarsal and
internal cuneiform bones is in a straight line and
readily opened. The most difficult part of the dis-
articulation concerns the separation of the second

Chap, xxiii.] NERVES OF LOWER LIMB.

493

metatarsal bone, which is deeply lodged between the
tarsal segments. The chief bond of union between
this bone and the tarsus is effected by a strong
inter osseous ligament
that passes between
it and the internal
cuneiform. In Fig. 59
the knife is placed in
the position required
to divide that liga-
ment.

Fig. 60 shows the
position of the more
important structures
that are divided in
amputation of the
great toe together with
its metatarsal bone.

The nerve sup-
ply of the lower
limb. — In Fig. 61 is
shown the cutaneous
nerve - supply of the
inferior extremities on
both the anterior and
the posterior aspect.

limbs are common, but
are more often due to
some lesion in the
inferior segment of the cord than to damage received
by any one individual nerve. Cases, however, are
recorded where a single trunk has been injured and a
limited form of paralysis has followed in consequence.
Paralysis of the anterior crural nerve
has been caused by injuries to the lower part of the
vertebral column implicating the cauda equina, by

Fig. 59. — Lisfranc's Operation (Agatz).

a, 6, c, Inner, middle, and outer cuneiform
bones ; d} cuboid : e,f, the metatarsal bones ;
g, tibialis anticus ; h, extensor proprius

))ollicis ; i, extensor c"mmunis digitorum ;
, extensor brevis digitorum ; fc, extensor
tendons ; I, dorsalis pedis artery.

494 SURGICAL APPLIED ANATOMY. [Chap. xxm.

fractures of the pelvis, by tumours of the pelvis, by
psoas abscess, by fractures and dislocations of the
femur, and by stabs in the region of the groin. In
this nerve lesion the patient is unable to flex the hip
and to raise the body from the recumbent position
(ilio-psoas). The power of extending the leg at the
knee is lost (quadriceps extensor cruris") ; the function

Fig. 60.— Amputation of Great Toe, with its Metatarsal Bone ^Agatz).

a, Internal cuneiform bone ; ft, adductor polliois; c, extensor longus pollicis:
d, flexor longus pollicis ; e, plantar branch of dorsalis pedis artery.

of the sartorius is destroyed and that of the pectineus
impaired. Sensation is impaired in parts supplied by
the internal and middle cutaneous nerves and the
long saphenous nerve.

Paralysis of the obturator nerve alone is a
rare condition, although it may be found associated
with a like lesion of the preceding trunk. It may be
brought about by the pressure exercised upon the
nerve in cases of obturator hernia and by the foetal
head during delivery. The muscles implicated are the
adductors, the gracilis, pectineus, and external ob-
turator. The patient is unable to press the knees
together, or to cross the legs. Rotation outwards of
the thigh is difficult, and sensation is affected in the

2

At

10

Fig. 61. — Cutaneous Nerve-Supply of Lower Limb.

Anterior Aspect.— 1, Ilio-inguinal ; 2, genito-crural ; 3, external cutaneous ; 4, middle
cutaneous ; 5, internal cutaneous; 6, patellar plexus ; 7, branches of external
popliteal; 8, internal eaphenous ; 9, musculo- cutaneous ; 10, external saphe-
nous ; 11, anterior tibial.

Posterior Aspect.— I, 2, and 3, small sciatic; 4, external cutaneous; 5, internal
cutaneous; 6, internal saphenous ; 7, branches of external popliteal ; 8, short
saphenous ; 9, posterior tibial ; 10, internal saphenous ; 11, internal plantar ;
12, external plantar.

496 SURGICAL APPLIED ANATOMY [Chap. xxm.

portions of the skin supplied by cutaneous branches
of the nerve.

Paralysis of the internal popliteal nerve.

— In this condition there is inability to extend the
ankle and to flex the toes (flexor longus digitorura,
flexor proprius pollicis, tibialis posticus, gastrocnemius,
arid soleus). The patient is unable to stand upon the
toes owing to loss of function in the two last-named
muscles. The power of adducting the foot and of
raising its inner border is impaired (tibialis posticus),
and lateral movements in the various toes are lost
owing to the paralysis of all the small muscles of the
sole. Sensation is impaired over the plantar aspect
of the toes, the sole of the foot, and in part of the
lower half of the back of the leg.

In paralysis of the external popliteal nerve
the action of the muscles on the front of the leg is
lost. The foot hangs down and the toes catch the
ground in walking. The foot can be neither flexed
nor abducted (extensor communis digitorum, extensor
propius pollicis, peroneal muscles). Adduction is im-
perfectly performed, owing to paralysis of the tibialis
anticus. Extension of the toes is only possible to the
slight extent effected by the interossei muscles. The
arch of the foot becomes flattened owing to loss of
the support furnished by the peroneus longus. Sen-
sation is impaired over the front and outer side of
the leg and on the dorsum of the foot, and also over
some part of the back of the leg, owing to paralysis of
the communicans peroriei.

When the great sciatic nerve is paralysed
there will be, in addition to the effects produced by
loss of function in the two preceding nerves, an in-
ability to flex the knee, owing to paralysis of the
hamstrings, while rotation of the limb may be
impaired by loss of power in the quadratus femoris
and obturator internus muscles.

497

part

CHAPTER XXIY.

THE SPINE,

THE vertebral column combines in a remarkable
way many very different and complicated functions.
It acts as the central pillar of the body, and as the
column that supports the weight of the head. It
connects the upper and lower segments of the trunk.
It gives attachments to the ribs. It has the property
of mitigating the effects of shocks that are transmitted
from various parts of the body. It permits, to a
wonderful degree, of a number of most complicated
movements ; and, lastly, forms a solid tube for the
reception of the spinal cord.

It owes much of its elasticity, and of its power
of breaking up divers forces communicated to it, to
its curves, which are most fully developed in adult
life. At the time of birth these curvatures do not exist,
and the infant's spine is straight. As the child begins
to sit and stand and walk, and throw, indeed, increas-
ing responsibility upon the column in the matter of
supporting weight, the curves begin to form. The
only marked curve seen in the back of the young child
is a general curving of the column backwards — a
cyphosis. When the infant is first encouraged to sit
erect, this is the outline assumed by the spine, and in
some weakly children, and especially in those afflicted
with rickets, this curvature is often very pronounced.
GG

498 SURGICAL APPLIED ANATOMY. [Chap. xxiv.

The normal curvatures of the column are maintained
to a great extent by the intervertebral discs. These
substances are twenty-three in number, and make up
nearly one-fourth of the entire length of the spine. If
the discs be removed, and the vertebrae be articulated
in the dry state, the cervical and lumbar convexities
almost disappear, and the column tends to present one
great curvature, the concavity of which is forwards,
and the most marked part of which corresponds to a
point just below the middle of the dorsal region. This
somewhat resembles the curve seen in the spines of
the aged, and in such individuals it may be to no
small extent due to the shrinking of the intervertebral
discs.

It is by means of the discs that the movements of
the spine are in the main permitted, and it will be
found that they are most developed in regions where
most movement is allowed. They act also as springs
in giving elasticity to the column, and in economising
muscular action, while at the same time they play the
part of buffers in modifying the effect of shocks trans-
mitted along the spine.

Although the motion permitted between any two
individual vertebrae is not extensive, yet the degree of
movement capable of being exercised in the column
as a whole is considerable. This movement is least
free at the dorsal region, and is most extensive in the
neck and loins. In the lumbar region (the base of
the column) exists the greatest degree of motion per-
mitted in the spine, and here is allowed, not only
forward and backward flexion, but also lateral bending,
and a certain amount of rotation. In the cervical
region flexion in the antero-posterior direction is not
so ready as it is in the loins, although the neck enjoys
the greatest degree of rotation and of lateral flexion.

Sprains of the vertebral column. — The many
joints and ligaments of the part, and the varied and

Chap, xxiv.] THE SPINE. 499

violent movements to which it may be exposed, render
it very liable to be the seat of sprains. These injuries,
however, cannot reach any great magnitude, for so
closely are the individual vertebrae articulated, that
any force severe enough to produce other than slight
tearing of the ligaments will tend to cause a fracture

o O

or dislocation of the bones.

Sprains are most commonly met with in the cervical
and lumbar segments of the spine. This localisation
is due to the mobility of those parts, and to their
tendency to diffuse any violence transmitted to them,
and so to render it more general. For it is to be noted
that the more localised an injury, the more likely it
is to produce a fracture or dislocation rather than a
sprain.

In the cervical region, also, the tendency to sprain
is increased by the near articulation of the column
with the head, and the possibility of any violence
applied to the skull being transmitted to the spine.

Sprains of the spine are not apt to be associated
with the external evidences of ecchymosis, since be-
tween the skin and the column there intervene not
only many layers of muscles, but also dense expan-
sions of fascia.

It has already been pointed out that sprains in the
loin, produced by severe bending forwards of the
column, may be associated with some damage to the
kidney, and consequent haernaturia (page 328).

A sprained back is often the seat of a considerable
degree of pain and stiffness, that persists long after
the immediate effects of the lesion must have passed
away. Such a condition may be understood by noticing
that the column presents a vast number of separate
articulations, each provided with cartilage, synovial
membrane, and capsular ligaments. These joints have
no qualities that exempt them from the common evils
incident to sprains of more superficial articulations ;

500 SURGICAL APPLIED ANATOMY. [Chap. xxiv.

and there is little doubt that the long-felt pain and
inconvenience often depend upon some synovitis of
the vertebral joints. In a few cases this synovitis
has gone on to suppuration, and in one instance at
least the pus so formed found its way into the
spinal canal, and induced some mischief in the cord.

Fractures and dislocations of the spine. —
The effects of violence applied to the column are much
diminished by the general elasticity of the spine, by its
curves, and by the circumstance that it is composed
of a number of separate segments. Each vertebra
meets the one immediately above or below it at three
points of contact, the body and the two articulating
processes. The bodies are separated by the inter-
vertebral disc, which acts as an excellent spring or
buffer in modifying the effects of violence. The ar-
ticulating processes are more or less wedge-shaped, the
thin edge of one being applied to the base of the other.
When a force is applied to the column that tends to
compress the vertebrae together, the bases of the two
wedges are brought in more and more close relation,
and thus an increasing resistance is offered to the com-
pressing power.

The parts of the spine most liable to injury are
(1) the atlo-axial ; (2) the cervico-dorsal ; and (3) the
dorso-lumbar. In the atlo-axial region the parts not
only enjoy a very considerable degree of movement,
but are very directly influenced by many forms of
violence applied to the head. In the two other regions
it will be noted that a flexible part of the spine joins a
comparatively rigid segment of it, and thus violence
applied to the column in either of these districts is
apt to be concentrated rather than diffused. The
mechanism is in a way illustrated by the circumstance
that a fishing-rod when it snaps commonly breaks near
a joint, that is to say, at a spot where a flexible seg-
ment of the rod meets a less elastic portion. In the

Chap, xxiv.] THE SPINE. 501

dorso-lumbar region, moreover, the vertebrae, although
they have to support almost as much weight as have
those of the lumbar region proper, are yet dispropor-
tionately small in size. Being placed, also, near the
middle of the column, they can be influenced on all
sides by a powerful amount of leverage. The
gravity of all injuries to the spine depends upon the
risk of damage to the cord enclosed in the column.
Apart from this complication, fractures and disloca-
tions in this region are apt to do well, and if the
patient survive, the former lesions nearly always heal
readily.

The position of the cord within the vertebral
canal and the arrangement of its membranes are such
that it presents many facilities for escaping injury
from violence. These will be dealt with subsequently
in speaking of the cord itself. It may, however,
be noted here that the construction of the vertebrae,
and their relation to one another, are of a character
to afford much protection to the cord, even in cases
where they themselves are expensively damaged.
" Being lodged in the centre of the column, it (the
cord) occupies neutral ground to forces which might
cause fracture. For it is a law in mechanics that when
a beam, as of timber, is exposed to breakage, and the
force does not exceed the limits of the strength of the
material, one division resists compression, another
laceration of the particles, while the third, between the
two, is in a negative condition." (Jacobson, Holmes'
" System "). Now, it happens that fractures of the spine
are most often due to violence that bends the column
forwards. The anterior segment, in such a case, will
be subject to compression, the posterior to laceration,
and the intermediate portion will be in a neutral con-
dition. When the spine is examined, it will be found
that its anterior part, composed of the large cancellous
bodies, is excellently adapted to resist the effects of

502 SURGICAL APPLIED ANATOMY. [Chap. xxiv.

compression, while its posterior parts, composed of
slighter and more compact bones and surrounded by
many strong ligaments, are well arranged to resist the
effects of a tearing force. The spinal cord, situated
between these two divisions, occupies the position of
least danger.

The vertebrae may be fractured without being dis-
located, but a dislocation without a fracture is rarely
possible.

It would appear, indeed, that a luxation of the
spine, with no fracture of bone, cannot occur in either
the dorsal or lumbar regions. Mr. Jacobson, in the
essay above referred to, writes, "I believe I am correct
in stating that there is no case recorded, and thoroughly
verified, in recent years, of dislocation of the lumbar
or dorsal vertebrae, unaccompanied with any fracture
of the body, transverse or articular processes." Dislo-
cation without fracture has been met with in the
cervical spine, although even there, if we except
the first two vertebrae, it is very rare. When it
occurs it most often involves the fifth vertebra, which,
with the rest of the column above it, is displaced for-
wards and downwards. Luxations in other directions
have been noted, but they are extremely uncommon.
The possibility of luxation in the cervical region with-
out dislocation is explained by the small size of the
vertebral bodies, the obliquity of their articular pro-
cesses, and the relatively slight opposition they offer
to displacement when compared with like processes in
the other parts of the column. The luxation is usually
bilateral and incomplete, and the result of a forcible
bending of the head and upper part of the spine for-
wards and downwards. When situated high up the
displacement may be appreciated by an examination
of the part through the pharynx. In the complete
bilateral dislocation the cord is usually hopelessly
crushed. These luxations have been reduced by forcible

Chap, xxiv.] THE SPINE. 503

extension, although the circumstances under which
such a procedure is advisable are neither frequent
nor very distinctly marked.

Since, in severe injuries, dislocation and fracture
are so usually associated, it is common to deal with
these lesions under the title of "fracture-dislocation"

Fracture-dislocation may be due to (1) indirect,
or (2) direct violence. 1. The injuries from indirect
violence are by far the more common. They are due
to a violent bending of the head, or of the spine above
the seat of lesion, forwards and downwards. Thus,
the cervical spine has been more than once broken by a
"header" into shallow water; while the dorsal vertebra
have been fractured and displaced by the acute bending
of the column, produced by a heavy sack falling upon
the back of the neck.

This form of injury is most commonly met with in
the cervical and upper dorsal regions. These parts of
the column possess great mobility, the bodies that
compose them are not large, and are influenced by
violence applied to the head. In a well-marked case
there is some crushing of the vertebrae involved, and
the usual deformity depends upon a sliding of the
centrum above downwards and forwards upon the
centrum below. Complete displacement of any two
vertebrae from one another is prevented by a locking
of the posterior processes. In some cases the luxation
is complete, a condition that is least frequently met
with in the lumbar spine.

In the cervical and dorsal regions, the parts, after
the dislocation, may often be returned to their normal
position ; but in the loins this replacement is usually
impossible, owing to the locking of the large and
powerful articular processes. In the neck the laminae
and spines may be fractured, while the articulating
processes, being broad and nearly horizontal, usually
escape, even when there is much displacement of the

504 SURGICAL APPLIED ANATOMY. [Chap. xxiv.

parts. In the dorsal spine the laminae and articular
processes are always torn when displacement occurs.
In the lumbar region the articular processes usually
escape fracture, although they are violently torn
asunder. In all cases there is more or less laceration
of the intervertebral discs, the supraspinous, inter-
spinous, and capsular ligaments are torn, as are also
the ligamenta subflava. When the bodies are much
crushed and displaced the anterior and posterior
common ligaments are commonly ruptured.

2. In the fracture - dislocations due to direct
violence the lesion may be at any part of the spine.
Some form of direct violence is applied to the back,
and the column tends to become bent backwards at
the spot struck. In the previous class of injuries it
will be noted that the anterior segments of the ver-
tebrae suffer compression, while the posterior suffer
from the effects of laceration and a tearing asunder of
their parts. In lesions due to direct violence the
circumstances of the injury are reversed, the posterior
segments tend to be crushed together, while the bodies
on the front of the spine are separated.

Much displacement is very rarely met with in this
form of accident. To produce separation of the ver-
tebrae the violence must be very extreme, and as a
rule the force expends itself upon a crushing of the
hinder portions of the spinal segments. It follows
from this, also, that injury to the cord is less common
and less severe in lesions due to direct violence than
in those due to indirect violence. In the atlo-axial
region the atlas and occipital bone have been dislocated
from one another by direct violence, although the
most frequent lesion is a dislocation of the former
forwards upon the axis, a lesion usually, if not always,
associated with fracture of the odontoid process.

The spinous processes may be broken off as a re-
sult of well-localised blows. The prominent spines in

Chap, xxiv.] THE SPINE. 505

the lower cervical region and the long processes of the
dorsal tract of the column are those that usually suffer.
The lumbar spines are less frequently broken, being
comparatively small and well protected by the great
muscles of the back.

The transverse processes and laminae can scarcely
be fractured alone.

In several instances of fracture-dislocation and of
fracture alone the spine has been trephined, or rather
portions of the laminae and spinous processes have been
resected. At the present time the operation is con-
sidered by most surgeons to be quite unjustifiable. It
involves a very deep wound, and an extensive dis-
turbance of the muscles and fasciae of the back. It
opens up the spinal canal, and affords an oppor-
tunity for blood or pus to enter it. In many cases
the rigidity of the injured spine depends upon the
locking of the posterior processes, and in this operation
the resection of some parts of those processes would
destroy the very desirable fixation of the column. In
the majority of instances the cord is crushed by the
projection backwards into the canal of the vertebra
immediately below the seat of the displacement, a
displacement that could not be remedied by any such
operation as the present. It is absurd, from an
anatomical point of view, to deduce any arguments in
favour of trephining the spine from the success of
the operation of the same name as applied to the
skull. Except in name the two procedures have little
in common.

The spinal cord is in the adult about eighteen
inches in length, and extends from the lower margin
of the foramen magnum to the lower edge of the body
of the first lumbar vertebra. In some cases it ends at
the second lumbar, and in other instances at the last
dorsal vertebra. It is to be noted also that in flexion
of the spine the cord is a Httle raised. In the earlier

506 SURGICAL APPLIED ANATOMY. [ChaP. xxiv.

months of foetal life the medulla spinalis occupies the
whole length of the vertebral canal, but after the third
month the canal and lumbar and sacral nerves grow
so much faster than does the cord itself, that by the
time of birth it reaches no farther than the third
lumbar vertebra. It is obviously a great advantage,
in cases of injury, that the spinal medulla does
not occupy that part of the vertebral pillar which joins
the base of the column, and which permits not only
of considerable movement, but is liable also to frequent
wrenches and strains. It is important to recollect
that although the cord itself ends at the spot indicated,
the dura mater, the arachnoid, and the collection of
cerebro-spinal fluid extend as far as the second piece
of the sacrum. Injuries inflicted, therefore, upon the
spine as low down as this latter point, may cause death
by inducing inflammation of the meninges. The cord
in the dorsal region measures about 10 mm. from side
to side, and 8 mm. in the antero-posterior direction.
The cervical enlargement is largest opposite the fifth
or sixth cervical vertebrse, where it measures about
13 mm. from side to side. The greatest part of the
lumbar enlargement is opposite the twelfth dorsal
vertebra, where its lateral measurement is about
12 mm.

The spinal dura mater is a strong and substantial
membrane, and between it and the walls of the ver-
tebral canal a considerable space exists occupied by
loose areolar tissue and a plexus of veins. It will be
readily understood that injury and inflammation of
the meninges, as results of lesions applied to the spine,
are much less frequent than are like complications
after injuries to the skull. The looseness of the spinal
dura mater, its freedom from any but slight and
occasional attachments to the bone, and the space
around it in which effusions can extend with little
possibility of becoming limited, will explain, the rarity

Chap, xxiv.] THE SPINE. 507

in the spine of those complications which follow upon
depressed bone, and extravasations of pus and blood in
connection with the dura mater within the skull. The
plexus of thin- walled veins that occupies the interval
between the theca and the bones may prove a source
of extensive haemorrhage in cases of injury to the
column. The blood so poured out tends to gravitate
to the lowest part of the canal, and when sufficient in
quantity may produce pressure effects upon the me-
dulla spinalis.

Over the arches at the posterior aspect of the ver-
tebrae is situate a plexus of vessels (the dorsal spinal
veins) that receives blood from the muscles and inte-
guments of the back. These vessels communicate
through the ligamenta subflava with the venous
plexuses within the spinal canal, and by means of
this communication inflammation from without may
be conducted to the theca of the cord. Thus spinal
meningitis has followed upon deep bed-sores, and upon
suppurative affections situated in the immediate
vicinity of the spinal laminae.

Within the dura mater are two spaces, the sub-
dural and the subarachnoid, as in the skull. They
are occupied by a considerable quantity of cerebro-
spinal fluid, continuous with the collection within the
cranium. By means of this open communication inflam-
matory affections may readily spread from the cord to
the brain. Into these spaces blood may be extrava-
sated in cases of injury. Instances have been recorded
where the theca has been opened by a wound, and the
cerebro-spinal fluid has escaped in large quantities.

The position of the cord is such that it is not
readily reached in incised and punctured wounds. The
only spots at which it is easy of access are the intervals
between the atlas and occiput and the atlas and axis.
Many cases have been recorded of fatal wound of the
cord in these positions. Lower down in the column

508 SURGICAL APPLIED ANATOMY. [Chap. xxiv.

the medulla spinalis maybe reached if the wound have
a certain direction. Thus, a case is reported where a
pointed body entered the canal between the ninth and
tenth dorsal vertebrae, having been introduced from
below upwards.

Several examples of damage to the cord by sword
or bayonet wounds have been put on record, but in
most of these instances the wound was associated with
some fracture of the protecting bone.

Concussion of the cord. — After certain in-
juries to the back a train of symptoms, usually of a
severe and complicated character, have been described,
which have been assigned to a concussion or shaking
of the spinal cord.

In these injuries it is assumed that, as a result of
a sudden shock transmitted to it, the cord undergoes
certain molecular changes, which lead to a more or
less severe disturbance of its function. The condition
has been compared to concussion of the brain, al-
though it must be owned that the symptoms often
accredited to concussion of the cord have a character
more complex than that seen in like lesions of the
more complex organ,

A great many surgeons are inclined to dispute the
existence of this lesion, or rather decline to recognise
the connection between a certain train of symptoms
and a simple molecular disturbance of the cord. It is
very probable that in many of the reputed instances of
cord-concussion the symptoms (if we except such as
are assumed and such as depend upon changes in the
brain) are due to a more distinct damage to the medulla
spinalis, to haemorrhages, to pressure, and to other
gross changes. Without entering into any discussion
upon the subject, it may be sufficient to point out some
of the anatomical objections that appear to oppose
themselves to the common conception of concussion of
the cord. The spinal cord is swung or suspended in

Chap, xxiv.] THE SPINE. 509

its bony canal, and is separated from the walls of that
canal on all sides by a considerable interval. It is,
indeed, only held in position by the nerve trunks that
pass out from it through the intervertebral foramina,
and by its connections with the theca. Above, it is
connected with that part of the brain that lies upon
the largest intracranial collection of the cerebro-spinal
fluid (page 27), and it would appear that the most
violent movements possible of the brain within the
skull could be but very feebly communicated to the
spinal cord. The cord, moreover, within its theca, is
surrounded on all sides by a space occupied by cerebro-
spinal fluid. It is difficult to understand, therefore,
how a structure so protected can be so violently dis-
turbed by a shock received upon the body as to undergo
a grave and progressive loss of function. The cord is,
indeed, somewhat in the position of a caterpillar sus-
pended by a thread in a phial of water. It would
probably be difficult to permanently disturb the in-
ternal economy of such an insect (even if it had a
structure as elaborate as the cord) by other than vio-
lence that would be comparatively excessive.

Contusion and crushing: of the cord. — As
has been already observed, the gravity of fractures and
dislocations of the spine depends upon the extent of
the damage received by the cord. In these accidents
it is very usual for some part of the injured vertebrae
to be projected into the spinal canal, so as to press
upon or actually crush the delicate nerve centre that
it contains.

It is needless to observe that the cord is extremely
soft, and thus it happens that it may be entirely broken
up by violence without the membranes being percep-
tibly damaged. Indeed, in fracture-dislocations it is
unusual for the theca to be torn, and it is possible for
the cord to be quite crushed at some one spot without
the corresponding pia mater being in any way lacerated.

510 SURGICAL APPLIED ANATOMY. [Chap, xxiv,

The amount of damage inflicted upon the cord will
vary, of course, with the magnitude of the accident ;
but, other things being equal, it will be found to be
more severely injured in fracture-dislocations of the
cervical and dorsal segments than in like lesions in the
lumbar spine. In the atlo-axial region the amount of
displacement that follows upon luxation of the two
bones from one another is such that the cord is, as a
rule, severely crushed, and death ensues instantaneously,
as is seen in cases of death by hanging. In the cervical
and upper dorsal segments of the column the vertebral
bodies are small, the spine is mobile, the fractures
met with in the parts are usually due to indirect
violence, and are associated with much displacement.
In the lower dorsal region, again, the greater rigidity
of the spine renders any displacement, when it does
occur, likely to be considerable. In the lumbar region,
on the other hand, it must be noted that the cord only
extends to the lower border of the first vertebra. The
bodies of the vertebrae, also, in this district, are very
large and cancellous, and can undergo a severe amount
of crushing without a corresponding degree of dis-
placement being produced. The part is also well
protected by the large intervertebral discs, and by the
immense masses of muscle that surround the spine in
the loins. Such portion also of the spinal medulla as
extends into the lumbar region is protected by the
many cords of the cauda equina, which, by their loose-
ness and comparative toughness, tend to minimise the
effects of violence.

The degree of displacement of bone required to
produce pressure effects upon the cord is often greater
than would be supposed. At post-mortem examina-
tions portions of injured vertebrae have been found
encroaching upon the spinal canal to a considerable
extent in cases where no evidences of damage to the
cord existed during life. Dr. J. W. Ogle reports the

chap, xxiv.] THE SPINE. 511

case of a man who, after an injury to the neck from
a fall, presented no spinal symptoms until three days
had elapsed. He ultimately became paralysed, and
died thirty-two days after the accident. The autopsy
revealed a dislocation forwards of the sixth cervical
vertebra, of such an extent that the body below
projected at least half an inch into the spinal
canal.

The remarkable manner in which the cord will
accommodate itself to a slowly progressing pressure is
often well seen in the results of chronic bone disease
in the column.

The symptoms due to injury to the cord and to the
nerves contained in the spinal canal, will obviously
depend from the situation and extent of the lesion.
The diagnosis of the situation of the lesion is compli-
cated by the relation the nerves bear to the various
vertebrae, and by the fact that the majority of the
great trunks arise from the cord at a spot above the
point at which they issue from the vertebral canal.
The two highest nerves, the first and second cervical,
pursue an almost horizontal course in their passage
from the cord to their points of exit from the canal.
The remaining nerves take a more and more oblique
direction, until at last the lowest nerve trunks run
nearly vertically downwards as they pass to their
respective inter vertebral foramina.

Points of exit. — The first cervical nerve leaves the
canal above the first cervical vertebra. The remaining
cervical trunks escape also above the vertebrae after
which they are named, the eighth cervical nerve leaving
the canal between the last cervical and the first dorsal
vertebrae. The dorsal, lumbar, and sacral nerves have
their points of exit below the vertebrae after which they
are named. Thus, the first dorsal nerve will pass
through the foramen between the first and second
dorsal vertebrae, and so on.

512 SURGICAL APPLIED ANATOMY. [Chap. xxiv.

Points of Origin from the Cord.

The first cervical nerve arises from the cord opposite the

interval between the atlas and occiput.
The second and third cervical nerves arise from the cord

opposite the axis.
The fourth, fifth, sixth, seventh, and eighth cervical nerves

arise from the cord opposite the third, fourth, fifth, sixth,

and seventh vertebras respectively.
The first four dorsal nerves arise from the cord opposite the

discs below the seventh cervical and the first, second, and

third dorsal vertebrae respectively.
The fifth and sixth dorsal nerves arise from the cord opposite

the lower borders of the fourth and fifth vertebrae.
The remaining six dorsal nerves arise from the cord opposite

the bodies of the sixth, seventh, eighth, ninth, tenth, and

eleventh vertebrae.
The first three lumbar nerves arise from the cord opposite the

twelfth dorsal vertebra.
The fourth lumbar nerve arises from the cord opposite the disc

between the twelfth dorsal and first lumbar vertebrae.
The last lumbar nerve, together with the sacral and coccygeal

nerves, arise from the cord opposite the first lumbar

vertebra.

It will be seen, therefore, that in taking note of
the symptoms due to crushing the entire nerve con-
tents of the vertebral canal at a certain spot, con-
sideration must be taken, not only of the effects of
damaging the medulla at that point, but also of the
result of lacerating nerve trunks that may issue there,
although their origins are above the seat of lesion.
The cord is also very often only damaged in part, or
it may entirely escape, while one or more nerves are
crushed by the fractured vertebrae, or by fragments of
bone separated by the lesion.

In fracture-dislocations the upper vertebral body,
as already stated, usually glides forwards, with the
result that the anterior and antero-lateral parts of the
cord are brought into violent contact with the pro-
tecting border of the vertebrae below the seat of lesion.

chap, xxiv.] THE SPINE. 513

It is in these parts of the cord that the main motor
tracts run, and thus it happens that motion is more
often lost in the parts below the site of the injury
than is sensation. If there be partial motor and
sensory paralysis, the disturbance of the former
function is likely to be in excess of that of the latter.
In no case, indeed, does there appear to have been a
loss of sensation without, at the same time, some
disturbance in the powers of movement. If the grey
matter .of the cord be not severely damaged, reflex
movements appertaining to that segment of the cord
can usually be induced in the paralysed parts by
proper stimulation. If those reflex movements be
lost, it may be inferred that the grey matter is broken
up, and that the entire spinal medulla has been
crushed at the seat of lesion.

The higher up the fracture in the column the
greater is the tendency for the function of respiration
to be interfered with. If the lesion be at the upper end
of the dorsal spine, then not only will all the
abdominal muscles be paralysed, but also all the inter-
costals. A fracture, associated with injury to the
cord, when above the fourth cervical vertebra, is, as a
rule, instantaneously fatal. The phrenic nerve comes
off mainly from the fourth cervical nerve, receiving
contributions also from the third and fifth. The
fourth nerve issues just above the fourth cervical
vertebra. If the cord be damaged immediately below
this spot, the patient can breathe only by means of
the diaphragm, and if the lesion be so high as to
destroy the main contribution to the phrenic, respi-
ration of any kind becomes impossible.

Certain disturbances of the act of micturition are
frequent in cases of injury to the cord. The reflex
centre for this act is lodged in the lumbar enlarge-
ment. The irritation of the vesical walls, produced
by the increasing distension of the bladder, provides

H H

514 SURGICAL APPLIED ANATOMY. [Chap. xxiv.

the needful sensory impulse. This impulse is re-
flected to the nerves controlling the bladder muscles,
and especially to the detrusor urinse, and by their
contraction the organ is emptied. The action, how-
ever, can be to some extent inhibited by influences
passing down from the brain to the lumbar centre,
and the tendency to a frequent discharge of urine
is resisted by contraction of the sphincter. When,
therefore, any part of the cord is damaged that lies
between the lumbar centre and the brain, this inhibi-
tion can have no effect. Immediately after the
accident the temporary suspension of reflex actions
from shock produces some retention of urine, and
after that the bladder empties itself at frequent
intervals, the patient being unconscious of the act,
and unable to influence it.

If the centre itself be damaged in the lumbar cord,
the patient, after a little retention, will suffer from
absolute incontinence ; and a like result will follow if
the nerve connections between the cord and bladder
below the spinal centre have been destroyed. The
principal nerves connecting the medulla spinalis with
the bladder are the third and fourth sacra].

The act of defsecation also is apt to be disturbed
in a like manner. Here there is, as in the previous
case, a reflex centre in the lumbar enlargement, with
motor and sensory nerves connecting it below with
the rectum and its muscles ; and also between this
centre and the brain are tracts, but little known,
along which inhibitory actions can extend.

When the centre itself is damaged, or the con-
nection severed that unites it with the viscus, the
patient will suffer from incontinence of fneces, and
will be unable in any way to control the act. When
the cord is damaged at any spot between the centre
and the brain, then the act of defsecation will be
performed at regular intervals, without either the

chap, xxiv.] THE SPINE. 515

patient being conscious of the act or being capable of
inhibiting it.

In some injuries to the cervical cord the patient
has suffered from severe vomiting for some time after
the accident, or has exhibited a remarkable alteration
in the action of his heart. Mr. Erichsen, for example,
reports the case of a man who, after a severe blow
upon the cervical spine, continued to vomit daily for
several months. In the other category, instances
have been recorded when the pulse has sunk as low
as 48, or even as 36, and 20, after lesions to the
column in the neck.

These changes are supposed to be due to dis-
turbance of the vagus, and it is further suggested
that the morbid influence is conveyed to the vagus by
the spinal accessory nerve with which it is so freely
associated.

It should be remembered that the spinal accessory
trunk has origin from the cord as. low down as the
sixth or seventh cervical nerves.

INDEX.

A bees en Mssac, 467.
Abdomen, Blows on the, 267.

• , Congenital deformities of

the, 277.

Emphysema of wall of, 267.

— Nerves of the, 273.

Protuberance of the, 262.

Skin of the, 265.

Surface anatomy of the, 262.

Wounds of the, 272.

" Abdominal belt," 266.

connective tissue and ab-
scesses, 271.

muscles, Kigidity of the, 274.

parietes, Anterior, 265, 267.

, Posterior, 290.

ring, external, Feeling for

the, 279.

— wall, nerve associations, 274.
Abnormalities in skull, 16.
Abscess about axillary region, 182.

about cervical region, 127.

, Gluteal, 383.

, Iliac, 291.

in antrum, 81.

in mastoid cells, 67.

in mediastina, 160.

in testis, 370.

in the abdominal parietes,

271, 291.

in the female breast, 153.

in the scalp, 5.

in the temporal fossa, 8.

Ischio- rectal, 347.

Lumbar, 295.

Orbital, 36.

Palmar, 245.

Parotid, 62, 88.

, Opening of, 91.

Pelvic, in hip joint, 397.

Perinephritic, 328.

Perityphlitic, 296, 311.

, Popliteal, 430.

Post-pharyngeal, 114.

Prostatic, 360.

Psoas, 293, 392.

ftenal, 328.

Thecal, 248.

A ccelerator urinse, 346.
Acetabulum, 396.
, Fractures of, 338.

Aching legs from standing, 455.
Acne hypertrophica, 71.
Acromial vault, 189.
Acromio-clavicular joint, 176.

, Dislocations of, 177.

thoracic artery, 166.

Acromion process, Fracture of,

179.

Addison's disease, 332.
Adductor longus muscle, 389, 393.
Air in veins, 143, 185.
"Alderman's nerve," 64.
Alexis St. Martin's case, 301.
Amputation (see Arm, Amputation

of, etc.).

Anal triangle, 344.
Anastomotica inagna, 426, 428.
Anatomical neck of humerus,

fracture, 199.
Anchylosis at the shoulder -joint,

193.
at the sterno-clavicular joint,

Aneurism, Aortic, 143, 333.

, Axillary, 186.

in the neck, 143.

of the posterior tibial artery,

454.

, Popliteal, 432.

Ankle and fibula, relations, 475.

and foot, 461.

, Surface anatomy of, 461.

joint, Amputation at, 490,

491.

, Disease of, 473.

, Dislocations at, 474.

, its movements, 473.

line, 462.

, Referred pains in, 474.

Annular ligaments of ankle, 468.

of wrist, 246, 248.

Anosmosia, 79.

Anterior crural nerve, 394.

, Paralysis of the,

493.

, Strength of the, 387.

Antero-posterior arch of the foot,

479.

Antrum of Highmore, 76, 81.
Anus, 344, 376.
in violent defsecatioii, 377.

SURGICAL APPLIED ANATOMY.

Aorta, Abdominal, 264, 333.

, Thoracic, 140, 143, 159.

Aortic orifice, 159.
Aponeuroses (see Fasciae).
Aqueduct of Fallopius, 67.
Aqueous humour, 51.
Arachnoid cyst, 26.

, The, 26, 506.

Arcus senilis, 41.
Arm, 202.

, Amputation of, 209.

, Issue on, 205.

, Skin of the, 204.

, , Ecchymosis in the, 204.

, Surface anatomy of the, 202.

Arnold's nerve, 64.
Arteria centralis retinae, 46.
Arteries (see Axillary, etc., and

Blood-vessels).
Arterio-venous aneurisms, 37, 215,

393.

Arthritic nail, 243.
Astragalo-scaphoid articulation,

462,483.
Astragalus, Fractures of, 488.

, Dislocations of, 481.

Atlas, Disease of, 114.
Atlo-axial portion of spine, 500.
Auditory meatus, External, 59.

, its relations, 62.

Auriculo-ventricular orifices, 159.
Avulsion of the fingers, 257.
Axilla, 165, 181.

, Suspensory ligament of, 182.

Axillary abscess, 182.

artery, 165, 186.

glands, 165.

, Removal of, 185.

nerves, 187.

vein, 185.

Axis, Dis-ase of, 114.
Azygos veins, 161.

Barbadoes leg, 396.

Bartholin's duct, 102.

Base of skull, Fractures of, 22.

Belly-ache and spinal disease, 275.

Bend of elbow, 210.

Bent arm after venesection, 215.

Biceps tendon in arm, 191.

in ham, 431.

Bichromate disease, 76.
Bicipital groove, 164.
Bifurcation of the aorta, 264.
Bile duct, Rupture of the, 321.
Bladder, Distance of the, from the
surface, 352.

, Distension of, 353.

, Double, 358.

Bladder, Extroversion of the, 278.

, Fasiculated, 357.

, Female, 358.

, Foreign bodies in, 359.

found in herniae, 355.

, Male, 353.

, Mucous membrane of the,

357.

of child, 359.

, Puncture of above pubes,

353.

, , per rectum, 355.

relations to the peritoneum,

355.

, Rupture of the, 356.

, Sacculated, 358.

stabbed through buttock,

388.

Blisters to knee, Effect of, 428.

Blood-vessels in the abdominal
walls, 272.

in foot and ankle, 470.

in Scarpa's triangle, 393.

of auditory meatus, 63.

of brain, 32.

of breast, 154.

of buttock, 385.

of face, 83.

of foot, 470.

of globe, 45.

of hand, 240, 249.

of heel, 491.

of knee, 428.

of nares, 78.

of neck, 142.

of orbit, 37.

of pinna, 63.

of rectum, 376.

of scalp, 9.

of the abdomen, 333.

of the soft palate, 112.

of tympanum, 70.

Brachial aponeurosis, 204.

, Principal structures re-
lated to, 205.

artery, 205, 216.

, Compression of, 206.

in phlebotomy, 215.

, Ligature of, 206.

plexus, 122, 258.

, Injuries to the, 131.

258.

, Strength of the, 387.

Brachialis antic us, 205.

Brain, 3l.

and skull relations, 29.

, Blood-vessels of the, 32.

, Compression of the, 25.

, Concussion of the, 32.

INDEX.

Brain, Congestion of the, neutra-
lised, 28.

, Fissures of the, 29.

injuries, 27, 32.

, Membranes of the, 25

, Motor centres of, 81.

Branchial fistulse, 59, 146.
Brasdor's operation, 143.
Breast, The female, 153.
Bregma, 12.

Broca's convolution, 30.
Bronchi, 131, 141, 157.

— , Foreign bodies in, 137.
Bronchocele, 138.
Brunner's glands in burns, 308.
Bryant's method of dhiding the

muscles of the palate, 112.
Buccal cavity, 102.

in foetus, 110.

nerve, 87.

Bulbous urethra, 364.

Bunions, 469.

BursEe about the foot, 468.

about the ham, 433.

about the shoulder, 190.

between the patella ligament

and the tubercle of the tibia,

429.
between the quadriceps and

the femur, 42?, 436.

of the elbow, 217.

• over the great trochanter,

385.
over the ischial tuberosity,

385.

over the knee joint, 429.

, Patellar, 429.

, Subacromial, 187, 190.

Buttocks, Arteries and nerves of

the, 385.

— , Surface anatomy of the, 380.
Button-hole action of tbe sesamoid

bones and their tendons, 257.

Caecum, 311.

, Foreign bodies in the, 311.

in intestinal obstruction,

312.

Caesarian section, 338.
Calcaneo-astragaloid joint, 480.

-cuboid articulation, 483.

scaphoid ligament, 462, 483,

486.

Calcar femorale, 406.
Canal of Nuck, Hernia in, 285.

of Schlemm, 51.

Cancer of gullet, 141.
Cancrum oris, 83.
Capsule of Tenon, 35.

Carbuncle on the neck, 123.
Cardiac orifice of stomach, 299.
Caries sicca, 68.
Carious teeth, Effects of irritation

caused by, 99.
Carotid artery, 120, 142.

, Aneurism of, 143.

destroyed by abscess,

128.

, Ligature of, 142.

, Wounds of, 130.

tubercle, 119.

Castration, 371.
Cataract, 50.

— , soft, Treatment of, 52.
Catheterism of Eustachian tube,

69.

of urethra, 362.

Centre of gravity of an adult body,

336.

Cephalbsematomata, 7.
Cerebral localisation, 30.
Cerebro-spiual fluid, 28, 506.
Cervical cord injuries and vomit-
ing, 515.

sympathetic, Paralysis of, 39.

Cervico-dorsal part of spine, 500.

Charbon, 83.

Cheek, Substances embedded in,

83.

Chemosis, 56.
Cholecystotomy, 322.
Chopart's operation, 491.
Chorda tytnpani nerve, 70.
Chproid, 42.
Ciliary zone, 45.
Circulus major, 45.

minor, 45.

Circumcision, 365.
Circumcorneal zone, 46.
Circumflex artery, external, Rup-

ture of, 420.

, internal, "Wound of, 420.

— • — , Posterior, 166, 188.

— — nerve, 166, 188.
Cirsoid aneurism, 10.
Clavi<-le, 162, 166.

, Dislocations of, 175, 177.

, Fractures of the, 169.

, Green-stick fracture of the,

171.

, Movements of the, 173.

, Ossification of the, 172.

, Relations of, 171.

, Removal of the, 168.

, Structures behind the, 167.

Cleft palate, 109.
Clergyman's sore-throat, 132.
Club-foot, 483.

520

SURGICAL APPLIED ANATOMY.

Coccygeus, 340, 341.

Coccygodynia, 340.

Cochin leg, 396.

Coeliac axis, 265.

Colectomy, 317.

Colles' fracture, 252.

Coloboma iridis, 44.

Colon, 310.

, Congenital malformation of

the, 314,

, Stricture of the, 312.

Colotomy, 315.
Compression of brain, 25.

of cord, 507, 509.

Concretions in the caecum, 312.
Concussion of "brain, 32.

of cord, 508.

Conditions lessening the danger

of blows upon the skull, 19.
Condyle of the elbow, External,

211.

, Internal, 211.

of the femur, Inner, 425.

, Outer, 425.

Condyles of femur, Condition of,

in knock-knee, 441.

, Fracture of, 446.

of humerus, Fracture of, 222.

Congenital club-foot, 484.

exomphalos, 278.

fistulse, 59, 146.

hernia, 283.

hydrocele, 283.

malformations of anus and

rectum, 377.

of bladder, 278.

of colon, 314.

of penis, 366.

tumour of sterno-mastoid,

124.

Conjunctiva, 56.
Contracted knee and anchylosis,

435.

Contre-coup, Fracture by, 22.
Convolutions of brain, Motor

centres on, 30.
, Relations of, to skull,

29.
Coraco-acromial arch, 189.

ligament, 164.

brachialis muscle, 203.

Coracoid process, Fracture of the,

179.
Cord, Spinal, 505.

, Concussion of, 508.

, Contusion of, 509.

, Injuries to the, symp-
toms of, 511.
Cornea, 40.

Corneitis, Seat of pain in, 47.

Coronal suture, 12.

Coronoid process, fracture of the,

225.

of the ulna, 211.

Corpus striatum, 30.
Coryza, 74.
Costo-colic fold, 324.

coracoid membrane, 182.

Coup de fouet, 453.
Cranial contents, 25.

sutures, 12.

Cranio-tabes, 13.

Cranium, Bony vault of the, 12.

Creases in the skin of the palm,

239.

on abdomen, 265.

Cremaster muscle, 370.
Cremasteric artery, 370.
Cribriform plate, 73.
Cricoid cartilage, 118, 119, 131,

132.

Crico-thyroid space, 119, 137.
Crural canal, 286.
Crushing the spinal cord, 503.
Crutch paralysis, 207.
Cuboid bone, 462.
Cuneiform bone, Inner, 462.
, , Dislocation of the,

488.
, , Fracture of the,

488.
Curves of the vertebral column,

497.
Cyphosis, 497.

Dacryops, 58.

Dangerous area of the scalp, 2.

Dartos, 266, 367.

Defaecation and the seminal vesi-
cles, 373.

Deltoid muscle, Insertion of the,
203.

region, 187.

tubercle, 162.

Dental foramen, 86.

Digital arteries, 240, 249.

Diploic veins, 11.

Discs, Inter vertebral, 498.

Dislocation (see the several bones
and joints).

Distension of the bladder, 353.

of the intestines, 310.

of the rectum, 374.

Distinguishing large bowel from
small in lumbar colotomy, 317.

Diverticula from the synovial
membrane of the shoulder- joint,
192.

INDEX.

Dorsal surface of the baud,
240.

vein of penis, 349.

Dorsalis pedis artery, 471.

— scapulee artery, 166.
Dorso-lumbar part of spine, 500.
Double chin, 123.

Drop wrist, 258.
Duodenum, 305.
Dupuytren's contraction, 244.

— fracture, 477.
Dura mater, 25, 506.

, Fungus of, 26.

Dy aphonia clericoruin, 132.

Ear, Abscess of, 61.

, Bleeding from, in fractures

of base of skull, 23.
— , Blood-supply of the, 63, 70.

coughing, 64.

, External, 59.

, Foreign bodies in, 62.

, Gangrene of, 63.

— , Haematomata of, 63.

, Nerves of, 63.

-, Polypi of, 62.

rings in eye disease, 65.

, Slits in, in scrofula, 60.

sneezing, 64.

, Tophi in, 60.

yawning, 64.

Earache and toothache associa-
tions, 65.

Ectropion, 54.

Ejaculatory ducts, 363.

Elbow, Disease of the, 218.

, Dislocations of the, 219.

, Fold of the, 210.

-joint, 216.

, Rigidity of, 219.

, Ligaments of the, 217.

, Eegion of the, 213.

, Selection of the, 225.

, Surface anatomy of the,

210.

Elephantiasis Arabum, 395.

in the labia majora, 372.

Embpli in cerebral arteries, 33.

in left carotid artery, 143.

Emissary veins of skull, 10.

Encephalocele, 15, 73.

Encysted calculi, 358.

hydrocele of the cord. 2^3.

End-bulbs in the nerves of the
foot, 466.

Enlarged spleen, 324.

Enostoses of frontal sinuses, 80.

Enterotomy, 309.

Entropion, 57.

Epicondyle of humerus, 223.

Epigastric artery, Deep, 265.

Epiphora, 58.

Epiphyses of acromion, 179.

of pelvis, Separation of, 337.

, upper, of the femur, Separa-
tion of the, 408.

Epiphysis, Lower, of femur in ex-
cision of knee, 449.

, , in knock-knee, 441.

, , , Separation of, 446.

, , of humerus, Separation

of, 224.

, , of radius, Separation

of, 255.

, , of tibia, Separation of,

458.

of clavicle, Separation of,

172.

of coracoid process, 179.

of olecranon, 225.

of third phalanx in whitlow,

248.

, upper, of humerus, Separa-
tion of, 200.

, , of tibia, Separation of.

448.

Epispadias, 366.

Epistaxis, 78.

Epitheliomataof the scrotum,366.

Erector- spinae muscles, 261

Eustachian catheter, To pass, 69.

tube, 68.

Excision (see special parts).

of the tongue, 108.

Extensor carpi ulnaris, 236.

communis digitorum, 236.

longus digitorum, 463.

pollicis, 463.

ossis metacarpi pollicis, 235.

primi internodii pollicis, 235.

secundi internodii pollicis,

236.

External auditory meatus, 60.

Extracapsular fracture of the fe-
mur, 407.

Extravasation of urine, 266, 349.

Eye-ball, 40.

, Blood supply of the, 45.

, Dangerous area of, 49.

, Nerves of the, 47.

Eyelids, 54.

, Layers of the, 55.

Face, 82.

, Extensive injuries to, 81.

, Nerves of the, 85.

Facial artery, 84, 121,
nerve, 90.

522

SURGICAL APPLIED ANATOMY.

Facial neuralgia, 11, 85.

paralysis, 58.

vein, 85.

Fasces, Incontinence of, in spinal

injuries, 514.
Fascia, Axillary, 182.

, Bicipital, 215.

, Cervical, 124.

, Clavi-pectoral, 182.

, Iliac, 290.

in region of Scarpa's trial gle,

391.

lata, 392, 419.

• lumborum, 295.

in lumbar colotomy,

315.

, Obturator, 342.

of arm, 204.

of buttocks, 383.

of Colles, 348.

of deltoid region, 187.

of foot, 463, 466.

of leg, 452.

of paim, 242, 244.

of the scalp, 7.

, Parotid, 88.

, Pectoral, 182.

, Pelvic, 341.

, Perineal, 348.

, Popliteal, 430.

, Prevertebral, 127.

, Eecto-vesical, 342.

, Temporal, 7.

, Transversalis, 290, 315.

Fasciculated bladder, 357.
Fatty tumours about face, 83.
Female bladder, 358.

breast, 153.

rectum and vagina, 374.

Femoral artery, Ligature of, 420.
Femur, Dislocations of the, 409.

fractures of, 405, 421, 446.

, , and shortening of linib,

422.
Fenestra ovalis, 67.

rotunda, 67.

Ferguson's method of dividing the

muscles of the palate, 112.
Fibula, fractures of, 458, 475.

, Head of the, 425, 450.

Fibular shaft, Lower half, 451.
Fissure of Eolando, 29, 31.
Fistula at the navel, 270.
between the gall bladder and

gut, 313.

in ano, 347.

, Lachrymal, 58.

, Salivary, 92.

Flat-foot, 485.

Flexing of the thigh in hip disease,

399.
Flexor carpi radialis tendon, 235.

ulnaris tendon, 236.

longus digitorum, 463.

pollicis pedis. 463.

— — sublimis tendons, 236.
Fold, Gluteal, in hip disease, 381.
Fontanelle, Sagittal, 17. ,

Fontanelles, 12.
Foot, Amputations of, 490, 491,

492.

, Arches of the, 479.

, Blood vessels of, 470.

, Chief joints of the, 480.

, Dislocations of, 474, 481, 482,

488.

, Fasciae of, 466.

, Fractures of, 487.

, Integuments of, 465.

, Lymphatics of, 472.

, Nerves of the, 465.

, Surface anatomy of, 461.

, Synovial membranes of, 480.

, The, 461, 479.

Foramen of Magendie, 28.

of Monro, 28.

Fore-arm, 227.

, Amputation of the, 234.

, Bones of the, 229.

, Fractures of the, 231.

, Luxations of the, 219.

, Surface anatomy of the, 227.

, Vessels of the, 228.

Fossa, Ischio-rectal, 344, 346.

, Nasal, 73.

, Subclavicular, 164.

of Eosenmuller, 69.

Fracture (see the several bones).
dislocation of the vertebral

column, 503.

h^licoide, 458.

Fraenum linguae, 105.
Frontal sinus, 80.
Fungus of the dura mater, 26.
of the testicle, 370.

Gall bladder, Eupture of the, 321.

, Fundus of, 318.

, Ulceratiou of the, 313.

stones, 321.

Gangrene of nose, 71.

of pinna, 63.

of the leg and embolism, 454.

Garters and the saphenous vein,

454.
Gasserian ganglion, affected by

abscess spreading from parotid,

90.

INDEX.

523

Gastric fistula, 301.
Gastrocnemius muscle, 451.

— , Eupture of the, 453.
Gastrostomy, 303.
Gastrotomy, 303.
Generative organs, Female, 372.
Genito-crural nerve, 370, 394.
Genu-valguni, 440.

— , Three stages of, 441.
Gladiolus separated from nianu-

brium, 148.

Glandular laryngitis, 133.
Glans penis, 365.
Glaucoma, 42, 53.
Glaucomatous cup, 54.
Glottis, 132.

, (Edema of, 132.

Gluteal abscess, 383.

aneurisms, 385.

— artery, 385.

bursae, 385.

region, 380.

Gluteus maximus, 384.

, Rupture of, 384.

Goitre, 138.
Granular lids, 57.
Great trochanter, 380.
Groin, Eegion of, 388.
Gullet, 139.
— , Foreign bodies in the, 140.

, Operations on, 141.

Gums, 104.

Gustatory nerve. Moore's method

of dividing the, 103.

Haematomata of scalp, 6.

on septum nasi, 77.

on the pinna, 63.

Hsernaturia after injury to back,

328.

Hasmophysis, 157.
Haemorrhage, Extra-meningeal,

25.

from choroid, 43.

from fraenum linguae, 105.

from intercostal vessels, 152.

from tongue, 106.

from tonsil, 117.

in lithotomy, 350, 352.

into subdural space, 26.

into vitreous, 47.

in tracheotomy, 136.

Hsemorrhoidal vessels and nerves,

347, 376.

Hsemothorax, 157.
Hamstring muscles, 418, 430.
Hamular process to be felt, 111.
Hand, 237, 241.
• 1 Amputation of, 257,

Hand, Blood-vessels and lym-
phatics in the, 240, 249.
— , Dislocations of, 255, 256.

, Fasciae of, 244.

, Surface anatomy of, 237.

, Synovial sheaths of, 247.

Hanging, Mode of death from,
510.

Hard palate, 110.

Htre-lip, 109.

Heart, its relation to the surface,
157.

, Wounds of the, 159.

Heel, Integuments of, 491.

Holicoidal fractures of Leriche,
422.

Hemiplegia, 33.

Hernia, Congenital, 283.

, , disposition to, 284.

, Diaphragmatic, 290.

, Direct, 280.

, versus indirect, ingui-
nal, 281.

, Encysted, 283.

, Femoral, 286.

, Infantile, 283.

, Inguinal, 278, 284.

into the funicular process,

283.

, Lumbar, 289.

, Mesenteric, 298.

, Meso-colic, 298.

, Obturator, 288.

, Perineal, 289.

, Pudendal, 289, 372.

, Bare forms of, 289.

, Sciatic, 289.

, Structures related to fem-
oral, 287.

1 , Umbilical, 289.

, , Congenital, 269.

, Vaginal, 372.

Herniotomy, 285.
Herpes labialis, 100.

zoster of face in association

with eye affections, 48.
Hip disease and pain in the knee,
403.

dislocations of, 409.

joint, 396.

, Amputation at the, 415.

disease, 398.

, Fractures about, 405.

movements of, 397.

, Eegion of the, 330.

Hippocratic hand, 243.
Holden's line, 388.
Hottentot Venus, 383.
Human tails, 340.

524

SURGICAL APPLIED ANATOMY.

Humerus, Dislocations of, 193.

, fractures of, 199, 207, 223.

, , non-union after, 208.

Hydatid cyst in the liver, 321.
Hydrencephalocele, 15.
Hydrocele, 369.

• of the neck, 146.

Hydrocephalus, 13, 28.
Hyoid bone, 119.

, Fracture of, 131.

Hypertrophy of the prostate,

360.

Hypopyon, 52.
Hypospadias, 366.
Hypothenar eminence, 237.
Hysterical hip, 404.
knee, 404.

Ichthyosis linguae, 105.
Ileo-csecal valve, 308.
Ileuin, 305, 308.
Iliac abscess, 291.

fascia, 290.

Ilio-psaas muscle, 290, 392.

tibial band, 384, 419, 425.

Indirect hernia, 280.

Inequality of limbs in length, 423.

Infantile hernia, 283.

Interior dental nerve, Dividing

the, 86.

maxilla, Dislocations of, 97.

, Excision of the, 98.

, Fracture of the, 95.

thyroid veins, 119, 129, 136.

Inflammation of the viscera and

blood-lettings, 334.
Infraorbital foramen, 86.

nerve, 86.

Inguinal canal, Female, 284.
Innominate artery, 143, 159.

bone, 335.

Intercostal artery, "Wounding of

the, 152.

spaces, 151.

Internal carotid artery, 67,115,117.

jugular vein, 67, 115, 117.

mammary artery, 152.

popliteal nerve, Strength of

the, 387.

Interstitial keratitis, 41.
Intervertebral discs, 497.
and fracture-dislocation,

504.

Intestinal calculi, 312.
Intestine, Diverticulum from, 308.

, Foreign bodies in, 309, 311.

, Large, 310.

, Resection of, 310, 317.

1 Rupture of, 307.

Intestine, Small, 305.
Intestines, Wounds of, 306.
Intracapsular fracture of the

femur, 405.

Intussusception, 309, 310.
Inversion of the testicle, 359.
Iridectomy, 44.
Iridodyalisis, 44.
Iris, 43.

Iritis, Seat of pain in, 47.
Ischio-rectal fossa, 344, 346.
Isthmus of thyroid, 135.
, Division of, 136, 138.

Jacob's ulcer of the eyelid, 55.
Jaws (see Inferior and Superior

Maxilla).
Jejunum, 305.
Joints, Surgical classification of

the, 189.

Keloid, its frequent seat, 148.
Kidney, 326.

, Hilus of the, 326.

, Horse-shoe, 329.

, its relations, 326.

, Movable, 329.

, Operations on, 330.

, Rupture of the, 328.

vessels, Point of origin of,

265.
Knee, Blood-supply of the, 428.

, Bursse about, 429, 433.

, Dislocations of the, 445.

, Fractures about, 446, 447.

, Integuments of, 427.

-joint, 435.

, Amputation through

the, 449.

, Disease of, 437.

, Excision of the, 448.

, Mobility of the skin over

the, 427.

pains and sigmoid flexure,332.

, Region of, 424.

, Surface anatomy of the, 424

Knock-knee, 440.

Labia majora, 372.
Lachrymal abscess, 58.

apparatus, 58.

canals, 58.

gland, 58.

sac, 58.

Lachrymation from irritation of

nasal nerve, 48, 79.
Lacuna magna, urethal, 364.
Lambda, 12.
Lambdoid suture, 12.

INDEX.

525

Lamina cribrosa, 54.
f usca, 43.

— suprachoroidea, 43.
Laparotomy, 309.
Laryngotomy, 133, 137.
Larynx, 131.

— , Foreign bodies in the, 137.
, Fracture of, 132.

— , Mucous membrane of the,
132.

— , Removing the, 133.

— , Submucous tissue of the, 132.
Lateral lithotomy, 349.
Left carotid artery, 159.

— innominate vein, 159.
Leg, 450.

— , Amputation of the, 459.

— , Fasciae of, 452.

- -, Fractures of the, 4^6.

— pain and diseased rectum, 456.
— , Eickets affecting bones of,

459.

, Skin of the, 452.

, Surface anatomy of the, 450.

, Vessels of, 453.

Length of lower limbs, 423.
Lengthening of the limb in hip

disease, 399.
Lens, 50.
Leucaemic enlargement of the

spleen, 324.

Levator ani, 341, 345, 346.
, relation to fistula in

ano, 347.
palati, 111.

— palpebrae, 55.
LJgamentum patellae, 425, 437, 444.

— pectinatum iridis, 51.
Lighterman's bottom, 385.
Linea alba, 263, 268.

— semilunaris, 263.
Lingual artery, 121.
Lipomata in deltoid region, 187.
in neck, 123.

in Scarpa's triangle, 391.

on the buttock, 383.

rare on face, 83.

, Seat of, 187.

Lips, 100.

Lisfrauc's amputation, 492.

Lithotomy, Lateral, 349.

• , in children, 351.

, Parts divided in, 349.

— — , that may be

wounded, 350.

Median, 351.

— versus lateral, 351.

Littre's operation, 313.
Liver, 318.

Liver, Abscesses of, 321.

in pyaemia, 321.

, Piece of, forced into heart,

319.

, Protrusion of, 319.

, Pus from, discharged by

bronchi, 321.

, Relations of, 318.

, Ruptures of, 318.

, Wounds of, 319.

Lockjaw, 100.

Lordosis of the spine in hip

disease, 400.

Lower limb, Nerve supply of, 493.
Lumbar colectomy, 317.

colotomy, 315.

fascia, 295.

region, 294.

spine, 498.

, Injuries to, 409, 502,

504, 505, 514.
Lung, 155.

and secondary deposits, 157.

, Relations of to surface, 155.

, Rupture of, 157.

, Wounds of, 156.

Lupus erythematosus, 71.
Lymphangioma cavernosum, 107.
Lymphatic glands and vessels (see

each region).

Macro-glossia, 107.

Malar bone, 87.

, Fracture of, 87.

Malleoli, 461.

, Fractures of, in dislocations

of the foot, 475.

Mammary abscess, 153.

gland, 152.

, blood-vessels and

nerves of, 154.

in groin, 391.

Manubrium, 148.

Masseter, 9, 100.

Mastoid cells, 67.

Maxillae (see Inferior and Supe-
rior).

Meatuses of nose, 76.

Meatus, Walls of the auditory,
62, 63.

Meckel's diverticulum, 270, 308.

Median basilic vein, 211, 213, 214.

, why selected for

venesection, 214.

cephalic vein, 211, 213.

lithotomy, 351.

nerve, 229.

, Paralysis of the, 260.

Mediastina, 160.

526

SURGICAL APPLIED ANATOMY.

Mediastina, Abscess of, 128, 160.

Medio-tarsal joint, 462, 483. .

, Amputation at, 491.

Meibomiaa glands, 55.

Melanotic growths of choroid, 43.

Membrana tympani, 65.

, Perforation of, 66.

Membranous uretha, 319, 363.

Meningeal artery, 8.

Meningesof brain, 25.
— of spinal cord, 508.

Meniugites (spinal) from bed-
sores, 501.

Meningitis from abscess in the
ear, 62.

Meningocele, 15, 73, 75.

Mesenteric arteries, 265, 333.

Mesentery, 297.

Meso-csecum, 311.

nephron, 329.

Metacarpo-phalangeal joint of
thumb, dislocations at, 256.

Metatarsal bone of great toe, Am-
putation of, 494.

bones, Fractures of the, 488.

Metatarso - phalangeal articula -
tions, 462.

joint of thumb, Dislocation

at, 489.

Micturition and spinal mjuriea,
513.

Miner's elbow, 217.

Motor centres on the cortex, 3,0.

paralysis in injuries to cord,

513.

Mucous polyp of nose, 77.

Mumps, 91.

Muscse volitantes, 53.

Muscles of mastication, 100.

Muscular coat of the bladder, 357.

Musculo-spiral nerve, 206.

, Paralysis of the, 258.

Nail, 2t3.

Nares, Anterior, 73.

, Posterior, 74.

Nasal bones, 72.

, Fracture of, 22.

cavity, 73, 78.

douche, 85.

duct, 76.

floor, 77.

fossae, 75.

mucous membrane, 77.

nerve and orbital connections,

48, 71.

polypi, 77.

septum, 76.

— — sim

Neck, 118.

, Abscess of, 127.

, Fasciae of, 124.

, Great vessels of, 142.

, Hydrocele of, 146.

, Integuments of, 122.

, Lymphatic glands of, 144.

, Middle line of the, 119.

, Surface anatomy of the, 118.

, Wounds of the, 129.

Necrosis of skull, 17.
Nelaton's line, 381.
Nephrectomy, 330.
Nephro lithotomy, 330.
Nephroraphy, 330.
Nephrotomy, 330. '
Nerve-stretching, 387.

supply of lower limb, 493.

of upper limb, 260.

Nerves (see various regions).
, Division of (see vai-io'is

trunks).
of the spinal cord, their

points of exit, 511.
Neuralgia, Facial, 11, 85.
Nipple in groin, 39 1 .

of the female breast, 154.

Nose, 70.

, Cartilaginous part of, 72.

— — , Nerve supply of, 79.

, Outer wall of, 76.

Notch of Eivini, 66.

Obturator hernia, 288.

nerve, Paralysis of the, 49*.

or thyroid dislocation, 409.

Occipital bone at birth, 15.

, Necrosis of, causing

wasting of tongue, 106.
Occipko-frontalis, Suppuration

under, 5.

(Edema of the glottis, 132.
(Esophagostomy, 141.
(Esophagotomy, 141.
(Esophagus, 159.
Olecranon, 212.

, Fractures of the, 224.

Omental sac, 297.

Omentum, Great, 297.

Omo-hyoid muscle, 120.

Onychia, 2i3.

Onyx, 40.

Ophthalmia, Sympathetic, 49.

Optic disc, 50.

neuritis, 51.

thalamus, 30.

Ora serrata, 50.

Orbicularis palpebrarum, 55.

Orbit, 33.

INDEX.

527

Orbit, Fasciae of, 35.

• , Fracture of, 34.

— , Pulsating tumours of, 37.
Orbital abscess, 36.

arteries, 37.

cavity, Bones of the, 34,

ecchymosis, 87.

— fat, Foreign bodies in, 36.
nerves, 37.

walls, 34.

Os calcis, Dislocations of the, 481.

, Fractures of the, 487.

, Tuberosity of, 461.

— epactal, 16.

— incisivum in hare-lip, 109.

— innominatum, 340.

— magnum, Dislocation of the,
253.

Otitis externa, 62.

Pacinian bodies in the hand, 241.

in the foot, 466.

Palate, 108.

, Cleft of, 109.

, Hard, 110.

, in idiots, 109.

, Soft, 111.

Palmar (see Hand).

Palmaris longus tendon, 235.

Pancreas, 325.

Puunus, 41.

Paracentesis of the pericardium,

160.

of thorax, 151.

of tympanum, 66.

of ventricles of brain, 13.

Paralysis in spinal injuries, 509,

513, 514, 515.

of anterior crural nerve, 493.

• of cervical sympathetic, 39.

— of external popliteal nerve,
496.

of great sciatic nerve, 496.

— of internal popliteal nerve,496.
of median nerve, 260.

— of musculo-spiral nerve, 258.

— of obturator nerve, 494.
of orbital nerves, 38.

— of ulnar nerve, 260.
Parietal fissures, 16, 17.
Parieto-occipital fissure, 29.
Paronychia, 243.

Parotid abscess, 88.

fascia, 88.

gland, 88.

— , Structures in, 90.

region, 87.

tumour, 91.

Patella, 424, 442.

Patella dislocation, 444.

r fractures, 442.

Patellar ligament, 425, 437, 444.
Pelvic arch, 335.

cellulitis, 342.

fascia, 341.

symphysis, 338.

Pelvis, 334.

, Floor of the, 341.

, Fractures of, 337.

— , Mechanism of, c34.
Penile urethra, 364.
Penis, 365.

Perforating ulcer, 466.
Pericranium, 4.
Perineal hernia, 289.

vessels and nerves, 317.

Perinephritic abscess, 328.
Perineum, Depth of, 346.

, Fasciae of, 348.

, male, 344.

Peritoneum, 295.
Perifcyphlitis, 311.
Peroneal artery, 451.

tubercle, 462.

Peroneus tertius, 463.
Petit's triangle, 264.
Phantom tumour, 270.
Pharynx, 112.

, Foreign bodies in, 113.

, Mucous membrane of, 114.

, Relations of, 114.

Phlebolithes, 361.

Photophobia, 48.

Phrenic nerve, 122, 332.

Pigeon breast, 147.

Piles, 376.

Pinna, 59.

Pirogoffs amputation, 491.

Plantar (see Foot).

Plantaris tendon, Kupture of, 453.

Plaques des fumeurs, 105.

Platysma myoides, 122.

Pleura, 155.

Pneumatocele, 68.

Pneumo -thorax, 156.

Politzer's method of inflating the

middle ear, 68.
Pollock's method of dividing the

muscles of the palate, 112.
Polypi of nose, 71.
Popliteal abscess, 430.

artery, 426, 431, 451.

bursse, 433.

— — fascia, 430.

glands, 427, 433.

nerves, 426, 427, 496.

space, 425, 429.

vein, 432.

528

SURGICAL APPLIED ANATOMY.

^Pott's fracture, 477.

•/Poulticing the loin in nephritis,

334.
Profunda arteries in arm, 203.

femoris, 390.

Prolapsus ani, 373.
Pronator radii teres, 210.
Prostate, 349, 359.

, Abscess of, 360.

— , Hypertrophy of, 360.
Prostatic plexus of veins, 361.
Psoas abscess, 293.

muscle, 290, 392.

Pterion, 12, 29.
Ptosis, 38.
Pubic spine, 263.
Pudendal hernia, 289 372.
Pudic vessels and nerves, 346.
Pulmonary apoplexy, 157.

artery, 158.

Pun eta lachrymalia, 58.
Puncturing the bladder per rec-
tum, 355.
Pylorus, 299.
, Eesection of the, 303.

Eachitic nail, 243.
Eadial artery, 228.

nerve, strength of the, 387.

vein in venesection, 215.

Eadius, Dislocations of the, 220,

222.

, FracttTres of the, 225, 232,252.

Eanula, 102.
Eectocele, 372.
Eecto-vaginal fistula, 372.
Eectum, Adult, 373.

, Attachments of the, 375.

, Effects of distension of, 374.

, Foreign bodies in, 374.

• , Infant, 373.

introduction of handinto,374.

Mucous membrane of the,

375.

, Serous membrane of the, 373.

, Vessels of, 376.

Eectus abdominis muscle, 270.

femoris, 417.

Eesection of the small intestine,

310.

Eesections (see the various parts).
Eespiration in fracture of the

spine, 513.
Eetina, 50.

Ehinolithes in the nose, 77.
Ehinoplasty, 9, 204.
Ehinoscopy, Posterior, 74.
Eibs, 149.
, Fractures of. 149.

Eickets, Effect of, on pelvis, 336.

, , on the ribs, 151.

, , on the skull, 13.

, , on tibia, 459.

Eider's bone, 393.
- — sprains, 393.
Eight auricle, 159.
Eima glottidis, 119, 132.
Eouge's operation, 73.

Sacculated bladder, 358.
Sacro-coccygeal joint, 340.

iliac synchondrosis, 335, 339.

Sacrum, 335.

, Dislocation of the, 339.

Sagittal fontanelle, 16, 17.
Salivary fistulas, 92.
Saphenous opening-, 390.

veins, 418, 426, 433, 452, 454.

Sarrorius muscle, 389, 392, 420.
Scalene muscles, 120, 123.
Scalp, Dangerous area of, 2.

, its mobility, 3.

, Suppuration in the, 6.

, Vascularity of the, 4.

wounds, 3.

Scaphoid bone, Dislocation of the,
488.

tubercle, 237, 461.

Scapula, 164, 178.

, Fractures of, 179.

, Eernoval of, 180:

Scarpa's triangle, 388.

Fascia of, 391.

Glands of, 394.

Vessels of, 393.
Sciatic nerve, Great, 386.

, Course of the, 382.

, Paralysis of the.

4yt>.

, , Strength of the,

387.

Sciatica, 386.
Sclerotic, 42.

Scrofula, Sign of, in pinna, 60.
Scrofulous pharyngitis, 114.
Scrotum, 366.

and elephantiasis, 367.

and oedema, 367.

, Application of leeches to the.

367.
, Subcutaneous tissue of the,

367.
Semilunar cartilages of knee,

Dislocation of the, 439.
Semi-membranous tendon,426,430.
Septum crurale, 286.
Shortening of the limb in hip dis

ease, 401, 403.

INDEX.

529

Shoulder, Bursse about, 190.

— , Dislocations of the, 193.

— , Fractures about the, 199.

joint, 189.

Amputation at the.

201.

, Disease of the, 191.

tip pain from liver ailments,

332.

Sigaultean operation, 338.
Sigmoid flexure, 313.
Sinuses of skull, 80.
Skull, 12.
. — , Abnormalities of, 16.

, Deformities of, 18.

, Development of the, 14.

— , Fractures of, 17, 21, 22.

— , Necrosis of, 17.

— , Sutures of, 14.

, Thickness of, 24.

, Trephining the, 8.

Socia parotidis, 92.
Soft palate, 111.
Solar plexus, 331.
Soleus, 451.

Spaces in the fasciae of the palm,
24*.

of fontana, 51.

Spasmodic stricture, 363.
Spermatic artery, 370.
— — cord, 370.

plexus of veins, 370.

Spina bifida, 340.

Spinal accessory nerve, 122.

— cord, Concussion of, 508.
, Contusion and crushing

of, 509.

, Length of the, 505.

, Loss of motion due to

injury of the, 513.
, of sensation due to

injury of the, 513.

, Protection of the, 501.

, Wounds of, 507.

injuries and defaecation, 514.

and micturition, 514.

and respiration, 513.

and vomiting, 515.

meninges, 508.

meningitis, 507.

nerves, Points of origin of,

512.

Spine, 497.
, Curves of, 497.

— fractures and dislocations,
500.

, Fractures of, 497.

, Sprains of, 499.

, Trephining the, 505.

I I

Spinous process of the vertebra
proniinens, 118.

processes, Breaking the,

504.

Sphincter ani, 346, 376.
Spiny-foot, 485.
Spleen, 322.

, Capsule of the, 324.

, Enlarged, 324.

, Extirpation of the, 324.

, Injuries to the, 322.

, Relations of, 322.

, Eupture of, 323.

Stenson's duct, 91.
Sterno-clavicular joint, 172.

, Disease of the, 174.

, Dislocations of the,

175.
, Movements of, 173.

-mastoid, Congenital tu-
mour of, 124.

muscle, 120, 123.

f Dividing the, 126.

xiphoid joint, 148.

Sternum, 148.

, Fractures of, 148.

, Holes in, 149.

, Operations on the, 149.

, Separation of segments of,

148.

, Trephining the, 149.

Stomach, 298.

, Fistulas of, 301.

, Foreign bodies in the,

302.
, its proximity to the heart,

299.
, its relation to the abdominal

wall, 299.

, Eelations of, 298.

, Vertical, 301.

, Wounds of the, 301.

Strabismus, 36, 39.

Stye, 56.

Subarachnoid spice, 27, 507.

Subastrago'oid dislocations of the

foot, 482.
Subclavian artery, 121.

vein, 121.

Subclavicular fossa, 164.
Subclavius muscle, 167.
Subconjunctival haemorrhage, 56.
Subdural space, 26, 27, 507.
Sublingual bursa mucosa, 103.
Subserous connective tissue of the

abdomen, 271.
Superior maxilla, 92.

, Excision of the, 93.

, Fractures of, 92.

530

SURGICAL APPLIED ANATOMY.

Superior maxilla, Necrosis of, 9.'{.

thyroid artery, 120.

vena cava, 159.

Supinator longus, 210, -27.
Supraclavicular artery, 121.

nerves, 166.

SupraorMtal foramen, 86.
Suprarenal artery, 265.
Surgical emphysema, 156.
Susteutaculum tali, 461.

, Fracture of, 487.

Sycosis, 56.

Sylvian fissure, 29.

Symblepharon, 57.

Syme's amputation at the ankle,

490.

Sympathetic ophthalmia, 49.
Synechise, 44.
Synostosis of skull, 19.
Synovial cavities of the foot, 489.
sacs and sheaths in the hand,

247.
Synovitis, Acute, in the hip joint,

398.

, , in the knee, 439.

Sweat glands in the skin of the

hand, 241.

Tabatiere anatomique, 240.
Tagliacozzi's operation, 204.
Talipes calcaneus, 484.

cavus, 467.

equinus, 483.

and the plantar fascia,

467.
, mixed or secondary forms,

485.

valgus, 484.

varus, 484.

Tapping antrum, 81.
Tarsal bones, Fractures and dis-
locations of, 487.
cartilage, 55.

— cyst, 56.
Tarsus (see Foot).
Taxis, Reducing an inguinal hernia

by, 285, 288.
Teale's operation for symble-

pharon, 56.
Temporal abscess, 8;

fascia, 7.

, Wound of simulating

fracture, 8.

fossa, 7.

Temporo-maxillary articulation,

96.

, Dislocations at, 97.

, Fractures at, 96.

sphenoidal lobe, 30.

Tendo AcL His, 453, 4C3, 469.

oculi, 58.

Tenotomyand theperoneal nerve,
431.

of hamstrings, 431.

of sterno-mastoid, 126.

Tensor palati, 111.

Testicle, 368.

Testis in the foetus, 282.

, Investments of, 3t>8.

Thecal abscess, 248.
1 henar eminence, 237.
Thickness of the skull cap, 24.
Thigh, 417.

Amputation of the, 424.

Fasciae of, 419.

Fractures of, 421.

Integuments of, 418.

Muscles of, 419.

Surface anatomy of, 417.

Thoracic duct, 334.

viscera, 155.

walls, 147.

Thorax, 147.

Thumb, Amputation of the, 258.

, Dislocation of, 256.

Thymus, 136.
Thyroid body, 119, 138.

, Division of isthmus of

138.

in tracheotomy, 136.

cartilage, 119, 132.

Thyroidea ima artery, 136.
Tibia and fibula fractures, 456.

, Anterior border of the, 450.

fractures, 447, 458.

in rickets, 459.

shaft, its strength, 456.

Tibial arteries, 451, 471.
Tibialis anticus muscle, 451.
Tongue, 104.

, Blood supply of, 108.

, Epithelium of, 105.

, Excision of, 108.

, Mucous cysts of, 105.

, Nerv^e supply of, 106.

tie, 105.

Tonsil, 115.

, Bleeding from, 117.

— , Foreign body in, 117.

, Hypertrophy of, 116.

, , and deafness, 116.

Tophi, 60.

Trachea, 119, 131, 157.

, Foreign bodies in, 137.

Tracheotomy, 133, 136.

tubes, 134.

Trans versalis fascia, 290, 315.
Transverse arch of the foot, 480.

INDEX.

53*

Transverse cervical artery, 121 .

colon, 310, 313.

process uf the atlas, 118.

of cervical vertebra, 118.

Trapezium, 240.

— ridge, 237.
Trephining, 8.

Triangular ligament of the

urethra, 341, 349.
Trigone, 355, 357.
Trismus, 100.
Tubera ischii, 335, 381.
Tubercle for the adductor magnus,

425.

— of the tibia, 425.
Tubercular nail, 243.
Tumours in the orbit, 34, 35.
Tunica abdominalis, 266.
albuginea, 369.

— vaginalis, 282, 369.
Tympanum, 67.

.Ulna, Dislocation of the, 220.

— , Fractures of the, 231, X33.
U Inar artery, 228.

nerve, 204, 216.

, Paralysis of the, 260.

, Strength of, 387.

vein in venesection, 215.

Umbilical hernia, 269, 289.
Umbilicus, Fibrous ring of the,
268.

, Position of the, 263.

Urachus, 269.
Ureters, 330.

and regu) gitation of urine,

358.

, Distension of, 330.

, Riipture of, 331 .

Urethra, Female, 365.

, Male, 361

, , Curve of, 361.

, Membranous, 363.

, Mucous membrane of, 364.

, Narrowest parts of the,

364.

— t Penile, 364.
— , Prostatic, 363.

, Rupture of the, 365.

Urethral tr'angle, 344, 347.
Uterus, Impregnated, 372.

Vagina, 372.

Vaginal cystocele, 372.

Valsalva's method of inflating the

middle ear, 68.
Valvulse conniventes, 306.
Varicocele, 371.
Varicose veins, 454.
Vas deferens, 370.
Vastus internus muscle, 417.
Veins (see various parts).

, Air in, 143, 185.

Venesection in the foot, 472.

on the arm, 214.

Vermiform appendix, 312.
Vertebral artery and articulation,

144.

and neuralgia, 144.

, Ligaturing the, 144.

column, 497.

Vesico-vaginal fistula, 359, 372.
Vitello-intestinal duct, 308.
Vitreous humour, 52.
Volvulus of the signaoid flexure,

313
Vulva, 372.

Wardrop's operation in the neck,

143.

Wax in ear, 62, 64.
Weaver's bottom, 385.
Wharton's duct, 102.
White line at anus, 376.

in tl,e pelvic fascia, 341.

Whitlow, 248.
Wrist, 235.

joint, 237, 251.

, Amputations at, 257.

, Dislocations at, 255.

, Fractures about, 252.

, Movements at, 251.

, Strength of the, 251.

, Surface anatomy of the, 235

Wry- neck, 124.

Zygoma, Fracture of, 9.

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