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SURGICAL

Applied Anatomy

BY

SIR FREDERICK TREVES

K.C.V.O., C.B., F.R.C.S.

SERGEANT SURGEON TO H.M. THE KING

SURGEON IN ORDINARY TO H.R.H. THE DUKE OP CORNWALL AND YORK

CONSULTING SURGEON TO THE LONDON HOSPITAL

LATE LECTURER ON ANATOMY AT THE LONDON HOSPITAL

N E W E D IT ION, REVISED BY T II E A V THO R

WITH THE ASSISTANCE OF

ARTHUR KEITH, M.D., F.R.C.S.

LECTURER ON AND SENIOR DEMONSTRATOR OF ANATOMY AT THE
LONDON HOSPITAL

PHILADELPHIA

LEA BROTHERS & CO.

7^

io\

PREFACE TO THE PRESENT EDITION.

In the present edition the work has been carefully
revised throughout ; certain sections have been re-
written, and much new matter has been added. Every
effort has been made to bring each chapter of the book
well up to date. Many new woodcuts have been added
or have replaced the illustrations used in previous
editions.

F. T.
A. K.

London Hospital,
May, 1901.

PREFACE TO THE FIRST EDITION.

Ai'J'lied Anatomy has, 1 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 experiments in
Physics bears to a treatise dealing with the bare data
of that science.

The student of Human Anatomy has often a nebul< rus
notion that what he is learning will sometime prove
of service to him ; and may be conscious also that the
study is a valuable, if somewhat unexciting, mental
exercise. Beyond these impressions he must regard
his efforts as concerned merely in the accumulation
of a number of hard unassimilable facts. It should be
one object of Applied Anatomy to invest these facts
with the interest derived from an association 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 com-
petency 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.

x Preface.

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 " Best and Pain."

I have assumed that the reader has some knowledge
of Human Anatomy, and have not entered, except in a
few instances, into any detailed anatomical descriptions.
The bare accounts, for example, of the regions .con-
cerned in Hernia I have left to the systematic 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, abnormalities, 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 ana-
tomical 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.

Frederick Treves.
Sept., 1883.

CONTENTS

PART L— THE HEAD AND NECK.

CHAPTER

I. — The Scalp ......

II. — The Bony Vault of the Cranium
III. — The Cranial Contents
IV. — The Orbit and Eye

V— The Ear

VI.— The Nose and Nasal Cavities .

VII.— The Face

VIII.— The Mouth, Tongue, Palate, and Pharynx
IX.— The Neck

PART II.

X.— The Thorax

PAGE
1

15

28
41
08
81
95
117
135

168

PART III. -THE UPPER EXTREMITY.

XL— The Region of the Shoulder .... 185
XII.— The Arm 223

XI I

Surgical Applied Anatomy.

CHAPTER

XIII. — The Region of the Elbow
XIV.— The Fore- arm
XV. — The Wrist and Hand .

PAGE

230
24fi
253

PART IV.— THE ABDOMEN AND PELVIS.

XVI.— The Abdomen 282

XVII. — The Abdominal Viscera 31H

XVIII.— The Pelvis and Perineum 372

PART V.— THE LOWER EXTREMITY
XIX.— The Region of the Hif

XX.— The Thigh

XXL— The Region of the Knee .

XXII.— The Leg

XXIII. —The Ankle and Foot .

423

458
4G5
489
500

PART VI.

XXIV.— The Spine
Index

537
557

(Surgical Applied Anatomy
tart ft.

The Head a n d X'eck.

CHAPTER 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
adherent, by means of the subcutaneous tissue, to the
aponeurosis and muscle beneath it, and, from this
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 (Fig. 1, b). 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

2 Surgical Applied Anatomy. [Chap. i.

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

Fig, 1. — Diagram showing the Layers of the Scalp and Membranes of
the Brain in Section.

a, Skin ; b, subcutaneous tissue with hair roots and vessels; c, epicranium
a, sub-aponeurotic layer ; e, pericranium ; '/, parietal ; g, dura mater ; /.•, arach-
noid ; l; pia mater ; m, cortex ; n, in subdural space near a Pacchionian body
projecting within the superior longitudinal sinus.

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 nover the bony vault save in the subcutaneous

Chap, i.] The Scalp. 3

liver, 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. For the same reasons fatty
tumours of the scalp arc very rare. The attachment
of the hairs collectively to the scalp is so strong that
there are many cases where the entire weight of the
body has been supported by the hair of the scalp.
Agnew records 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 whs
torn off from the skull. The patient recovered. I
have seen a precisely similar case in a girl aged 1.3.
(Museum, R. Coll. Surgeons, 87 F.)

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
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.

The exposure of the skull in a post-mortem exami-
nation is effected by peeling off the seal]) along
this layer of loose tissue, and it is remarkable with
what ease the skull can be exposed by this manoeuvre.
Sutures may be safely applied to adjust scalp
wounds, provided they are not too long retained.
They probably include the aponeurosis, and if long
retained may act as setons and set up suppuration,
which may find its way into the loose layer beneath
the aponeurosis.

4 Surgical Applied Anatomy. [Chap. i.

Wounds of the scalp never gape, unless
the wound lias 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 wounds. 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 cleanly 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 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 practic-
ally 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

Chap, i.] The Scalp. 5

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.

For the same reason it is almost impossible to pick
up an artery divided in a scalp wound. The bleeding
is checked by a hare-lip pin or by pressure.

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 vascularity,
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 produced, as in a case
I saw, where the tissues over the frontal and occipital
regions sloughed from the continued 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
(Fig. 1, e). 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 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 super-
ficial 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

6 Surgical Applied Anatomy. [Chap. i.

disposition of the pericranium is also well illustrated
by its action in cases of necrosis of the cranial bones.
In necrosis of a long bone, the separation of the seques-
trum 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 cir-
cumstances is frequently illustrated.

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 way
between the aponeurosis and the pericranium. Sup-
puration 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 attach-
ments 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

Chap, i] The Scalp. 7

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.

Haematoiiiata, or blood tumours of the
scalp region, occur in the same localities as abscess.
The extravasation of blood above the aponeurosis must
be of a limited character, while that beneath it may
be very extensive. It fortunately happens, however,
that the cellular tissue between the aponeurosis and
the pericranium contains but very few vessels, and
hence large extravasations in this tissue are uncommon.

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 parts of the scalp. There is a
good deal of fat in the temporal fossa, and when this

8 Surgical Applied Anatomy. [Chap. i.

is absorbed it leads to more or less prominence of tlie
zygoma and malar bone, and so produces the projecting
" 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 on the frontal and parietal 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
of several lines in length was found loose at the bottom
of the wound, and was removed. After its removal
the ringer 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 compound fracture of the squamous bone, with
separation of a fragment and exposure of the brain.
A bystander, 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.

Trephining?.— This operation is frequently per-
formed in the temporal region, its object being to reach
extravasations of blood from the middle meningeal
artery. This artery crosses the anterior inferior angle

Chap. I.]

The Scalp.

of the parietal bone at a point \1> inches behind the
external angular process of the frontal bone, and If
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

D

Fia\ ?. -Points for Tve 'limine-.

a, v.. Spots for trephining in middle meningeal haemorrhage : c, spot for trephin-
ing in abscess of the temporo-sphenoidal lobe: d, mastoid foramen. (.After
Nancrede.)

epicranial aponeurosis ; (4) the temporal fascia ; (5) the
temporal muscle ; (6) the deep temporal vessels ; and
(7) the pericranium.

Trephining for meningeal hcemorrfiage. — Unless
localising symptoms give other indications, Kronlein
advises that the trephine holes in cases of meningeal
haemorrhage be determined as follows : — A line is drawn
around the skull at the level of the upper margin of the
orbit, and is throughout parallel with Reid's base-line,
Fig. 2. (See also page 35.) The trephine is first placed
at a point on this line, which is from l\ to 1| inches

io Surgical Applied Anatomy. [Chap. i.

(according to age and size of head) behind the external
angular process of the frontal bone (Fig. 2, a). Should
no clot be revealed, a second hole is made upon the same
line, just below the parietal eminence, and at a point
where a vertical line carried up from the posterior border
of the mastoid process bisects the line already given
(Fig. 2, b). The anterior branch of the middle menin-
geal artery is exposed at the first point, and the posterior
branch at the second.

Trephining for intracranial abscess. — The abscess
is often due to middle-ear disease, and is then very com-
monly found in the temporo-sphenoidal lobe or in the
cerebellum. It is estimated to be threee times more
common in the cerebrum than in the cerebellum.

The abscess of the temporo-sphenoidallobe is usually
found, according to Mr. Barker, between two lines
drawn at right angles to Keid's base-line. These lines
are about 1 \ inches apart ; one passes through the
meatus, the other about \\ inches behind that opening
(Fig. 2, xx). The trephine should be introduced in the
centre of the space marked out by these two lines, and
at a distance of about \\ inches above the base-line
(Fig. 2, c).

In dealing with an abscess of the cerebellum, the
best spot to select is, in the adult, \\ inches behind
the centre of the meatus and a quarter of an inch below
the base-line (Fig. 3, d).

In some cases it is impossible to say if the abscess
is situated in the temporo-sphenoidal lobe or cerebellum.
In such cases Mr. Dean trephines at a point which lies
\\ inches behind and a quarter of an inch above the
centre of the meatus. The lateral sinus is thus exposed
with a part of the dura mater above the tentorium
cerebelli, through which the temporo-sphenoidal lobe
may be explored. By extending the trephine opening
half an inch downwards the cerebellum may be examined.

Trephining for cerebral tumour. — The position of
the opening in the skull is obviously determined by
the localising symptoms. It is remarkable that little
trouble from haemorrhage has attended these operations.

Chap. I.J

The Scalp.

ii

In any ease, after trephining, the portion or portions
of bone removed may — if properly treated — be replaced
in the opening, and will serve to make good the gap
left by the operation.

In trephining the skull generally, the comparative
thickness of the cranial wall in various parts should
be borne in mind (page 28), and the large arteries of

Fig. 3.— Posterior part of Skull showing Points for Trephining.
{After Dean.)

rr, Reid's base line ; a, mental point (central point of external auditory meatus) ;
b. over sigmoid smus(|" behind mental point) ; c, over lateral sinus (1" behind
and \" above mental point); d, over cerebellum (lj" behind and J" below
nuatal point); B, supra-meatal triangle, over mastoidal antrum ; f, point
for tapping lateral ventricle di" above nieatalpoint) ; a l, meato-lambdoidal
line— the second inch of this line lies over the convexity of the lateral sinus.

the scalp should be avoided if possible. In order to
accommodate the instrument to the varying thickness
of the skull, the pin of the trephine is not allowed to
protrude more than t^th of an inch. 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. The
bone, moreover, at certain of these lines is of unequal
thickness. Between the bones forming the sutures

12 Surgical Applied Anatomy. [Chap. I.

passes the sutural membrane. This structure blends
with the dura mater, and laceration of it may conduce
to meningitis. Especially must the superior longitud-
inal sinus be avoided, which runs backwards in the
middle line, and terminates at, or slightly above, the
external occipital protuberance. Lateral lacuna? of this
sinus may be encountered over an inch distant from
the middle line. The lateral sinus begins at the external
occipital protuberance, passes forwards and slightly
upwards and then bends downwards to groove the
mastoid three quarters of an inch behind the external
auditory meatus. In its passage forwards it rises
half an inch above the level of the meatus. If a line be
drawn from the meatal point to the lambda, it will be
found that the second inch of this line, counting from
the meatus, lies over the convexity of the lateral sinus
{see Fig. 3). •

The zjgoma may be broken by direct or indirect
violence. In the latter case the violence is such as
tends to thrust the upper jaw or malar bone backwards.
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 temporal artery,
with the auriculo-temporal nerve behind it, crosses
the base of the zygoma just in front of the ear. The
vessel divides into its two terminal branches (the an-
terior and posterior) 2 inches above the zygoma. The
branches of this artery, especially the anterior branch,
are often very tortuous in the aged, and afford early
evidence of arterial degeneration. Arteriotomy is some-

chap, i.] The Scalp. 13

times 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 be-
tween the occipital protuberance and the mastoid process.

Certain of the emissary veins are of great import-
ance in surgery. These veins pass through apertures
in the cranial wall, and establish communications be-
tween 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 connecting
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 answer 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 condylar foramen (incon-
stant). 4. Minute veins following the twelfth 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 pterygoid venous plexus, the pharnygeal 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.

14 Surgical Applied Anatomy. [Chap i.

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 super-
ior 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. Mis-
chief may even spread from within outwards along an
emissary vein. Erichsen reports a case where the
lateral sinus was exposed in a compound fracture. The
aperture was plugged. Thrombosis and suppuration
within the sinus followed, and some of the pus, escaping
through the mastoid vein, led to an abscess in the
neck.

Certain venous tumours are met with on the skull.
They consist of collections of venous blood under the
pericranium that communicate, through holes in the
skull, with the superior longitudinal sinus. They are
median, are reducible on pressure, and receive a faint
pulsation from the brain. The holes are sometimes
the result of accident, others depend upon bone disease
or atrophy about a Pacchionian body, and a few are
due to a varicose emissary vein or to a congenital defect
in the cranium.

The scalp nerves, especially such as are branches
of the fifth pair, are often the seat of neuralgia. 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 nerve has been resected
(neurectomy) in the same situation.

Chap, ii.] Bony Vault of the Cranium. 15

Some forms of frontal headache depend upon
neuralgia of this nerve. The inner branch of the nerve
reaches the middle of the parietal bone ; the outer
branch, the lambdoid suture.

The lymphatics from the occipital and posterior
parietal regions of the scalp enter the occipital 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 submaxillary glands (Fig. 21).

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 a point jugi:
in front of 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 represented
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 zygomatic arch. On this line,
at a spot about on a level with the external angular
process of the frontal bone, and about 1^ inches behind
that process, is the pterion, the region where four bones
meet, viz. the squamous bone, the great wing of the
sphenoid, the frontal and parietal bones. The summit
of the squamous suture is If inches above the zygoma.

In the normal subject all traces of the fontanel les
and other unossified parts of the skull disappear before
the age of two years. The anterior fontanelle is the
last to close, while the posterior is already filled at the
time of birth. It is through or about the anterior
fontanelle that the ventricles are usually aspirated

1 6 Surgical Applied Anatomy. [Chap. ii.

in cases of hydrocephalus. The needle is entered either
at the sides 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-tafoes, a condition
'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 adjacent parts of the parietal
•bones, but especially in the posterior inferior angles
of these bones. In this condition the bone is greatly
thinned in spots, and its tissue so reduced that the
affected district feels to the finger as if occupied by
parchment, or, as some suggest, by cartridge paper.
The thinning is mainly at the expense of the inner
table and diploe. The pits are situated in early formed
convolution impressions. 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 represented 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 resem
blance, 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
the skill i in order to render intelligible certain
conditions (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

Chap, ii.] Bony Vault of the Cranium-.

17

and parietal bones, the squamo-zygomatie 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 in a menagerie, and that, in con-
sequence 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 remarkable to note
that these changes are limited to such parts of the skull
as are formed in membrane, the base remaining free.

Among the more common of the gross malformations
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 protruded brain is dis-
tended by an accumulation of fluid
within the ventricles, it is called
hydrencephalocele. These protru-
sions are most often met with in
the occipital bone, and next in fre-
quency 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

Fig. 4.— The Occpital
Bona at Birth.

1 8 Surgical Applied Anatomy. [Chap. n.

{see Fig. 4), 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 the four angles of the
bone to meet at the occipital protuberance. The gap
running up in the median line from the inferior angle
at the foramen magnum to the occipital protuberance

Fig. 5 —Back View of Abnormal Skulls, showing Occipital and

Parietal Bones.

a, The " os epactal " ; n, parietal Assures ; c, the sagittal fontanelle.

is especially distinct (the temporary occipital fontanelle
of Sutton). It exists from the beginning of the third
to the end of the fourth month of intrauterine life.
Meningoceles of the occiput are always in the middle
line, and the protrusion probably occurs through this
gap. The gap associated with meningocele may extend
through the whole vertical length of the occipital bone,
and very commonly opens up the foramen magnum.
The lateral or transverse fissures divide the bone into
two parts. The upper part is developed from membrane,

chap, ii.] Bony Vault of the Cranium. 19

the lower part from cartilage. The 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 ns epactal of the French (Fig. 5, a), the
interparietal bone of some animals.

Parietal fissures.— In the developing parietal
bone, fibres concerned in ossification radiate towards the
periphery from two nuclei about the centre of the 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. 5, b). If
the fissure persists equally on the two sides an elong-
ated lozenge-shaped gap is left, the sagittal fontaneUe.
It is situate about an inch in front of the lambda, and
occurs in over 4 per cent, of newly born children (Lea)
(Fig. 5, c). The parietal foramina are remains of this
interval.

Wormian bones. -These irregular bones may
be mistaken for fragments produced by fracture. They
are most usually met with in the lambdoid suture.
One Wormian bone deserves special notice, as it may
be met with in trephining over the middle meningeal
artery. It exists between the anterior inferior angle
of the parietal bone and the great wing of the sphenoid.
It is scale-like, and gives the impression that the tip of
the great wing had been separated. It is known as
the epipteric bone.

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

20 Surgical Applied Anatomy. [Ghap. 11.

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 Saviard, 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. (See page 5.)

Necrosis of the skull, as well as caries of the part,
is attended by certain special dangers that depend
upon the anatomical relations of the cranial bones.

Thus, when the whole thickness of the skull is
involved by disease, or when the inner table is
especially attacked, a collection of pus may form
between the dura mater and the affected bone, and
may produce compression of the brain. When the
diploic tissue is implicated, the veins of that part may
become thrombosed, or m?,y be the seat of a suppurative
phlebitis. The mischief thus commenced may spread,
the great intracranial sinuses may be closed by throm-
bus, or septic matter may be conveyed into the general
circulation and lead to the development of pyaemia.

Mere local extension may also cause meningitis.

In cases of necrosis of the external table the growth
of granulation tissue from the exposed and vascular
diploe plays a very important part in aiding the exfolia-
tion of the lamella of dead bone.

When bone disease leads to perforation of the skull,
the pulsations of the brain may be visible through the
abnormal opening.

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

Chap, ii.] Boxy Vault of the Cranium. 21

skull of an infant is to that of an old man as a
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 breaking
ability of the cranial bones derived from the study
of the dried specimens 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 dis-
appointed 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 consciousness, and recovered without a symptom.

The following anatomical conditions tend to minimise
the effects of violence as applied to the skull : The density
of the scalp and its great mobility ; the dome-like

22 Surgical Applied Anatomy. [Chap. n.

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 membrane, which acts as a kind
of linear buffer ; the mobility of the head upon the
spine ; and the elasticity of the cranial bones themselves.

The skull is further strengthened by the presence
of six buttresses or pillars at the junction of the vault
and base. Two of these are lateral, the orbito-sphenoid
anteriorly and the petro-mastoid posteriorly, while the
fronto-nasal and occipital strengthen the anterior and
posterior ends of the skull.

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, then in the
coronal and lambdoid, 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"Mriven
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 splintering than does^the
external. There are many reasons for this. The\in-

chap, ii.] Boxy Vault of the Cranium. 23

ternal 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 external plate ; and,

lastly, Agne w assigns a reason for the greater vulner-
ability of the inner plate that has reference to the general
yielding of the bone. In Fig. 6 a b represents a section
of a part of the vault through both tables, and c d and
two vertical and parallel lines. Now, if force be

EF

applied to the vault between these parallel lines, the
ends of the arch, ab, will tend to become separated.

.24 Surgical Applied Anatomy [Chap. if.

: and the whole arch, yielding, will tend to assume the
i curve shown in Fig. 7. In such case, the lines c d
.and ef will converge above and diverge below (Fig. 7),
: so that the violence would tend to force the bone 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
ibones inwards. Such driving in of these borders must
ibe associated with a corresponding outward movement
< of the inferior borders. This latter movement is forcibly
i resisted by the squamous bone and the great wing of
the sphenoid, which overlap 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
bone. 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, be-
cause 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 dis-
tinctly provided for, and it must be owned that a by
no means heavy fall is sufficient to break this bone.

Chap, ii.] Bony Vault of the Cranium. 25

It must receive, however, much protection from its
connections with the two parietal and temporal hones,
and from its articulation with the elastic vertehral
column.

Fractures of the !>asc 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 super-
imposed part of the brain. When the body in falling
has alighted upon the feet, knees, or buttocks, the force
has been transmitted 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 sugges-
tion. Such a case was recorded by Mr. 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 uninjured. (3) Fractures of the
vault, and especially linear fractures due to such diffused

26 Surgical Applied Anatomy. [Chap. ii.

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, P. Hewett has divided the skull into three
zones. The anterior zone included 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 \h& 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 meatus,
through a rupture in the tympanic membrane, and is
derived from the vessels of the tympanum and its mem-
brane, 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

chap, ii.] Bony Vault of the Cranium. 27

discharge "), (a) the fracture must have passed across
the internal auditory meatus ; (b) the tubular pro-
longation of the membranes in that meatus must have
been torn ; (c) there must be a communication between
the internal ear and the tympanum ; and (d) the
membrana tympani must have been lacerated. (3)
In fractures of the posterior fossa an extravasation of
blood may appear about the mastoid 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. After simple fracture
of the vault in children a swelling may form at the
injured part, which fluctuates, becomes tenser when
the patient cries, and may possibly pulsate synchronously
with the brain. Such swellings are due to a collection
of cerebro-spinal fluid beneath the scalp, and indicate
a coincident rupture of the brain membranes. 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. In a few instances it may
possibly be blood serum, or depend upon mild catarrh
of the meatus. Some authors assert that it may be
due to the escape of the liquor Cotunnii, but the very
minute quantity of that fluid in the ear renders the
suggestion improbable.

Separation of sutures.— This condition, as the
result of injury, is practically restricted to the young
skull. In later life, force applied at the site of an
obliterated suture may cause a fracture, which accu-
rately follows the old suture line. Separation of the
sutures, independent of fracture, is very rare in the
adult skull. In the few instances of such a condition
the temporal bone has usually been the one displaced
and the separation noted at the squamous suture. When
associated with fracture, the coronal and sagittal sutures
are those most frequently separated, and next in fre-
quency the lambdoid.

28 Surgical Applied Anatomy. [Chap, n.

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 process, 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 grooves for the meningeal
vessels. It is especially thin over the anterior inferior
angle of the parietal bone. It is important to remember
in trephining that the inner table is not always parallel
with the outer.

Craniectomy.— -This operation is carried out in
cases of microcephaly in infants and children. It con-
sists in the removal of a strip of bone from the vertex
of the skull so as to give to the brain, as an American
author expresses it, " more elbow room."

CHAPTER III,

THE CEANIAL CONTENTS.

The membranes of the brain.— The dura
mater, from its toughness, forms an excellent protection
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 hsemorrhagic and purulent
extravasations to collect between the dura mater and the
bone. S uch extravasations usually lead to compression of
the brain, and it may be noted that in the great majority
of all cases of compression the compressing force is out-
side the dura mater. Thus, in uncomplicated cases

Chap, in.] The Cranial Contents. 29

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
extravasated 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.

Sir C. Bell pointed out that the dura mater of the
vault may be separated from the bone by the vibration
produced by a blow. " Strike the skull of a subject
with a heavy mallet ; on dissecting you find the dura
mater to be shaken from the skull at the point struck.
Repeat the experiment on another subject, and inject
the head minutely with size injection, and you will
find a clot of injection lying betwixt the skull and dura
mater at the part struck, and having an exact resem-
blance to the coagulum found after violent blows on the
head." Tillaux has demonstrated that the adhesions
between the dura mater and the bone are particularly
weak in the temporal fossa?, the most usual site of
meningeal haemorrhage.

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
the source of the bleeding in twenty-seven instances
(P. HewTett). The vessel, having passed through the
foramen spinosum, divides into two branches ; the
anterior, the larger, runs upwards across the anterior
inferior angle of the parietal bone and ascends the vault
some distance behind the coronal suture ; the posterior
runs backwards, with a horizontal sweep across the
squamous bone, and takes the course of the second tem-
pjral convolution. (See page 9.)

Mr. Jacobson has shown that the branches of the
artery are more frequently ruptured than the trunk.
The vessel is very frequently torn as it crosses the an-
terior 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 embedded in the

30 Surgical Applied Anatomy. [Chap. in.

bone that fracture without laceration of the vessel would
hardly be possible ; and lastly, the particular region
of the artery is a part of the skull peculiarly liable to be
fractured. Mr. Jacobson shows that the artery may be
ruptured by a force that does not fracture the skull,
but merely leads to detachment of the dura mater.
{See page 29.) Failing this vessel, the most frequent
source of extra-meningeal haemorrhage 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 12), 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 be-
come thrombosed in cases of inflammation within the
orbit by the extension of the mischief along its great
tributaries, the two ophthalmic veins.

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
arachnoid" (Fig. 1, p. 2). According to Prescott Hewett,
extravasations 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 dis-
coloured, 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 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 peritoneal
sacs in preventing the effects of friction during the
movements of the brain.

The subarachnoid space is between the arach-
noid and the pia mater, and it is here that the chief

chap, in.] The Cranial Contents. 31

part of the cerebrospinal 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 sphenoid.
The posterior two-thirds of the brain rests, upon the
" water-bed," and is thus admirably protected.

It is well known that the brain may be damaged
by contre-coup. That is to say, if the head be struck
at one particular part, the brain may be found uninjured
at the spot struck, but damaged at a corresponding
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, and
were it not for the " water-bed," the under parts of the
cerebrum would be torn against the many projections
in the base of the skull. These projections, which are
so conspicuous in the dry skull, are moulded off in the
living by the dura mater, and also by the blood sinuses
which occupy the hollows about these projections, and
also certain margins of bone. As it is, the only part
that usually suffers is the under surface of the frontal
lobe (a comparatively unimportant segment), which,
being brought violently in contact with the irregular
orbital plate, is readily contused.

The subarachnoid space communicates with the
ventricles through the foramen of Majendie. This

o*

Surgical Atplied Anatomy. [Chap, ill

foramen leads into the fourth ventricle, and is an aper-
ture 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.
If the great nerve centres in the lateral ventricles are
swollen by congestion, they are not met by an unyielding
wall, but merely displace some of the cerebro-spinal
fluid through the foramen of Majendie, 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. The fluid also
drains into the veins of Galen, hence pressure on these
may bring about a like result. It has been proposed
to relieve the pressure within the lateral ventricles in
cases of hydrocephalus by draining the cerebro-spinal
fluid into the subdural space. It is absorbed at any
pressure above that within the cerebral veins (Hill). 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 subarachnoid 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 increased by expiratory efforts
when the nose and mouth were held closed, and the
veins compressed in the neck. The subarachnoid space
is most easily tapped by a lumbar puncture {see p. 548).

The surface relationships of the brain {see
Figs. 8 and 9). — The longitudinal fissure of the brain
is indicated by a line drawn along the vertex from
the glabella to the external occipital protuberance. It
is narrow in front, but as it contains the longitudinal
sinus, which rapidly enlarges as it passes backwards,

Chap, in.]

The Cranial Contents.

33

it becomes of considerable breadth behind, and as a
rule lies somewhat towards the right of the median
line, owing to the predominance of the left cerebral

ROLANDO

BR.

NASION.

inion.-X:-.-,

Fig. S. — Showing the Relation of the Brain and Sensori-niotor Areas of
Cortex to the Skull. {Modified from Quain.)

dr., Bregma— at the junction <>£ coronal and sagittal sutures ; la., lambda— at the
junction of lanibdoidal and sagittal sutures ; x. position of parietal eminence.
The sensori-niotor areas are shaded : the leg and trunk areas with vertical
lines; the arm and hand areas with lines slanting forwards; the face and
mouth areas with lines slanting backwards ; the tongue, pharynx, and larynx
areas are stippled. The motor centre for speech on Broca's convolution is
shaded with horizontal lines. The ''word-hearing" centre is indicated on the
superior temporal convolution, and that for the "word-seeing" centre on the
angular convolution. The area shaded with horizontal lines on the posterior
parts of the middle and inferior frontal convolutions is the centre for com-
bined movements of the head and eyes.

hemisphere. Between the external occipital pro-
tuberance and the ear, the lateral sinus bounds the
lower level of the cerebrum and the upper of the
cerebellum. A line drawn from the external occipital
protuberance to the upper margin of the external

34

Surgical Applied Anatomy. [Chap, in.

auditory meatus indicates fairly the position of the
sinus, yet it must be remembered that just behind the
ear its convexity passes above the level of this line. In
front of the ear the upper border of the zygoma in its
posterior two-thirds marks the lower border of the
temporal lobe. The pole of the temporal lobe is f of
an inch behind the outer margin of the orbit. On
the forehead a line drawn behind the external angular
process and above the eyebrows to the glabella indicates
the lower level of the frontal lobe.

• iOLANDO

MID POiN

BREGMA .

INION

Pig. 9.— Showing the Lines which indicate the Position of the Principal
Fissures of the Brain.

m.p., Meatal point— the centre of the external auditory meatus; iNioy, over
external occipital protuberance ; t,\m., lambda : p.o.f., parietooccipital
fissure; x on fronto-malar suture at external angular process ; n.s., lateral
siuus, crossing the posterior inferior angle of parietal. -.-(See also Fig. 3^P- 11.)

chap, in.] The Cranial Contents. 35

The cerebellum is best explored at a point \\ inches
behind and \ of an inch below the level of the external
auditory meatus {see Fig. 3, p. 11). It is deeply placed,
being covered by the insertions of the occipital muscles.

Of the many methods which have been suggested
for marking out the fissure of Rolando, the most
simple and accurate is the following : — A point over
the sagittal suture is taken midway between the glabella
and external occipital protuberance. Half an inch behind
the mid point terminates the upper end of the Fissure
{see Fig. 9). A line 3^ inches long drawn downwards
and forwards from this point, at an angle of 67° to the
line of the sagittal suture, will indicate the position of
the fissure of Rolando in the adult. In the child the
fissure is shorter and the contained angle is 5° smaller.
The angle is easily obtained by folding twice the corner
of a square piece of paper at, and removing a fourth of, the
right angle. This line may lie not exactly over the fissure,
for it varies somewhat in position according to the
shape of head. The sensori-motor areas of the brain
are mostly represented in the ascending frontal and
parietal convolutions which bound the fissure of Rolando.
The average width of each of these convolutions is f of
an inch. The coronal suture is about 2 inches in front
of the fissure of Rolando at its upper part and 1\
inches at its lower.

The fissure of Sylvius is indicated thus :—
A point is taken 1 \ inches behind and \ of an inch above
the most prominent point of the external angular
process {see Fig. 9). This point on the temple overlies
the anterior inferior angle of the parietal bone — the
pterion. The pterion marks the junction of the three
limbs of the fissure of Sylvius with its stem. A line
drawn backwards and upwards from the pterion to a
point f of an inch below the parietal eminence indicates
the situation^ of the posterior horizontal limb or ramus
(Fig. 9). This ramus is bounded below by the superior
temporal convolution, which contains in its middle third
the " word-hearing " centre (Fig. 8). Above, it is bounded
from before backwards by the basilar part of the inferior

$6 Surgical Applied Anatomy. [Cbap. in.

frontal convolution, the lower ends of the ascending
frontal and parietal convolutions, and the supramarginal
gyrus. In the three parts first named are situated centres
for movements of the tongue, larynx, pharynx and mouth.
A penny piece placed directly behind the termination
of the Sylvian line will cover the angular convolution
in which the " word-seeing " centre is placed (Fig. 8).
The parietal eminence covers the supramarginal con-
volution. The ascending limb of the fissure of Sylvius
is indicated by a line § of an inch long drawn upwards
and slightly forwards from the pterion, while the short
anterior horizontal limb is indicated by a line \ an inch
long drawn forwards from the same point. Between
the ascending and anterior limbs is situated the pars
triangularis of the inferior frontal convolution in which
the centre for " motor speech " is placed. The stem
of the Sylvian fissure is | an inch long and runs down
wards and forwards under the great wing of the sphenoid
(Fig. 8). The temporal pole lies below it.

The four angles of the parietal bone have important
relationships to the brain. The anterior inferior angle
covers the posterior part of the inferior frontal con-
volution and the anterior horizontal and ascending
limbs of the fissure of Sylvius. The anterior branch of
the middle meningeal artery ascends beneath it. The
anterior superior angle at the bregma covers the terminal
part of the superior frontal convolution and the centre
for movements of the hip. The posterior superior
angle at the bregma lies over the upper part of the
occipital lobe and \ an inch behind the parietooccipital
fissure. The posterior inferior angle covers the con-
vexity of the lateral sinus and marks the lower limit
of the cerebrum. In its anterior half the posterior
limb of the Sylvian fissure lies beneath the squamosal
suture, but behind it passes entirely beneath the parietal
bone. It will be thus seen that the parietal bone covers
the whole of the parietal lobe, the posterior parts of
the frontal and temporo-sphenoidal lobes, and the upper
margin of the occipital.

The inferior temporal convolution passes

Chap, in.] The Cranial Contents. 37

backwards above the upper border of the zygoma and
external auditory meatus and rests on the thin roof of
the tympanum. Hence it is the most common site
of abscess which may follow middle-ear disease. (Fig. 8.)

The basal ganglia of the brain — the corpus
striatum and optic thalamus — are capped on their outer
aspect by the Island of Eeil. The Island lies buried
in the anterior half of the fissure of Sylvius, and hence
the surface markings for the fissure may be also used
for the Island and the basal ganglia. A half-circle,
with a radius of \ an inch, drawn in front of the pterion,
will indicate the anterior limit of the basal ganglia,
while behind they terminate behind the mid point of
the posterior limb of the fissure of Sylvius.

A point taken \\ inches vertically above the external
auditory meatus marks the junction of the descending
and posterior horns with the body of the lateral
ventricle. This point lies behind the pulvinar of the
optic thalamus.

The sensori-motor areas of the brain. — A
knowledge of the position of these areas is most important
in enabling certain brain lesions to be localised and in
guiding the surgeon in operations upon the cerebral
cortex. The precise extent of each area is not yet
accurately determined, and to some extent they over-
lap. The areas in front and behind the upper third
of the fissure of Rolando are centres for movements
of the lower limb and trunk, the middle third for the
upper limb, and the lower third for the face, mouth,
tongue, larynx, and pharynx (Fig. 8).

The areas for the lower limb are confined to the
posterior part of the superior frontal convolution, the
anterior part of the superior parietal lobule, and to the
upper parts of the ascending frontal and parietal con-
volutions lying between (Fig. 8). Areas for the lower
limb are also found in the paracentral lobule on the
mesial surface of the brain. The hip, knee, ankle, and
the toe areas are represented from before backwards. The
shoulder, elbow, wrist, thumb and finger areas follow
each other from above downwards in the middle third

38 Surgical Applied Anatomy. [Chap. hi.

of the ascending frontal and parietal convolutions.
The posterior parts of the middle and inferior frontal
convolutions, just anterior to the ascending frontal
fissure, give rise to combined movements of the head
and eyes when stimulated. The centres of movement
for the face, mouth, and. muscles of mastication are
situated in the lower third of the two ascending con-
volutions. The areas for the larynx and pharynx lie
in the pars basilaris of the third frontal convolution,
while the motor centre for speech lies in the pars
triangularis of the same convolution. The " word-
hearing " centre is situated in the superior temporal
convolution, while the " word-seeing " centre is placed
in the angular gyrus (Fig. 8).

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
yielding structure, and does not entirely fill the cranial
cavity, it may, as it were, be thrown about with the
skull, and be damaged 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 experi-
ments, 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 surface, both as regards the cere-
bruin and cerebellum, than 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's systole upon the brain. On entering

Chap, in.] The Cranial Contents. 39

they are almost immediately blended into an anastomos-
ing circle (circle of Willis), which has the effect of
equalising the cerebral circulation. Embolism of the
middle cerebral artery leads to a wide-spread disturb-
ance of the cerebral cortex. It supplies the third
frontal, the upper and middle temporal, the angular
supramarginal, and lower two thirds of the ascending
frontal and parietal gyri. The only parts of the sensori-
motor areas which escape destruction in such a case
are those for the lower limbs and trunk. The anterior
cerebral artery supplies these centres, the mesial surface
of the frontal and parietal lobes, and the adjacent part
of the cortex on the outer aspect. The occipital lobe
and temporo-sphenoidal convolutions are supplied by
the posterior cerebral artery. 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 dis-
tributed 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 no marked cerebral
disturbances have followed. In no case, however, has
the patient recovered when the 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. After ligaturing all four
arteries in the dog, the anastomosis between the spinal
and cerebral arteries within the foramen magnum was
sufficient to maintain life (Hill). 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

40 Surgical Applied Anatomy. [Chap. m.

brain, and has produced a plugging of one of the cerebral
vessels. Thus, hemiplegia has followed upon the mere
examination 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 manipulation
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.

The pulsations of the brain may be communicated
to any tumours or collections of fluid that reach the
surface of the brain through an aperture in the skull.
Such pulsations are synchronous with the arterial
pulse, but the sphygmographic tracings of the cerebral
pulsation exhibit also the " respiratory curve," conveyed
directly from the thorax by the blood within the veins.
The valve at the lower end of the jugular vein prevents
direct regurgitation of blood from the heart to the
brain, but it 'does not prevent the transmission of
pressure.

Although wounds of the brain bleed freely, the
bleeding is checked without difficulty, the vessels being-
capable of ready contraction. Large tumours have
been excised from the cortex of the brain, without
undue trouble from haemorrhage. The terminal branches
of the cerebral arteries anastomose freely in the pia
mater, but the minute arteries which perforate and
supply the cortex are terminal. Hence any pressure
applied to the surface of the brain will lead to anaemia
of that piece of cortex, and, if the pressure is continued,
to its destruction.

41

CHAPTER IV.

THE ORBIT AND EYE.

The orbit. — The antero-posterior diameter of the
orbit is about If inches, its vertical diameter at the
base a little over 1|- inches, and its horizontal dia-
meter at the base about l| inches. The diameters of
the globe are as follow : transverse, 24 mm. ; antero-
posterior, 24'5 mm. ; vertical, 23 mm. (Brailey). The
eye-ball is therefore nearer to the upper and lower
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 usually introduced on that side when
the optic nerve has to be divided. In excising the left
eye, however, it may be more convenient to divide the
optic nerve from the inner side. The bones forming
the floor, the roof, and the inner wall of the orbital
cavity are very thin, especially in the last-named situa-
tion. 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 antrum. 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. Certain cases of
pulsating orbital tumour which depend upon a com-
munication between the carotid artery and the cavernous
sinus have a traumatic origin.

A reference to the relations of the orbital walls will
show that a tumour may readily invade the orbit by
spreading (1) from the base of the skull, (2) from the
nasal fossae, (3) from the antrum, and (4) from the
temporal or zygomatic fossa1. In any of these instances

42 Surgical Applied Anatomy. [Chap. iv.

the growth may enter the orbit by destroying the inter-
vening 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 fossse named,
through the sphe no-maxillary fissure. After violent
blows upon the temple blood has found its way into
the orbit through the spheno-maxillary fissure, and
has led to subconjunctival ecchymosis. Distension of
the frontal sinus by retained mucus or pus may lead
to a prominent tumour at the upper and inner margin
of the orbit, above the level of the tendo oculi, which
may cause displacement of the globe downwards, out-
wards, 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 orbi-
cularis muscle, and is often connected at some depth
with the orbital periosteum.

The capsule of Tenon.— The best description
of this capsule has been given by Mr. Lockwood ; of
his researches Prof. Cunningham provides the following
resume : —

The capsule is a firm loose membrane spread over
the posterior |ths of the globe, the cornea alone being
free from it. In front it lies under the ocular con-
junctiva, with which it is intimately connected, and it
ends by blending with that membrane close to the
margin of the cornea. Behind it fuses with the sheath
of the optic nerve, where the latter pierces the sclerotic.
The surface of the membrane towards the globe is
smooth, and is connected to the eye-ball by some soft
yielding areolar tissue. It thus forms a kind of dome
for the globe, a species of socket or bursa in which it
moves. The posterior surface of the capsule is in con-
tact with the orbital fat. The tendons of the ocular
muscles pierce the capsule opposite the equator of the
globe. The lips of the openings through which the four

Chap, iv.] The Orbit and Eye. 43

recti pass are prolonged backwards upon the muscles,
in the form of sheaths, very much as the inf undibuliform
fascia is prolonged upon the cord from the internal
abdominal ring. Mr. Lockwood points out that each
of these four apertures is strengthened by a slip
of fibrous tissue, the intracapsular ligament. As
the capsule is fixed at various points to the wall of the
orbit, these ligaments act as pulleys, and protect the
globe from pressure during contraction of the muscles.
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 connections with the capsule still give it some hold
upon the globe, and still enable it to act upon that struc-
ture. Moreover, the attachments of the capsule to the
margins of the orbit 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.

Of these orbital attachments the suspensory liga-
ment of Lockwood is the most important. It stretches
across the fore part of the orbit after the fashion of a
hammock, and supports the eye-ball. Its two extremi-
ties are attached respectively to the malar and lachrymal
bones. Below the eye-ball it widens out, and blends
with the capsule of Tenon. Strong bands, known as
the check ligaments, pass from the sheaths of the external
and internal recti muscles to the malar and lachrymal
bones respectively. They limit excessive rotation of
the globe in an outward or inward direction. The
action of the superior rectus is checked by its connec-
tion with the levator palpebral, and that of the inferior
rectus by the connection of its tendon with the suspensory
ligament.

Mr. Lockwood points out that in removing the
upper jaw the surgeon should take car.:- to preserve

44 Surgical Applied Anatomy. [Chap. iv.

the attachments of the suspensory ligaments. If these
be destroyed the eye-ball sinks downwards.

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, limiting 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 ease where a piece of an iron hat-peg, three
inches long, was embedded in the orbit for several days
without the patient being 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
ail excellent nidus for growing tumours. Fractures of
the inner wall of the orbit involving the nasal fossae or
sinuses, may lead to extensive emphysema of the orbital
cellular tissue. The air so introduced may cause the
globe to protrude, may limit its movements, may spread
to the lids, and will, in any case, be increased in amount
by blowing the nose, etc.

The orbital muscles.— The four recti muscles
end in thin, flat membranous tendons. The tendon
of the external or internal rectus muscle is frequently
divided for strabismus. The width of the tendons
varies from 7 mm. to 9 mm. They are inserted into
the sclerotic near the cornea. The internal rectus is

chap, iv.] The Orbit and Eye. 45

inserted 6'o mm. from the corneal margin, the external
6*8 mm., the inferior 7'2 mm., and the superior 8 mm.
(Merkel).

The external and inferior recti arc the longest, the
internal rectus is the broadest, and the superior is the
narrowest and slightest.

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, hemorrhagic and
inflammatory effusions. Thus Lawson records 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 fractures involving
the lesser wing of the sphenoid. The third, fourth, and
sixth nerves, and the first division of the fifth, may be
affected in cases of aneurism involving the internal
carotid artery, where they lie in relation with the cavern-
ous 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 involving that part (Prescott
Hewett).

In paralysis of the third nerve there is
drooping of the upper lid (ptosis) ; the eye is almost

46 Surgical Applied Anatomy. [Chap. iv.

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. tho, 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.

In paralysis of the sixth nerve there is con-
vergent strabismus, with consequent diplopia, and an
inability to rotate the eye directly outwards. Paralysis
of the sixth nerve may be accompanied by paralysis
of the nerve to the internal rectus of the opposite side,
giving rise to conjugate deviation of the eyes. Such
a condition indicates a lesion in the nucleus of the sixth
nerve, for although the fibres for the internal rectus
pass out with the third nerve they take their origin
with the sixth.

Sometimes all the oculo-motor nerves of the eye
are paralysed, and in such cases the lesion is probably
situated either at their nuclei or origin or at the
cavernous sinus, in the wall of which the^nerves lie
close together.

In paralysis of the first division of the fifth
there is a loss of sensation in all the conjunctiva, except

chap, iv.] The Orbit and Eve. 47

such as covers the lower lid (supplied by the palpebral
branch of the infraorbital nerve), loss of sensation in
the globe, and in skin supplied by the supratrochlear
and supraorbital nerves, and in the mucous and cuta-
neous surfaces supplied by the nasal nerve. The area
of anaesthesia is much less than the anatomical dis-
tribution of the nerve, owing to the extent to which
cutaneous nerves overlap. No reflex movements
(winking) follow upon irritation of the conjunctiva,
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 anaesthesia 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 (Nettleship).

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 narrowing 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 palpebral, and is attached to the
tarsal cartilage near its upper margin (Fig. 12). This
layer of muscle, which, when in action, would keep
up the lid, is under the influence of the cervical
sympathetic. The recession of the globe is supposed
by some to be due to paralysis of the orbitalis muscle
of H. Miiller. 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

48

Surgical Applied Anatomy. [Chap. I v.

sympathetic in animals) causes protrusion of the globe,
while section of the sympathetic in the neck produces
retraction of the eye-ball (CI. 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 '9 mm. in the central parts to l'l mm.
at the periphery. 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 laminse 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 lamelhe, between which
are anastomosing cell spaces containing the corneal
corpuscles. If the nozzle of a fine syringe he thrust

Fig. 10.-A Horizontal Section of the Globe through the middle.

a- Cornea ; b, sclerotic ; c, choroid ; d. retina ; e, lens ; /, iris ; g, ciliary process
7;, canal of Sculemm.

Chap, iv.i The Orbit axd Eye. 49

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 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 corneal
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 pannus, the cornea appears to be vascularised ; but
here, owing to continued irritation, vessels, derived
from the neighbouring conjunctival arteries, pass over
the cornea just beneath its epithelial 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 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 distributed to every part
of the tunic. In glaucoma, a disease of which the

50 Surgical Applied Anatomy. [Chap. IV,

phenomena depend upon greatly increased intraocular
pressure, the cornea becomes anaesthetic. 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 54.)

The sclerotic, choroid, and iris,— The sclerotic
is thickest behind, and thinnest about \ 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. At the point of penetration
of the optic nerve the sclerotic is thin, and pierced by
numerous holes for the passage of nerve bundles. This
weakened part, the lamina cribrosa, plays an important
part in glaucoma (page 62). It gives the stippled
appearance to the optic papilla. Brailey states that
the lateral parts of the sclerotic are thinner than the
upper and lower segments, the inferior part being the
thickest and the external wall the thinnest. It happens,
therefore, that under the influence of intraocular
pressure the eye expands more laterally than in the
vertical direction. 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 supra-
choroidea and lamina fusca, which are separated
from one another by a lymph space. In injuries to the
globe, therefore, extensive bleeding may take place
between these two coats, and indeed a like haemorrhage
may be the result simply of a sudden diminution in
the ocular tension produced by such an operation as

chap, rv.j The Orbit and Eye. 51

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 itis is, from its great vascularity, very easily in-
flamed. 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 condition of the little mem-
brane, the pupil becomes encroached on, and appears
to be contracted, while the movements of the mem-
brane 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 ad-
hesions may readily take place between the two parts
(Fig. 11). After iritis, therefore, it is common to find
the posterior surface of the iris (most often its
pupillary margin) adherent to the lens capsule by
bands of lymph, either entirely or in one or more
different points. Such adhesions constitute posterior
synechias, the term anterior synechia being applied to
adhesions between the iris and 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 case of injury to the eye, it may be torn more

52 Surgical Applied Anatomy, [cbap. iv.

or less from its attachments without any damage being
done to the other tunics. The iris has been completely
torn away in a few instances, and has escaped through
a wound of the globe. The ciliary processes have been
thus exposed. Congenital absence of the iris has been
recorded. In cases of penetrating wounds of the cornea
the iris is easily prolapsed. It is so delicate and yielding
a membrane that in performing iridectomy the necessary
piece of the iris can be seized and pulled out through
the corneal 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
probably 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.

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 (venae 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

chap, iv.] The Orbit and Eve. 53

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 con-
verging 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 anasto-
mosing loops. These arteries lie in the subconjunctival
tissue. Their episcleral or non-perforating 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 nearly parallel to one another,
are very closely set, and do not move with the con-
junctiva. This zone is known as the zone of ciliary
congestion, or the circumcorneal zone,

4. The vessels of the conjunctiva are derived from
the lachrymal and the two palpebral arteries. These
vessels, in cases of inflammation, are readily distinguished
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 conjunctiva, and as easily
emptied of their blood by pressure. The differences
presented by these two sets of vessels serve in one way
to distinguish inflammation 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

54 Surgical Applied Anatomy. [Chap iv.

has a vascular system of its own, supplied through the
arteria centralis retina, 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 circula-
tion that is established by the minute anastomoses
about the entrance of the nerve is quite insufficient,
the retina soon becomes cedematous. A permanent
plugging of the central artery means, therefore, a
practical extinction of the vascular system of the
retina. In some cases of embolism only a branch of
the retinal artery is plugged, the patient retaining
vision except in that part of the retina supplied by the
branch. The fovea centralis, the centre of acute vision,
receives twigs from both the superior and inferior
temporal branches of the arteria centralis retinae.

In cases of haemorrhage between the choroid and
retina the blood must come from the choroidal vessels ;
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 mem-
brane, 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 :

chap, iv.] The Orbit and Eye. 55

above, the supratrochlear ; on the inner side by the
infratrochlear ; on the outer side, the lachrymal (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 un-
yielding sclerotic in cases of increased intraocular tension.
The sensation of the globe itself is derived solely
from the first division of the fifth. In inflammatory
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.
The explanation of this fact has to be sought for in the
common origin of the ophthalmic division from the upper
sensory nucleus of the fifth nerve in the floor of the fourth
ventricle. Not only are the nerve cells connected with
the eye-ball disturbed, but the neighbouring cells are
also affected, and by a psychical error the pain is re-
flected along the nerves with which they are connected.
There is pain over the forehead along the supratrochlear,
supraorbital, and lachrymal branches (circumorbital
pain), and pain down the side of the nose following
the nasal nerve. Or the pain may spread to the second
division of the fifth, and discomfort be felt in the tem-
poral 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. Although the orbicular muscle
is supplied by the facial nerve, its fibres are derived,
not from the nucleus of the seventh, but from the
oculo-motor nucleus, situated near the upper sensory
nucleus of the fifth, and connected with it by reflex
paths. Photophobia is most marked in superficial affec-
tions of the cornea, and is often much benefited by a

56 Surgical Applied Anatomy, [chap. iv.

seton in the temporal region. Inflammation of the iris
and glaucoma are accompanied by hyper-sesthesia and
referred pains over the outer frontal and anterior tem-
poral areas (Head). The nerve centres for the skin of
this region and the eye-ball are closely connected, a
relationship which may explain the application of
counter irritation to the temples in eye disease. In-
flammation of the cornea gives rise to no referred pains
(Head). Strain of the ciliary muscle, which occurs
with errors of refraction, leads to referred pains and
areas of hyper-sesthesia over the mid orbital region of
the forehead. 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
uninitiated 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 intimate relation between the nasal nerve and the
eye. In this affection, when the regions of the supra-
orbital and supratrochlear branches of the first division
are alone implicated, the eye is usually unaffected ; but
when the eruption extends over the 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 ot the eye. — Penetrat-
ing 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 anas-
tomoses that take place in the part. Indeed, as regards
blood and nerve supply, there is no more important

-Chap, i v.i The Or hit axd Eye. 57

'district in the eye-ball. From the ciliary body alsu
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
lip in the sound eye, which is, however, not usually
involved until two or three months after the other eye
has been injured. " Although at present the exact
nature of the process which causes sympathetic imflamna-
tion 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 " (Xettleship). It Is now
generally believed that the sound eye is directly infected
from the diseased one. The subarachnoid spaces which
surround the optic nerves are in continuity at the
chiasma, and offer a path whereby infection may spread
from one eye to the other.

The lens measures \ of an inch from side to side,
and 1 of an inch from before backwards. It, together
with its capsule, is in all imrts 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 exer-
cised 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 operations, and may be ruptured
by many forms of violence applied to the eye-ball. When
the capsule is wounded the aqueous humour enters.

58 Surgical Applied Anatomy. [Chap. iv.

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. " In so-called ' con-
cussion cataract,' where after a blow on the eye a part
of the lens becomes opaque, it appears probable that
the capsule has been very slightly torn opposite to the
opacity " (Lawford).

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 hsemorrhagic
or other effusions, and may indeed be so detached b}'
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 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 subdural, the inner from
the subarachnoid spice. 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 extsnd 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. Optic neuritis usually implies
that the optic disc or papilla is inflamed, but in excep-
tional cases the changes are limited to that part of the
nerve behind the globe (retro-bulbar neuritis). The length
of the optic nerve within the orbit is 28 to 29 mm.

Chap. IV.]

The Orbit and Eve.

59

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 re-
presented by a
little angular
interval be-
tween the iris,
the ciliary pro-
cesses, and the
suspensory
ligament of the
lens (Fig. 11).
The depth of
the anterior
chamber is
3 '6 mm. The
cornea at its
circumference
breaks up into
bundles of
fibres, which
are partly con-
tinued into the
front of the iris,
and which con-
stitute 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 com-
municate with a large circular canal situate in
the sclerotic close to its junction with the cornea, and
known as the canal of Schlemm. Tins space is in
communication with the veins of the anterior part

Fig-. 1 J. —Section of Globp, showing Iris, Lens,
Ciliary Region, etc. (After Allen Thomson.)

a. Cornea : b, Fcleroiic ; c, lens : r?, iris : c, ciliary pro-
ess ; /, conjunctiva ; if, canal of Seblemm ; h. canal
of iviir; i, anterior margin of vitreous humour; j,
choroid covered by retina ; k, aqueous chamber-

60 Surgical Applied Anatomy. [Chap. iv.

of the sclerotic,* and thus through this somewhat
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
chamber (hypopyon) it is usually readily absorbed.
The same applies to moderate extravasations of blood
in the chamber, and the speedy removal of such effusions
contrasts with the difficulty that is experienced in the
absorption of blood from the vitreous chamber. The
treatment of soft cataracts by the " needle operation "
depends for its success upon the absorptive powers of
the aqueous. In this procedure, the lens capsule having
been torn tb rough, 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 may be secondarily affected in inflamma-
tion of adjacent parts, may be the seat of haemorrhages,
and is often occupied by opaque bodies of various kinds.
Foreign bodies have lodged in the vitreous for con-
siderable periods without causing any symptoms. The
muscae 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,

This vessel is a branch of the central artery of the
retina, and may persist as a fibrous cord in adult life.
In some rare cases it has continued to transmit blood,
and in such instances its pulsation can be seen by the
ophthalmoscope.

Glaucoma is a disease the symptoms of which are

* The j>recise manner in which these spaces communicate with
the neighbouring veins has not been demonstrated histologically.
The statement is founded mainly upon the experiments of
Schwalbe.

Chap, iv.] The Orbit and Eve. 6i

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 glauco-
matous, 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.
This fluid is derived mainly from the ciliary body, and
in a less degree from the posterior surface of the iris.
Atrophy of the epithelium on the ciliary body is said
to lead to diminished tension. From the anterior
chamber the fluid can escape into the veins through
the gaps in the ligament um pectinatum already alluded"
to (Fig. 11). 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 importance of
the peripheral part of the anterior chamber in relation
to the outflow of fluid from the eye is shown in many
ways. If this part be blocked by the iris in perforation
of the cornea, or by the lens in some dislocations of
that body, increased tension of the globe is apt to follow.
A like increase of tension is said to attend the appli-
cation of the actual cautery to the sclero-corneal margin
and some cases of episcleritis. Dr. Brailey believes that
some outflow also takes place along the optic nerve.
It is well known that pressure upon that nerve may
produce oedema of the disc. The relief given to glaucoma
by iridectomy appears to depend upon the circumstances
that the operation practically opens up again these
channels of communication from the aqueous, since
the procedure, to be successful, should involve an incision
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 attachment, and
that the portion resected should be considerable. The
symptoms of glaucoma are. all explained by the effects

62 Surgical Applied Anatomy. [Chap, rv.

of the abnormal tension. Thus, the ciliary nerves are
compressed against the unyielding sclerotic, and give
rise to intense pain, while the disturbance in their
functions 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 gradual
narrowing of the visual field which is constant in glau-
coma, 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 circulation
is shown in the distended vessels that appear upon the
glob3.

The eyelids.— The skin over the eyelids is extremely
thin and delicate, and shows readily through its sub-
stance 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 thus to produce entropion. The lids
present many transverse folds ; one of these on the
upper lid, deeper and more marked than the rest, divides
the lid into two parts, the part below being that which
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.

Chap. IV.]

The Orbit and Eve.

63

I

&.

B6

JU

Incisions should follow the direction of these folds. The
lids are very freely supplied with blood, and are often
the seat of naevi and other vascular growths. Rodent
ulcer so frequently at-
tacks this part that it
was originally 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 orbicularis palpe-
brarum ; (4) the tarsal
cartilage and ligament ;
(5) the layer of Meibo-
mian glands ; and (6)
the conjunctiva. In the
upper lid the levator
palpebral is found pass-
ing to the tarsal cartilage.
The subcutaneous tissue
is very lax, and hence the
lids swell greatly when
cbdematous, or when in-
flamed, and when the
seat of haemorrhage. On
this account it is inad-
visable 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 membrane, is apt to be
the seat of irritative affections. Being a free be .'der also,

I

I

;'<(^£s_ , { MOS

7i£T. 12— Vertical Section through
Upper Eyelid. (After Waldeyer.)

1, Skin ; b, orbicularis ; &', its ciliary part ;
r, involuntary muscle of eyelid ; d, con-
junctiva; e. tarsal cartilage;/, Meibo-
mian gland; g, modified sweat gland ;
It, eyelashes ; i, post tarsal glands.

64 Surgical Applied Anatomy. fOiap. rv,

the circulation is terminal, and stagnation in the blood
current is not difficult to produce. Sycosis, an inflamma-
tion involving the hair follicles and some of the glands
at the edge of the lid, is among the most common of
ophthalmic affections. The common stye also is a sup-
puration 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 reten-
tion cyst developed in one of these glands.

Two arteries supply either lid : a palpebral branch
of the ophthalmic running along the inner part of each
lid, and a branch of the lachrymal along the outer part
of each lid. Four nerves supply the upper eyelid, the
supraorbital, the supra- and infra-trochlear, and the
lachrymal. One nerve supplies the lower lid, the infra-
orbital. Some of the lymphatics of the eyelids enter
the pre-auricular glands, hence in cases of chancre of the
lid the glandular enlargement has nearly always been
noticed in front of the parotid gland (Fig. 21, p. 164).

The conjunctiva.— The ocular part of this mem-
brane 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 opera-
tions : as, for example, in Teale's operation for sym-
blepharon, where a bridge of conjunctiva, dissected 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, subcon-
junctival h&emorrhages may occur from severe vomiting,
or during a paroxysm of whooping cough. Blood
also may find its way beneath the membrane in fractures

chap, iv.] The Orbit and Eye. 65

of the base of the skull. Haemorrhages beneath the
membrane arc unlike other extravasations (bruises), in
that they retain their scarlet colour. This is clue 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 considerable 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 between 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, hut they appear to be made up, some of nodules
of adenoid tissue, others of enlarged mucous follicles
and of hypertrophicd 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
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

66

Surgical Applied Anatomy. [Chap. iv.

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

fron. SINUS.
ROOF,

INFUNDIBULUM.

SAC

FOLD.

MIDDLE TURB. PROG
NASAL DUCT.

=-VALVE.

SEPTUM.

INF. TURB. PRO&

Fig. 13. — Vertical Section at the Root of the Nose to expose the Nasal Duct.

{After Merkel.)

The outline of the frontal sinus, with its duct, the infundibuluni, is indicated.
Tlie position of the upper and lower lachrymal canaliculi is shown (ab).

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 (Fig. 13). 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

chap, iv.] The Orbit and Eye. 67

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,
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,
atid 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 back-
wards and outwards. The nasal duct perforates the
mucous membrane of the nose below the inferior turbinate
process very obliquely, so that its inner wall acts as a
valve. If this is destroyed by ulceration, as sometimes
occurs in syphilis, the lachrymal sac may be inflated
by blowing the nose. In the upper part of the duct
the mucous membrane is thrown into a spiral fold,
which, after inflammatory conditions, may give rise
to stricture (Fig. 13).

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.

68

CHAPTER V.

THE EAE.

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 the so-called supernumerary
auricle consists in an irregular leaf of fibro-cartilage
developed from the margins of one of the lower branchial
clefts. (See page 166.) The tag-like supernumerary
auricles that are found on the cheek just in front of the
pinna or meatus are due to the irregular development
or want of fusion of one or more of the six tubercles
from which the pinna itself is developed. The pinna
may present a congenital fistula. This may be due
to a defective closure of the first branchial 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 fistuke, 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 entirely absent.
In other cases the " fistula " appears merely as a
narrow sinus or a depression, running through the
helix. Some of the smaller and more superficial fistulas
are due not to a defective closure of the branchial cleft
but to want of complete fusion between certain of the
tubercles from which the pinna is primarily developed.
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 con-
tains but very little fat. In inflammatory conditions
of the surface, such as erysipelas, the pinna may become

Chap, v.] The Ear. 69

extremely swollen and very great pain be produced
from the tenseness of the parts. The pinna and carti-
laginous 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 producing many slits
in the same lobule. He considers such conditions as
absolutely diagnostic of scrofula. *

The external auditory meatus is about \\
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 cartilaginous part.

In the infant at one year, a third only of the meatus
is formed of bone. The rest is cartilaginous. In a
child of five or six years of age the bony and cartilaginous
portions of the meatus are about of the same length
(Symington). The meatus is relatively as long in a
child as it is in an adult. 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
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

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

7o

Surgical Applied Anatomy

[Chap. v.

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
ceruminous 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.
Lacerated wounds of the cartilaginous meatus are apt
to bleed freely, owing to the difficulty with which the
vessels bound up with the cartilage contract. In the
floor of this part of the meatus are certain fissures,
fissures of Santorini. They are filled up with fibrous
tissue. They permit of easier movement of the carti-

[Fig. 14.— Section through the External Meatus, Middle Ear, and
; Eustachian Tube (Tillaux).

a, External auditory meatus ; b, attic of tympanum ; c. Eustachian tulie ;
rf, internal auditory meatus ; e, cochiea; /, ossicles j g, membrana tympani;
h, styloid process.

chap, v.] The Ear. 7 1

laginous meatus. It is through these gaps in the cartilage
that a parotid abscess may burst into 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 ex-
terna. 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 vtaR of the meatus is in relation with the
cranial cavity, from which it is only separated by a dense
layer of bone. Thus, abscess or bone disease in this part
may possibly lead to meningitis. A case is reported
where an inflammation of the cerebral membrane fol-
lowed 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 move-
ment in the cartilaginous 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.
The posterior wall separates the meatus from the mastoid
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. Directly behind the posterior wall is the lateral

"]2 Surgical Applied Anatomy. [Chap. v.

sinus. 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 to 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 little branch
from the pneumo-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 stimula-
tion of Arnold's nerve, a nerve whose main trunk goes

Chap, v.] The Ear. 73

to the stomach. Hence, this little branch has been
facetiously termed " the alderman's nerve."

Ear coughing, ear sneezing, 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 snch
cases the irritation is conveyed to the respiratory and
cough centres in the floor of the fourth ventricle by
Arnold's nerve, a small branch of the vagus. Gaskell
has shown that the vagus also contains the disassociated
visceral fibres of the fifth nerve. Hence, disturbances
may be set up in the vagal nuclei through branches of
the fifth nerve, such as the auriculotemporal.- The
connection of the nerves of the external auditory meatus
with the vagal nuclei also explains the sneezing or vomit-
ing which is sometimes caused by the presence of
foreign bodies in the external meatus. The same nerve
connection also explains the occurrence of repeated
yawning, sometimes set up by ear ailments. Irritation
eonveyed along the inferior dental or lingual nerves
may be referred along the auriculotemporal. Hence the
need to examine the tongue and lower teeth in cases of
earache. Head has pointed out that disease of the ear,
the tonsil, the tongue or the lower jaw may be associated
with an area of tenderness in the skin along and below
the jaw.

It is a common practice to introduce ear-rings, with
the idea of relieving obstinate affections of the eye. No
anatomical basis can be offered to explain such treatment.
The lobule is supplied by the great auricular nerve which
springs from the second and third cervical nerves, while
the eye is supplied by the ophthalmic division of the
fifth. The lower sensory nucleus of the fifth is a direct
continuation upwards of the grey matter from which
the posterior roots of the cervical nerves arise.

Hilton reports a case of obscure pain in the ear which
was found to be due to an enlarged gland in the neck,

74 Surgical Applied Anatomy. [Chap. v.

that pressed upon the trunk of the great auricular
nerve.

Memlirana tympani.— This membrane is very
obliquely placed, forming with the horizon an angle
of 45°. At birth it appears to be more nearly hori-
zontal, although it is not really so. In cretins, and
in some idiots, it is said to retain this apparent inclination.
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 membrane a kind of sinus in which small
foreign bodies may readily lodge (Fig. 14). The ring
of bone to which the membrane is attached is deficient
at its upper and anterior part. The gap so formed
is called the notch of Rivini, and is occupied by loose
connective tissue, covered by a continuation 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 membrane
gives way owing to a violent concussion transmitted
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 concussions such as that produced by a loud
report.

The umbo, or deepest point of the depression in the
diaphragm, is just below the centre of the entire mem-
brane, 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 mem-
brane, being situated in the attic of the tympanum
above the level of the membrane. The segment of the
membrane above the umbo is very freely supplied by
vessels and nerves ; it corresponds to the handle of the

chap, v.] The Ear. 75

malleus, and to the chain of ossicles, and is opposite to
the promontory and the two fenestra?. The chorda
tympani nerve also runs across this supraumbilical
portion. The segment below the umbo, on the other
hand, corresponds to no very important parts, and is less
vascular and less sensitive. Paracentesis of the tym-
panum through the membrana tympani should therefore
always be performed in the subumbilical segment.
If performed above the umbo the knife may strike
the incus and loosen that bone from its frail attach-
ments, or the chorda tympani be cut, which would give
rise to a paralytic secretion of saliva. The malleus and
stapes are too firmly attached to be readily separated.

The membrane is supplied by the stylo-mastoid
artery, and the tympanic branch of the internal max-
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 r^th to \Xh 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 tympanum
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 petro-squ anions suture unites at
the end of the first year and usually contains the petro-
squamous vein, a remnant of the primitive jugular.
The floor is very narrow. Its lowest part is below

76

Surgical Applied Anatomy. [Chap. v.

the level of both the membrana tympani and the orifice
of the Eustachian tube, and hence pus may readily
collect in this locality. It is separated by a thin piece
of bone from the internal jugular vein behind, and
from the internal carotid artery in front. Fatal hsepaor-
rhage from the latter vessel has occurred in connection
with destructive changes in this part of the ear. The

/' HELIX. \

SQUAM. •'

Fig. 15.— Showing the Position and Relationships of the Antrum of the
Mastoid (see also Fig. 3).

a, Antrum. The suprameatal triangle is indicated in front of the letter. The
shaded space in front of the triangle and above the meatus is the attic of
the tympanum ; x x on the continuation of the upper border of the zygoma
backwards indicating the position of the tegmen tympani ; e, placed on the
floor of the external auditory meatus. The tympanum is seen in the depth
of the meatus; vn. showing the position of the facial nerve ; l.s., lateral
sinus; m.f., mastoid foramen ; zy., root of zygoma; co>\, condyle of jaw.
The outline of the auricle is indicated by a single dotted line; that of the
facial nerve by a double dotted line.

posterior wall in its upper part presents the opening
of the antrum of the mastoid.

The antrum of the mastoid (Fig. 15) lies above
and behind the external auditory meatus and opens into
the attic of the tympanum. Implication of this space
and of the mastoidal cells, which open into it and
surround it, forms one of the most serious complications
of middle ear disease. It is large enough to contain
a small bean, and is present at birth, being developed
with the cavity of the tympanum. It is closely sur-
rounded by important structures. Its roof, formed by

Chap, v.] The Ear. 77

the tegrnen tympani, a plate of bone only 2 mm. thick,
separates it from the third temporal convolution. Small
veins perforate the roof to join the petro-squanious
vein, in the remnant of the suture of the same name.
In the infant the communication is even more free,
for this suture does not close until the end of the first
year. The facial nerve passes downwards on its inner
wall, where the antrum opens into the attic, and behind
the facial nerve, also on the inner wall, is the external
semi-circular canal. Facial paralysis or giddiness may
follow operations on the antrum if the inner wall is
injured. The antrum is separated behind from the
lateral sinus and cerebellum by a plate of bone which.
varies in thickness from 3 mm. to 6 mm. The temporo-
sphenoidal lobe, the lateral sinus, and the cerebellum
are the common seats of secondary infection in cases
of middle ear disease. At the mouth of the antrum
and in the attic of the tympanum are situated the incus,
the head of the malleus, and their ligaments, structures
which may be diseased and require removal.

At birth the outer wall of the antrum is
formed by the post-meatal process of the squamosal,
a plate of bone 2 mm. thick. Every year, until
about the twentieth, this process of bone increases
about 1 mm. in thickness, and hence in the adult
the mastoidal antrum lies at a depth of 20 mm. from
the surface, but it must be remembered that the depth
varies considerably. In the child it is comparatively
superficial, and pus may easily escape or be evacuated.
The suture between the post-meatal part of the squamosal
and the petro-mastoid disappears in the second year
of life and so shuts off a possible route that pus may
take to reach the surface. A shallow triangle {see
Fig. 15) above and behind the meatus, formed by the
post-meatal process of the squamosal, lies directly over
the antrum and serves as a guide to it. It may also
be reached by following the junction of the posterior
wall and roof of the external auditory meatus. The
drill is entered 5 mm. behind the meatus and on a level
with its upper margin. Its roof lies 5 mm. above the

78 Surgical Applied Anatomy. [Chap. v.

level of the meatus. The posterior auricular artery
passes upwards behind the meatus, beneath the concha
of the auricle, and lies within the field of any operation
on the middle ear.

The mastoid cells develop with the growth of the
mastoid process. The mastoid process appears in the
third year, but the cells are not formed until puberty.
Three varieties of the mastoid process are recognised, each
of which is about equally common : (1) those in which
the cells are large and communicate with each other
and with the antrum, (2) those in which the central
cells are large and communicate with the antrum,
while the peripheral are small and closed, (3) those in
which all the spaces are small and closed. The cells
surround the antrum, and may pass backwards to the
masto-occipital suture, forwards to the suprameatal
region, upwards to the masto-parietal suture, and down-
wards to the apex of the mastoid. Inflammatory
conditions may lead to a thickening of the walls of the
mastoidal cells, and the bone may become so dense as
almost to resist the chisel. Veins drain into the peri-
osteum of the mastoid from the more superficial cells,
and by these, inflammation may reach the surface
and give rise to oedema and swelling behind the ear.

In cases where the outer surface of the mastoid
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 opening
of the Eustachian tube. This tube is If inches
long, and by opening into the pharynx serves to keep
a proper supply of air in the tympanum, and so equalise
the pressure upon the two sides of the membrane. The
floor of the tympanum is below the level of the outer

Chap, v.] The Ear. 79

opening of the Eustachian tube. The line of direction of
the tube lies almost exactly midway between the trans-
verse and antero-posterior axes of the base of the skull.
In the adult it inclines downwards, so as to form an angle
of 40° with the horizon. In the child this angle is only
10° (Symington). In adults fths of the tube is carti-
laginous and Jth bony (Symington). On the outer
side of the tube lie the tensor palati, the third division
of the fifth nerve, and the middle meningeal artery.
On the inner side are the retro-pharyngeal tissue and
(quite posteriorly) the internal carotid artery. The
pharyngeal orifice of the tube is usually shut. During
swallowing, however, it is opened, by the action mainly
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 membrana tympani by the air thus forced
into the tympanum. This method of inflating the
middle ear is known as Valsalva'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 are 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 passes between the
patient's meatus and his own. Prolonged closure of
the Eustachian tube leads to deafness, and thus impair-
ment 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 and post-nasal
growths, 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

8o Surgical Applied Anatomy. [Chap. v.

pharyngeal end of the tube to the posterior nares serves
to explain a. case where suppuration in the mastoid
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,
and would 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). In the foetus the orifice is below the hard
palate ; at birth on the same level. The form of the
opening is that of a triangle. The opening of the tube
is effected by the tensor palati, levator palati, and sal-
pingo-pharyngeus.

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 lateral recess or fossa of
Rosenmuller (Fig. 16). It may be mistaken for the
orifice of the tube, and may readily engage the point
of a Eustachian catheter. In cases in which the
pharyngeal tonsil (Luscha's tonsil) is enlarged, this
fossa on either side may be greatly deepened and made
to form a narrow diverticulum. (See page 131.) To
pass the Eustachian catheter, the instrument 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 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

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

Chap. vi.] The Nose. Si

maxillary and internal carotid, the petrosal of the middle
meningeal, and the stylomastoid of the posterior auricu-
lar. 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 petrosquamous vein, which crosses
the roof of the middle ear, also receives branches from
the antrum and attic and joins the lateral sinus behind
and the meningeal veins in front (Cheatle).

The connection between deafness and tinnitus aurium
and affections of the stomach has to be sought for in the
central connections of the eighth and tenth nerves.
The blood supply of the labyrinth is derived entirely
from the vertebral artery (Woakes).

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 and Schulte have shown that such disease in
this part may be associated with anomalies of taste.

The osseous labyrinf li is formed independently
of the other bony parts of the ear. Portions of this
labyrinth have necrosed and have been expelled in
recognisable fragments. In a case recorded by Dr.
Barr the whole of the osseous labyrinth (the cochlea,
vestibule, and semicircular canals) was removed entire
as a necrosed fragment from the auditorv meatus.

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 ake, however, it is thick, very adherent to
the deeper parts, and plentifully supplied with sebaceous
and sweet 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

82 Surgical Applied Anatomy. [Chap. vi.

engorgement. The pain depends 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 and 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 72), is prone
to gangrene from exposure to severe cold. A specimen
in the museum of the Royal College of Surgeons illus-
trates 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
nose is supplied by the second division of the fifth, and
is the seat of pain in neuralgia of that trunk. The

Chap. vi. j The Nose. £3

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 affectio'hs about the nostril, as, for example,
when the edge of the nostril is pinched (page 46).

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, there-
fore, in those who have had " snuffles " in infancy.

The na§al 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 displace-
ment that occurs is due 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 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 fossge. In
fractures of the upper third of the ossa nasi the cribri-
form plate may be broken, but it is questionable whether
this complication can occur when the fracture is limited

84. Surgical Applied Anatomy. [Chap.vi.

to the lower third of the bones. The root of the nose is
a favourite place for meningoceles and encephaloceles,
the protrusion escaping through the suture between the
nasal and frontal bones. Such protrusions, when occur-
ring in this place, are often covered by a thin and vascu-
lar integument, and have been mistaken for nsevoid
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 \\
inches vertically, and a little less than \\ inches trans-
versely, at its widest part. The plane of the nostril
is a little below that of the floor of the nares. To ex-
amine 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 intro-
duced 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 turbinated bone.
The anterior nares, and front of the nasal cavities, can
be well explored by Rouge's operation. In this pro-
cedure 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 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 month, and illumined from the mouth, the following
parts may, under favourable circumstances, be seen :

Chap, vi.] The Nasal Cavities. 85

the posterior nares, the septum, the middle turbinated
bone, part of the superior and inferior turbinated bones,
and part of the inferior meatus. The middle meatus
is well seen, and also 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 dimensions of the apertures.
Each aperture is of regular shape, and measures about
\ an inch transversely by \\ 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.
The width of the fossae increases somewhat from above
downwards, thus the superior turbinated bone is only
2 mm. from the septum, while a space of from 4 to 5 mm.
intervenes between the inferior turbinated bone and
the septum. The nasal cavity is so very narrow above
the middle turbinated bone that that bone really forms
the surgical roof of the nasal fossae.

From a reference to the relations of the nasal fossae
(Fig. 16) it will be understood that inflammation of the
lining membrane (coryza) may extend to the pharynx
via the posterior nares ; may extend up the Eustachian
tube and cause some deafness ; may reach the lachrymal
sac and conjunctiva through the nasal duct ; and may
extend to the frontal sinuses and the antrum, producing
frontal headache and cheek-ache. 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

86 Surgical Applied Anatomy. [Chap. vi.

of various kinds 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 disposition to
breathe 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. Meningitis has followed inflammation of the
nasal fossae, the inflammation extending through the
cribriform plate. Through the perineural and peri-
vascular sheaths the lymphatic system of the nose is
in continuity with that of the meninges, and by these
channels infections may spread from the roof of the
nose to the membranes of the brain. 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 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 in adults ;
the deviation being more often towards the left. It is,

Chap, vi.] The Nasal Cavities. 87

however, straight in children, and remains so up to
the seventh year. In adults the septum deviates in
76 per cent, of all persons. The deviation 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 dependent 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 mistaken 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 implication 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 (Fig. 16). — 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 f of an inch behind
the orifice of the nostril. The opening of the nasal duct
is about 1 inch behind the orifice of the nostril, and
about f of an inch above the nasal floor. This opening
is usually slit-like and narrow. The nasal duct pierces
the nasal mucous membrane in the same oblique and-
valvular manner as the ureter enters the bladder. The
height of the inferior meatus is about f of an inch. The
superior meatus is a very short and narrow fissure, and
into its upper and fore part open the posterior ethmoidal
cells. The middle meatus opens widely in front upon
a part of the outer wall called the atrium, 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.
Upon the wall of the middle meatus is a deep gutter (the
hiatus semilunaris), which runs from above downwards
and backwards (Fig. 16). Into this groove open the
infundibulum (the aperture of the frontal sinus), the

88 Surgical Applied Anatomy. [Chap. vi.

anterior ethmoid cells, and, near its posterior end, the
antrum. The aperture of the frontal sinus appears as
a small round hole at the upper and anterior end of
the groove. The ethmoid cells open a little way lower
down on the groove, while the antrum has its orifice at
or near the hinder part of the hiatus. This orifice is
slit-like, situated about the centre of the middle meatus,
and is quite 1 inch above the floor of the nasal fossae
(Fig. 16). The orifice is nearer to the roof than the
floor of the antrum, and thus no facility is offered for
the escape of accumulated fluids.

The middle turbinated bone is high up. Its highest
point (its anterior extremity) is nearly on a level with
the "te ndo oculi.

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 ^ an inch,
or a little over. Its smooth surface greatly favours
the passage of instruments. It presents a gentle slope
from before backwards. At its anterior part is a
depression of mucous membrane over the incisor
foramen. This foramen is a vestige of the great com-
munication that once existed between the cavities of
the nose and mouth.

The mucous membrane lining the nasal cavi-
ties varies in parts. It is very thick and vascular over
the turbinate bones and over the lower two-thirds of
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 mem-
brane is provided 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 consider-
able hypertrophy. 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.

Chap. VI.]

The Nasal Cavities.

89'

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.
So thick and lax is the normal mucous membrane over

Fig. 16.— Outer Wall of the Nose, showing the Openings of the Sinuses.
The middle (m.t.) and inferior (i.t.) turbinate processes have been cut
off at their attachments, but their outlines are indicated.

f.s., Frontal sinus; IK., infundibulum opening into the middle meatus at the upper
end of the hiatus semilunaris ; h, placed on the bulla ethmoidals below the
opening of the middle ethmoidal cell (2) and above ihe hiatus semilunaris ;
a, the opening of the antrum at the posterior end of the hiatus ; b, on the

atrium in front of the beak of the middle turbinate process; N.D., opening
of the nasal duct ; (1), posterior ethmoidal cell opening in superior meatus ;
(3) anterior ethmoidal cell opening into infundibulum ; (4), lachrymo-
ethmoidal cell, also opening into infundibulum ; p, position of pituitary
body; s.s., sphenoidal sinus; l. i:., lateral recess of pharynx ; BUS., Eusta-
chian tube.

the lower borders and posterior extremities of the middle
and inferior turbinated bones that it forms in these
situations a kind of soft cushion. This condition
is mainly due to the presence of a rich submucous venous
plexus, the vessels of which run, for the most part, in
an antero-posterior direction. Over the lower turbinate

90 Surgical Applied Anatomy. [Chap.vi.

bone the veins form a kind of cavernous tissue, " the
erectile body." When turgid with blood it swells so as
to obliterate the interval between the bone and the
septum. When the seat of chronic inflammation, the
mucous membrane over the inferior bone may appear
as a polypoid swelling. The great vascularity of the
mucous membrane is probably for the purpose of raising
the temperature of the inspired air. From the con-
struction of the fossae the inspired air is encouraged to
pass along the middle meatus, the expired air along the
lower meatus. From the comparatively lax attachment
of the mucous membrane of the septum to the parts
beneath, it happens that haematoixiata 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
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 fossae. It was
mistaken for a polyp, and attempts to remove it led
to meningitis and death.

The blood supply of the nasal cavity is extensive,
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

Chap, vi.] The Nasal Cavities. 91

and the superior longitudinal sinus through the foramen
caecum. This communication may also be maintained
in the adult. These connections may, in part, serve
to explain the occurrence of intracranial mischief as
a consequence of certain inflammatory affections of the
nasal cavities. Bleeding from the nose, or eyistaxis,
is a common, and often a serious, circumstance. Its
frequency is to a great extent 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 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 lb. of
blood were lost in sixty hours, and Fraenkel records a
case where 75 lb. 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.
In many cases the bleeding point is situated on the
septum, \ an inch above and behind the nasal spine.

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 example
of transference of nerve force in the opposite direction
may be noted cases Avherc a strong sunlight falling
upon the eyes has produced an attack of sneezing.

92 Surgical Applied Anatomy. [Chap. vi.

Troubles involving the vagal centres, such as cough
and bronchial asthma, have followed affections of the
nasal cavities. The vagus nerve contains visceral fibres
which originally belonged to the fifth nerve. The
olfactory nerves are situated in the upper third of 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. The
olfactory roots cross the edge of the lesser wings of the
sphenoid, and in falls on the forehead are liable to injury.
The olfactory centre is situated in the hippocampal gyrus.
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 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, however,
reported the strangest case of all, a case in which
all the coverings of a large femoral hernia were
ruptured 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, parotid, and upper deep
cervical lymph glands, and it is common to find the
former set of glands enlarged in nose affections, especially
in the scrofulous. The lymphatics of the nose also
communicate with those of the meninges through the
cribriform plate.

The sinuses.— These may be briefly dealt with.
The frontal sinuses (Figs. 13 and 16) are not present

Chap. vi. ] The Nasal Cavities. 93

in early youth, but develop as age advances. They
do not exist before the age of ten years, but are well
developed by twenty. They are formed by outgrowths
of the nasal mucous membrane, which cause the diploe
to be absorbed as they advance. Large frontal sinuses
do not necessarily imply large external prominences
over the glabella and superciliary eminences. One
sinus may develop at the expense of the other, and the
septum may be displaced or absent. The body of the
sinuses lies behind the glabella, and they extend outwards
over the inner two-thirds of the orbit and backwards
for about \ an inch. They are larger in men than in
women. They are absent on one side in 25 per cent,
of cases, and on both sides in 15 per cent. 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
inspissated contents of the sinus have been mistaken
for brain matter escaping. Since the sinuses com-
municate 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,
and maggots that have developed within the nose have
managed to make their way to the frontal sinuses.
A case is reported where epistaxis, extending over many
years, was due to an insect (the pentastoma tamioides)
that had settled in these sinuses. One day it was sneezed
out, and no further bleeding occurred (Med. Times,
1876). The last-named parasite is said to be often met
with in the frontal sinus of the dog. The infundibulum
is f of an inch long, and runs downwards and slightly
backwards to open at the anterior end of the hiatus
semilunaris. Along the hiatus the secretion of the frontal
sinus is conveyed to the antrum, which in cases of chronic
inflammation may become a cesspool for the sinus

94 Surgical Applied Anatomy. [Chap. vi.

(Fig. 16). The infundibulum is frequently tortuous, and
can be catheterised from below with difficulty even
after the beak of the middle turbinate process is
removed. Hence in cases of obstruction the frontal
sinus is trephined over the glabella, and a probe passed
downwards and slightly backwards to drain the sinus
into the nose. The frontal diploic vein, which joins
the frontal vein at the supraorbital notch, receives
blood from the frontal sinus. By this channel infec-
tion may be disseminated in the frontal bone from
disease of the frontal sinus.

The sphenoidal sinus opens on the roof of the nose
behind the superior meatus (Fig. 16). It is deeply placed,
and not very accessible for operation when the seat of
disease. The pituitary body, within the sella turcica,
rests on its roof, and tumours of this body frequently
invade the sinus.

The walls of the sinuses are thin and easily perforated,
as the following case, which occurred recently at the
London Hospital, will show. A man stumbled forwards
on his umbrella as he left a public-house in Whitechapel,
the point entering his face above the bicuspid teeth.
He walked to the hospital, and died three days after-
wards. The ferrule of the umbrella was found embedded
in the pons, the point having traversed the antrum
of Highmore and the sphenoidal sinus.

The antrum exists at birth, but attains its largest
dimensions in old age. The walls of the cavity are
thicker in children than in adults. 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 some-
what 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 backwards,
although it sometimes invades the zygomatic and pterygo-

Chap, vii.] The Face. 95

maxillary fossae. 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 is 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
sufficient 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. Not unfrequently the antrum communicates
at its upper anterior part with the frontal sinus.

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
incisor was found lying loose in the antrum three and
a half rears 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 adherent
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 eruption that
specially involves the sebaceous follicles. It happens
from the thinness of the skin, and from the absence of
dense fascia?, that facial abscesses usually soon point
and seldom attain large size.

g6 Surgical Applied Anatomy. [Chap. vn.

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 re-
sembles the integument of the scalp. When such
parts of the integuments of the face as cover prominent
bones, such as the parts over the 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. Although there is a large
quantity of fat in the subcutaneous 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 favours 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 3 inches long from
the cheek, in the tissues of which it had been embedded
for several years. The soft tissues of the cheek greatly
favour the spread of destructive processes. 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, especially the rodent and lupoid

Chap, vii.] The Face. 97

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 " charbon."

Blood supply.— The tissues of the face are very
vascular, and are liberally supplied with blood-vessels
in all parts. The finer vessels of the skin often appear
permanently injected or varieoso 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 fare, while they
may bleed readily when inflicted, are apt to heal with
singular promptness and accuracy. All wounds, there-
fore, of this part should have their edges carefully
adjusted as soon after the accident as possible. Exten-
sive 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. Ex-
tensive injuries of the face associated with great loss of
substance are often repaired in a most remarkable
manner, as has been illustrated in gunshot Avounds
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 possesses, 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 included, so that there remained
only the cranium, supported by the neck and spine."
Ho 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

H

98

Surgical Applied Anatomy, [chap. vii.

muscle. It is here covered only by the integument and
platysma, and can be readily compressed 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. Jhe facial
vein is only in contact with the artery near the lower
border of the jaw ; on the face it is separated 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 intracranial 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 unfrequently fatal by inducing thrombosis of the

Fig. 17.— Showing the Development of the Face. {Modified from Merkel.)

f.s.p.. Part formed from the frontonasal process,' l., from its lateral and m.
from its mesial parts ; max., formed by the maxillary process ; max., formed
by the mandibular process.

Chap, vu.] The Face. 99

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 communication
with the great vein in the neck may explain those abrupt
deaths from thrombosis that have followed upon the
injection of facial naevi in infants.

A reference to the development of the face assists
to explain the distribution of the fifth nerve and the
occurrence of certain abnormalities (Fig. 17). The face
is developed from five processes, a mesial — the fronto-
nasal, and two lateral — the maxillary and mandibular.
The front o-nasal process forms the middle part of the
upper lip and the nose. It may fail to develop when
the condition of cyclops is produced. It springs from
the frontal region and carries with it a branch of the
first division of the fifth, the nasal nerve. The second
division of the fifth is the nerve of the maxillary process,
while the third is that of the mandibular.

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, and the extensive
sensory nucleus of the fifth nerve, that severe irritants
applied to the face may set up a widespread nerve dis-
turbance. 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 positions of the supra-
and infra-orbital 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 bicuspids in both jaws will
hit both the infraorbital and mental foramina. The
infraorbital foramen is a little over -\ of an inch below
the margin of the orbit. The mental foramen in the
adult is midway between the alveolus and the lower
border of the jaw, and is a little over \ of an inch below

ioo Surgical Applied Anatomy. [Chap. vti.

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. Meckel's ganglion has been
repeatedly excised for the relief of neuralgia involving
the second division of the fifth nerve. A triangular
flap of skin is turned up from the front of the cheek,
and the infraorbital canal is exposed. The anterior
wall of the antrum is opened with a trephine, and the
bone is cut away from the floor of the infraorbital groove
so that the nerve lying in that canal is fully exposed.
The nerve is followed back to the posterior wall of the
antrum. This wall having been trephined, the spheno-
maxillary fossa is opened up and Meckel's ganglion
exposed. Beyond the ganglion the foramen rotundum
can be made out. The infraorbital artery runs with the
nerve, and that vessel, together with its anterior dental
branch to the incisor and canine teeth, will probably
be divided. The infraorbital vein ends in the pterygoid
plexus. The ganglion is surrounded by the terminal
branches of the internal maxillary artery. It is a triangular
body, with a diameter of about -i of an inch. It is a little
convex on its outer side, and is of a reddish colour.

The following are the relations of the ganglion in the
spheno-maxillary fossa : —

Above.
The second division of the fifth nerve.

Outer side.
Termination of internal UlecRel'S
maxillary artery. i _.

External pterygoid ganglion.

muscle.

Behind.

Vidian canal.

Sphenoid bone.

Inner side.

Yertical plate of palate.

Sphenopalatine

foramen.

Chap, vn.] The Face. tot

The inferior dental nerve has been diTided at the
mental foramen by an incision made through the mucous
membrane. Through this incision the nerve can be
stretched and the cutaneous portion of it excised. Its
trunk has been reached, and a part excised, through
a trephine hole made in the body of the lower jaw.
This operation, however, inflicts great damage upon the
. bone, and cannot be recommended. The artery, more-
over, is liable to be wounded.

The nerve has been divided also before its entry
into the mental 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 membrane
down to the tendon of the temporal muscle. The
ringer is introduced into the incision, and passed between
the ramus of the jaw and the internal pterygoid muscle
until the bony point is felt that marks the 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 neuralgia,
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 trunk of the third division of the fifth nerve
has been divided at the foramen ovale through a flap
wound made in the cheek. Considerable damage of
the soft parts results.

After section of a branch of the fifth nerve the area
of anaesthesia is surprisingly small. When the first
or ophthalmic division has been cut, only a narrow strip of
skin above the eyebrow is destitute of the sense of touch,
while the area insensitive to pain and temperature
is slightly wider. Owing to the overlapping of neigh-
bouring nerves the area is much less than the anatomical

102 Surgical Apt lied Anatomy. [Chap. vn.

distribution of the ophthalmic nerve. If the second

division is cut, the area of anaesthesia is confined to a
narrow space between the orbit and the mouth ; on
section of the third division, to a strip running down-
wards in front of the ear and along the course of the
lower jaw (Head).

Excision of the Gasserian ganglion. — For cases of
intolerable and intractable neuralgia Rose proposed
the excision of the Gasserian ganglion. It is the sensory
ganglion of the fifth nerve, and corresponds to the gang-
lion on the posterior root of a spinal nerve. The nerve
fibres of the fifth necessarily undergo degeneration
when it is excised.

The operation usually performed is the following :
An omega-shaped flap of skin is raised from the temples,
having the zygoma at its base and the temporal ridge
at its convexity. The tissues are reflected down to the
floor of the temporal fossa. The superficial and deep
temporal vessels have to be tied. A wide trephine
opening is made in the squamosal and great wing
of the sphenoid on a level with the upper border
of the zygoma and the dura mater exposed. This is
usually followed by a profuse haemorrhage from the
middle meningeal vessels which cross the field of operation.
The dura mater and the superimposed temporo-sphenoidal
lobe are raised from the bone, when the third and second
divisions of the fifth nerve are brought into view as
they escape by the foramen ovale and foramen rotundum.
They are seen to spring from the Gasserian ganglion
situated over the apex of the petrous bone and on the
outer wall of the cavernous sinus. The motor root
which supplies the muscles of mastication lies under
the ganglion and should not be cut. The ganglion
is embedded in the dura mater and surrounded by a
prolongation of the subarachnoid space (Meckel's space),
which is necessarily opened. Only the part of the
ganglion connected with the second and third divisions
is removed, the part connected with the ophthalmic
division being left, as it is firmly embedded in the outer
wall of the cavernous sinus and in close proximity to

Chap, vii.] The Face. 103

the internal carotid artery and oculomotor nerves.
The hippocarnpal convolution containing the olfactory
centres lies immediately over the ganglion.

The malar bone.— Such is the firmness of this
hone, 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 compara-
tively 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 (Fig. 18). 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 f 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 movements that
tend to narrow the space occupied by the gland. The
obliquity of the ramus 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,

104

Surgical Applied Anatomy. [Chap. vii.

forms the stylo-maxillary, ligament, and is connected
with the sheaths of the pterygoid muscles and the

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

a, Orbicularis oris and, behind it, the buccinator ; A, internal pterygoid.; r, mas-
seter ; d, styloglossus, stylo-pharyngeus, and styloid process; e, Splenitis
capitis ;/, digastric. ; ci, sterno-mastoid ; k, obliquus superior; i, trachelo-
mastoid ; j, biventer cervicis and coiuplexus ; k, trapezius; I. tonsil ; ?/i, facial
artery ; n, facial vein ; o, gustatory nerve ; p, inferior dental nerve and artery ;
g, styloid process ; r, external carotid artery ; s, internal carotid artery ;
t, vagus ; u\ parotid gland ; :r, internal jugular vein, \\\t\i the vagus, spinal
accessory, and hypo-glossal nerves to its inner side; y, vertebral artery;
z, odontoid process; 1, occipital artery.

chap, vii.] The Face. T05

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 communicates 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 fossae,
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 of the jaw and other bony parts, and is closely
related with the temporo-maxillary joint. Thus, a
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 Virchow 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 supply the gland
with sensation, and the presence of these nerves, to-
gether with the unyielding character of the parotid
fascia, serves 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 auriculotemporal nerve. Thus, a patient with
parotid growth recently under my care had pain in

106 Surgical Applied Anatomy. [Chap. vn.

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 auricalo-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 jawr, 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 backwards 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, therefore, 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
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.

The nerve has been stretched close to its point of exit
from the stylo-mastoid foramen for the relief of facial
tic. It is best found at a spot about \ of an inch in
front of the centre of the anterior border of the mastoid
process. It will be found above the posterior belly of
the digastric, which serves as a guide to it in the depth
of the wound.

It follows, from the complex 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

Chap. vii. i The Face. 107

is separated by a mere layer of fascia from tli^ internal
carotid artery, the internal jugular vein, the vagus,
glossopharyngeal, and hypoglossal nerves (Fig. 18).
Thus, in stabs in the parotid region it may be difficult

at first to tell whether the internal or the external caro-
tid is wounded. It has been suggested that the cerebral
hyperemia sometimes noticed in severe parotitis
(mumps) may be due to the pressure of the enlarged
gland upon the internal jugular vein.

Tumours of the parotid are very apt to contain car-
tilaginous tissue. It is well known that metastases
after mumps are quite common in the testis. It is
significant in this connection that the testis is one of the
few parts of the body, apart from bone, where carti-
laginous matter forms a frequent constituent of the
neoplasms of the part. Mr. Paget lias pointed out that
inflammation of the parotid is peculiarly frequent after
injuries and diseases of the abdomen and pelvis. It
occurs also very often as a sequela of some specific fevers,
but more especially after typhoid. The anatomical or
physiological basis of this connection has not been made
out.

Many lymphatic glands are placed upon the surface
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 fossa?,
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 §th 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 with the masseteric. This
bend should be taken into consideration in passing a
probe along the duct from the mouth. The duct opens
on the summit of a papilla placed on a level with the
second upper molar tooth. The course of the duct across

io8 Surgical Applied Anatomy. [Chap. yit.

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 infra-orbital
branches of the facial nerve below it. The duct has
been ruptured subcutaneously, leading to extravasations
of saliva. Wounds of the duct are apt to lead to
salivary fistula?. 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.
Fistulae 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. Inflamma-
tory 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 93 ; for hard palate, see Mouth, page 127). —
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 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

Chap, vil] The Face. 109

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
induced 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 pre-maxillary, or incisive bone.

The periosteum of the superior maxilla is, lil<r' the
pericranium, not disposed to form new bone. In or-
dinary cases of necrosis of the upper jaw no reproduction
of bone takes place, the gap being left permanent. In
the lower jaw abundant new bone is produced by the
periosteum, and extensive losses may be repaired. It is
remarkable, however, that in course of years this new
bone is liable to be very extensively reabsorbed.

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 in-
stances the separation is effected by a cutting instrument ;
in the last-named, by simply twisting out the bone.
Soft parts divided : These may be considered under
three heads : The parts cut (1) in the first incision ;
(2) in turning back the flap ; and (3) in separating
the bone.

(1) The'following are the parts cut in order from
above downwards in the usual, or " median," incision.

no Surgical Applied Anatomy. [Chap. vii.

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,
part of lev. labii superioris, angular artery and vein,
lev. labii sup. alaeque nasi, lateralis nasi artery and
vein, nasal branches of infraorbital nerve, compressor
naris, depressor alae nasi, attachment of nasal cartilage
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, if the
nasal process is removed entire, the levator anguli, the
buccinator, a few fibres of the masseter, and, on the
orbital plate, the inferior oblique muscles. The infra-
orbital 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. " Any 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 spheno-palatine 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 turbinated bone comes away of
course, with the maxilla.

Chap, vii.] The Face. hi

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 interarticular 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 envelop 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 down-
wards by the 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, the
masseter, internal pterygoid, and temporal. It must be
remembered that the mylo-hyoid muscle will be attached
to both fragments, and will modify the amount of dis-
placement. 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

i j 2 Surgical Applied Anatomy. [Chap. vii.

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 articula-
tion, and is most likely to find an exit through the
anterior part of the capsule, although this part is to a
great extent protected by the attachments of the ex-
ternal 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 ligament
of the joint (the external lateral) has a direction down-
wards 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

Chap, vii.] The Face. t t 3

be unilateral or bilateral, blie latter being the mere
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
fibro-cartilage, glide forward. The fibro-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. Xow if the external 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 ptery-
goid, 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 corf moid process
against the malar bone.

Subluxation of the jaw is a name given to a
slight and quite incomplete dislocation of the jaw not
infrequently met with in delicate women. It is due
to a displacement of the interarticular cartilage, and
can be cured by exposing the cartilage and attaching
it by suture to the fibrous structures around the joint
(Annandale).

Excision of the inferior maxilla.— Con-
siderable portions of the lower jaw can be excised through

ii4 Surgical Applied Anatomy. [Chap. vii.

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 : Those concerned (1) 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. (6) In the horizontal cut : Skin, etc., pla-
tysma, branches of superficial cervical nerve, branches
of supra-maxillary part of facial nerve, facial artery and
vein at edge of masseter, and inframaxillary branch
of facial nerve (not necessarily divided), (c) The pos-
terior 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.

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-giossus, 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 in-
sertion 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

chap, vii.] The Face. 115

nerve, the parotid, .submaxillary, and .sublingual glands.
After subperiosteal resection the entire bone lias been
reproduced.

Deformities.— The lower jaw may be entirely

absent, or may be of dwarfed dimensions, or be incom-
pletely formed. These conditions are congenital, and
depend upon the defective development of the mandibular
or first visceral arch, out of which the lower jaw is formed
(Fig. 17). They are often associated with branchial
fistuke, 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 wry-neck have been reported as due to the irritation
of carious teeth. Hilton gives the case of a man who
was much troubled by a carious tooth in the lower jaw
(supplied by the third division of the fifth), and who
developed a patch of grey hair over the region supplied
by the auriculo-temporal nerve (a branch also of the
third division).

Caries of the teeth is frequently associated with areas
of hyperesthesia on the side of the face and neck. The
dental and cutaneous nerves of these areas are connected
centrally, and to these areas pain is referred. Disease
of the peri-dental membrane does not give rise to referred
pains (Head).

The mtiseles ot mastiea tion 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 amongst the first symptoms
of tetanus. It is also very apt to be produced by irrita-
tion 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

n6 Surgical Applied Anatomy. [Chap. vn.

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.

Teeth.— As a test of age the following periods
for the eruption of teeth are given by Mr. C. Tomes :
Temporary teeth : Lower central incisors, six to nine
months ; upper incisors, ten months ; lower lateral
incisors, and four first molars, a few months later ;
then, after a rest of four or five months, the canines ;
and, lastly, the second molars ; the whole being in place
by the end of the second year. Permanent teeth : First
molars, sixth or seventh year ; next in order the lower
central incisors, then the upper central incisors, and a
little later the laterals, the eighth year ; first bicuspids,
ninth or tenth year ; second bicuspids and canines,
about the eleventh year, the lower preceding the upper ;
the second molars, the twelfth or thirteenth year ; the
wisdom teeth, eighteen to twenty-five or later.

An alveolar abseess is an abscess about the
fang of a tooth. In the case of single-fanged teeth
the pus may escape along the groove of the fang. With
other teeth the pus tends to pierce the alveolus. If the
point of the fang is within the reflection of the mucous
membrane from the gum to the cheek the abscess will
break into the mouth, but if the point of the fang is
without that reflection, or if the pus can gravitate with-
out the line of the reflection, then the pus may break
through the cheek. Alveolar abscess of the upper incisors
and canines never breaks through the cheek. When con-
nected with the upper molars it sometimes does. When
connected with any of the lower teeth the abscess may
find its way through the skin of the cheek.

The upper wisdom tooth is developed in the pos-
terior border of the upper jaw, and the lower wisdom
on the inner aspect of the ascending ramus. They may
fail to come into position or remain buried. They may
give rise to an abscess which frequently points in the neck,
at some distance from its seat of origin.

1 1

CHAPTER VIII.

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 cor-
puscles. The upper lip is supplied with sensation by
the second division of the fifth nerve, and the lower
lip by the third division. Over these labial nerves a
crop of herpes often appears (herpes 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 oede-
matous. 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 vascularity 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 noevi 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

1 1 8 Surgical Applied Anatomy. [Chap.vni.

arteries are very apt to be wounded. As such wounds
are concealed from view, the consequent hsemorrhage
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 escaping from a coronary
artery, was for a while supposed to be suffering from an
internal injury. As the anastomoses 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 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 freenum lingua?, can be observed the sublingual
papilla with the openings of Wharton's ducts. 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 sublingual papilla near the frsenum.
It indicates the position of the sublingual gland, and also,

Chap, viii.] The Mouth. 119

so far as it goes, the line of Wharton's duct and the
lingual nerve. These structures, with the sublingual
artery, lie beneath the mucous membrane between
the gland and the side of the tongue. The ducts of
the sublingual gland, some ten to twenty in number,
open into the mouth along the ridge of mucous mem-
brane just referred to. Eanula, a cystic tumour filled
with mucous contents, is often 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 forward to be re-
flected on the gums, is attached near to the upper border
of the jaw. Here also are situated some mucous glands
which may become cystic. 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 mucosa. It is constricted in its centre
by the fraenum lingua?, 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
\ 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 £ 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.

1 2 O Si' J! GICA L A PPL [ED A NA TOM V. [Chap. V 1 1 1 .

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 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 dermoid cyst is sometimes found in
the floor of the mouth between the tongue and the
lower jaw. Such cysts have been supposed to be due
to the imperfect closure of the first visceral or post-
mandibular cleft.

The gums arc 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, therefore,
is said not to occur in those who keep the teeth clean.

The tongue. — On the under surface of the tongue,
less than h an inch from the fraenum, 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 longer than usual
that the chest could be touched with its tip while the
head was held erect.

In rare cases the frseiiiim linguae may be

chap, viii.] The Tongue, 121

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
hemorrhage, 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 suffoca-
tion 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 epiglottis, 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
184G 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 super-
ficial inflammation of the organ it often becomes heaped
up, forming dense opaque layers, ichthyosis linguae,
plaques cles fumeurs, leucoma, etc. From the mucous
glands, situated chiefly beneath the mucous membrane
near the base of the tongue, the mucous cysts are de-
veloped that are sometimes met with in this part.

The tongue is very vascular, and is in consequence
often the seat of nevoid 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 attachment
of the member. At the same time it must be observed

122 Surgical Applied Anatomy. [Chap. viii.

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 experiments,
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 glossopharyngeal nerve supplies
the mucous membrane at its base, and especially the
papillae vallatae. In painful affections of the tongue
in the district supplied by the lingual nerve, the patient
often is troubled with severe pain deep in the region
of the meatus of the ear, and an area of skin from the
ear along the lower border of the jaw may be tender
(Head). The anterior two-thirds of the tongue is a
derivative of the mandibular arch, which also forms the
anterior boundary of the meatus. Hence the nerve
supply of the anterior part of the tongue from the third
division of the fifth nerve and the reference of pain to its
cutaneous termination. The posterior third of the tongue
is derived from the second (hyoid) and third visceral
arches and is associated with tender areas in the skin
over the larynx (Head). 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 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. An 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,

Ch aP. v 1 1 1 . ] The Toxg i te. 123

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 hypoglossal
nerve, which leaves the skull through the anterior
condyloid foramen in the occipital bone. The case
illustrates the importance of remembering even small
foramina, and the structures they transmit.

The tongue contains much lymphoid tissue, a con-
siderable part of which (the lingual tonsil) is massed
under the mucous membrane at the posterior part of
the organ. Hypertrophy of this tissue may lead to
troublesome symptoms by interference with the proper
action of the epiglottis. The lingual and pharyngeal
adenoid tissue, with the tonsils proper, form a complete
ring of lymphoid tissue round the isthmus of the fauces.

The lymphatics of the tongue are large and numerous,
and offer a free channel for the dissemination of cancerous
emboli. The tongue is one of the commonest sites for
cancer, and the disease commonly affects the anterior
two-thirds, which is derived from the mandibular arch.
So is the lower lip, which also is a common site. Cancer
spreads along the lymphatic vessels, which for the greater
part accompany the lingual vein and artery and pour their
lymph and emboli in the upper deep cervical glands,
behind and below the angle of the jaw. The normal
paths are soon choked, and the lymph has to follow
circuitous by-paths. The lymphatic glands over the
submaxillary gland, the lymphoid tissue in that gland
and in the sublingual, become the seats of secondary
deposit. The submental gland may also be affected.

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 Q\ inches in length and 10 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,

124 Surgical Applied Anatomy. [Chap. vni.

lymphangioma, cavernosum, proposed by Vircliow),
and to an increased development of lymph tissue through-
out the part. The portion most conspicuously affected
is the base of the tongue, where the lymphatics are
usually the most numerous.

A dermoid cyst may be met with on the under surface
of the tongue. It is usually placed in the median line
between the genio-hyo-glossi muscles. Such cysts are
probably due to some infolding of the integumental
layer during development.

Accessory glands about the tongue.—
Streckeisen states that accessory glands, belonging to
the thyroid body, are frequently found in the vicinity
of the hyoid bone. Some may be superficial to the
mylo-hyoid muscle, others may be just above the hyoid
bone, and others in the hollow of that bone. Cysts
lined with ciliated epithelium may sometimes be found
in the same situations. All these structures are the
remains of the neck of the central diverticulum which
is protruded from the ventral wall of the pharynx in
the embryo, and from which the isthmus and pyramidal
parts of the thyroid gland are formed. The foramen
caecum on the tongue indicates the spot where this
diverticulum leaves the pharynx. It marks the junction
of the mandibular with the hyoid part of the tongue.
Ducts lined with epithelium have been found leading
from the foramen caecum to accessory glands about
the hyoid bone. It is probably from these glandular
and epithelial collections about the hyoid bone that
certain deep-seated forms of cancer of the neck are
developed. Some of these take the form of malignant
cysts described by the author {Path. Soc. Trans., 1886).

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 pbtain more

chap, viii.i The Tongue. 125

room the cheek lias been slit up in one procedure, 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 com-
mencing 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. This method allows free removal
of the upper deep cervical glands, the lymphatic glands,
and tissue over and in the submaxillary and sublingual
glands which form the seat of secondary cancerous
deposits. *

In the removal of the entire organ, the following
parts are of necessity divided : The fnenum, the mucous
membrane along the sides of the tongue, the glasso-
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, glossopharyngeal, and hypo-glossal
nerves, the lingual vessels, and, at the side of the tongue
near its base, some branches of the ascending pharyngeal
artery, and of the tonsilar branch of the facial artery.

Bleeding from the stump of the tongue, after removal,
can be instantly and almost entirely arrested by pressing
the root of the tongue forwards with two fingers passed
down behind it into the pharynx. The lingual arteries
as they lie divided in the floor of the mouth are difficult
to secure. They are embedded in muscle, and appear
to be peculiarly brittle.

When both Unguals have been ligatured in the
neck (through the hyo-glossus muscle) before removing
the tongue, bleeding still takes place from the dorsalis
linguae branches of the lingual and from small branches
of the ascending pharyngeal and facial arteries.

The palate.— The arch of the hard palate varies

126 Surgical Applied Anatomy. [Chap, viii

in height and shape in different individuals, and it
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. The os incisivum or premaxillary
bone is developed with the central part of the upper
lip from the fronto-nasal process (Fig. 17, p. 98). Each
premaxillary may be developed by two centres, hence
the cleft is sometimes between the central and lateral
incisor. Sometimes at the end of the cleft the upper
lip is fissured (hare-lip). Hare-lip is exceedingly rare
in the middle line. The slit usually corresponds to the
suture j List named, and is therefore opposite the interval
between the lateral incisor and canine teeth. Sometimes
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.

Chap, v 1 1 1 . ] The Pa la te. i 2 7

The buccal cavity, when first formed in the foetus,
exists as a wide cleft in the face bounded above by the
fronto-nasal process, at the sides by the superior maxillary
processes, and below by the first visceral arch, from
which the lower jaw is formed (Fig. 17, p. (J8). The nasal
and buccal cavities are one. " The separation of the
cavity of the mouth, strictly so called, from the nasal
fossae, 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
descending 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 readies
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 understood
that hare-Hp 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 operation
for the cleft palate.

The main blood supply of both the bones of the
hard palate and its mucous covering is derived from
the descending palatine brunch of the internal maxillary

128 Surgical Applied Anatomy. [Chap. Viii.

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 membrane 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 \
of an inch. When the soft palate is cleft, the edges
of the fissure are approximated during swallowing 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 direction. 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 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, trans-
verse to the direction of the muscle. The tensor is not
divided in this procedure. (2) Pollock's : A thin narrow

Chap. VII f.]

The Palate.

129

knife, with the cutting edge upwards, is introduced
into the soft palate a 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 to cut the posterior
surface of the velum to a sufficient
depth to divide the levator palati
(Fig. 19). (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 descend-
ing palatine branch of the in-
ternal maxillary artery, the as-
cending pharyngeal artery, and
the ascending palatine branch
of the facial artery. The latter
vessel reaches the velum by fol-
loAving the levator palati muscle,
and must be divided in the section
made of this muscle in the
procedures just described.

The muscles of the palate are supplied by several
nerves. The levator palati, azygos uvulae, and palato-
pharyngeus are innervated with the muscles of the
pharynx by the spinal accessory ; the palatoglossus
with the muscles of the tongue from the hypo-
glossal, and the tensor palati with the tensor tympani
from the third division of the fifth nerve through the
otic ganglion.

The pharynx is about five inches in length. It
is much wider from side to side than from before back-
wards. It is widest at the level of the tip of the greater
cornua of the hyoid bone, where it measures about

e f

Fig. 19.— The Muscles of
the Soft Palate, from
behind.

a. Levator palati ; b, tensor
palati ; c, hamular process;
d, wall of pliHiynx; e. azy-
gos uvula? ; /, the point of
entry of the knife in Pol-
lock's operation; above it
is the line of incision made
on withdrawing the knife.

130 Surgical Applied Anatomy. [Chap. viii.

2 inches. It is narrowest where it joins the gullet oppo-
site the cricoid cartilage, its diameter here being less
than f 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 commence-
ment of the gullet is about 6 inches, a measurement
that should be borne in mind in extracting 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 accom-
modate for some time large substances. Thus, in a case
reported by Dr. Geoghegan, a man of 60, who had
for months some trouble in his throat for which he could
not account, was supposed to have cancer. On examina-
tion, however, a plate carrying five false teeth, and
presenting niches for five natural ones, was found em-
bedded 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 pre-
sented the ordinary vertebral segment of bone, together
with 1|- inches of ribs, and was " pretty well covered with
meat." Attempts to remove it failed, and it was finally
vomited up. Dr. Hicks (Lancet, 1884) reports the case
of a woman who committed suicide by cramming half
a square yard of coarse calico (belonging to her
nightdress) into her mouth and throat.

The walls of the pharynx are in relation with the
base of the skull, and with the upper six cervical ver-
tebrae. 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 ver-
tebra. The upper vertebrae can be examined, as regards
their anterior surface, from the mouth. When the

Chap, vin.] The Pharynx. 131

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 also have 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. The submucous tissue
of the aryteno-epiglottic folds and of the neighbouring
part of the pharynx is peculiarly loose, and in cedema-
tous conditions the upper aperture of the larynx may
be almost closed. Much adenoid tissue is distributed
in the mucous membrane of the pharynx, and it is this
tissue that is the primary seat of inflammation in scrofu-
lous pharyngitis. A distinct collection of adenoid tissue
stretches across the hinder wall of the pharynx between
the openings of the Eustachian tubes. It is known as
Luschkas tonsil, or the pharyngeal tonsil. This deposit
of adenoid tissue may undergo hypertrophic change
and the condition known as " adenoid vegetations "
or " post-nasal growths " be produced. These growths
may cause deafness, and may block the posterior nares.
They need to be removed by operation. The lateral
recess, behind the opening of the Eustachian tube, also
contains adenoid tissue (Fig. 16, p. 89). The tissue immedi-
ately 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 ccsophagus, reaching the posterior mediastinum
and advancing even to the diaphragm. In the lax
connective tissue betAveen the pharynx and the spine
abscess is not infrequent, due, as a rule, to caries of
the vertebrae (post-pharyngeal abscess). In this con-
nective tissue, and opposite the axis, is also found a
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,

132 Surgical Applied Anatomy. fChap. vni.

or may cause severe dyspnoea by interference with tlie
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, glossopharyngeal,
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.
18, p. 104). The styloid process, when prominent, and an
ossified stylo-hyoid ligament, can also be felt at the side
of the pharynx. In more than one case an ossified
stylo-hyoid ligament has been mistaken for a foreign
body, and an attempt made to excise it. Langenbeck
has three times extirpated the pharynx for malignant
disease, but without success. He reaches it from the
neck through an incision that, beginning below the jaw,
midway between the symphysis 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
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

Ch ap. v 1 1 i . ] The Tonsil . 133

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, and overlying the internal jugular
vein. These glands receive the tonsillar lymphatics,
and are almost invariably enlarged in all tonsil affections.
The fact that these glands are so frequently the first to
enlarge when the cervical glands become tubercular
points to the tonsil as a common site of primary infection.
It must be remembered that many structures are inter-
posed between the tonsil and the skin, and as the hyper-
trophied 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 attached to the pharyngeal
wall to be affected by the movements of the pharyngeal
muscles. Thus it is moved inwards by the superior con
strict or 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-giossus 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 open the Eustachian tube. The deafness in these
cases is probably due rather to an extension of the
hypertrophic process to the lining membrane of the
tube than to any pressure effects, since it is usually

T34 Surgical Applied Anatomy, [Chap, viii;

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 decomposition 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. Calculi
may form in these crypts and give rise to a spas-
modic cough. In this case the glosso - pharyngeal
nerve conveys the afferent impulse to the respiratory
centre.

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 some way behind the gland (Fig. 18, p. 104).
The vessel is, indeed, about |- of an inch posterior
to that body, and is in comparatively little danger of
being wounded when the tonsil is excised. The internal
jugular vein is a considerable distance from the tonsil.
The facial artery, in its cervical stage, is close to the
tonsil. Of important cervical structures, 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, bleeding 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. Several
haemorrhages occurred from the tonsil wound, and on
the fourth day after the accident 1 inch of the stem
of a clay pipe was discovered deeply embedded in the
glandular substance. It was removed, and the common

Chap, ix.] The Neck. 135

carotid tied. The patient, however, never rallied from
the previous severe hemorrhages, and soon died. The
autopsy showed that the stem of the pipe, which had
not heen missed by the patient, had divided the ascending
pharyngeal artery (St. Bart's Hosp. Reports, 1876).

The tonsil is often the seat of malignant growths.
Such tumours have been removed through the mouth,
but are more conveniently dealt with through an in-
cision in the neck along the anterior edge of the sterno-
mastoid (Cheever's operation).

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 on a level with the
disc between the second and third dorsal vertebra?.
(See page 169.) 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
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

136 Surgical Applied Anatomy. [Chap. ix.

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, the whole of the body of the vertebra divided will
be seen to lie within the anterior 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 cartil-
age, 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 \\
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.

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

Chap, ix.] The Neck. 137

the neck. The interval between the sternal and clav-
icular 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, or not unfrequently
nearly \ an inch above that point. 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. Both the artery
and vein lie under the anterior border of the sterno-
mastoid. The superior thyroid artery comes off just
below the great eornu of the hyoid bone, and curves
forwards and 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.

138 Surgical Applied Anatomy. [Chap. ix.

,The external jugular vein follows a line drawn 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 corre-
sponds to the sterno-clavicular joint, the other end to the
centre of the clavicle, the summit of the curve rising
to a point about \ 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 superficial cervical nerve.
A second line drawn up across 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 suprasternal, supraclavicular, and supra-acromial
nerves.

The spinal accessory nerve reaches the anterior
border of the sterno-mastoid muscle at a point about
1 inch below the tip of the mastoid process. It emerges
from beneath that muscle about the middle of its pos-

Chap, ix.] The Neck. 139

terior border, crosses the posterior triangle, and passes
beneath the trapezius at a point between the middle
and lower thirds of the anterior border of that muscle.

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 subjects. 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 external to the centre
of the clavicle.

The neck. — The skin in the submaxillary region
is lax and thin, and is often found o." 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 subcutaneous fat in the cervical
region varies in different parts. In the suprahyoid
region it is apt to undergo extensive development, pro-
ducing 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. Common carbuncle is very commonly met
with behind 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 integu-
ments at the back of the neck, just below the occiput.

i4o Surgical Applied Anatomy. [Chap. ix.

These measures were accredited with not infrequently
producing tetanus.

When the steriio-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 illus-
trates 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
inflammation of the cervical glands in the posterior
triangle. Such inflammation has irritated some
branches of the 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
disturbance in such cases is therefore not difficult to
follow. It is to be remembered, also, that the spinal
accessory nerve passes between the upper two or three
deep cervical lymph glands which may compress it.
A like contraction has also been produced by direct
irritation of the second cervical nerve in cases of disease
of the first two cervical vertebrse. For the relief of some
forms of wry-neck, the sterno-mastoid muscle is divided
subcutaneously, as in an ordinary tenotomy operation,
about -| 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 anterior jugular which follows its an-
terior 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. For spasmodic
wry-neck the spinal accessory nerve and the communi-
cating branches of the third and fourth cervical nerves

chap, ix.] The Neck. 141

have been cut. The .spinal accessory nerve is found
at the anterior border of the sterno-mastoid, li inches
below the mastoid process.

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 foUow just
such a course as the arrangement of the fascia? would
lead us to suppose, while, on the other 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 (6) the deeper processes.

(a) The superficial layer forms a complete investment
for the neck, and covers in all the cervical structures,
except 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. Arriving
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

142

Surgical Applied Anatomy. [Chap. ix.

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. Both these

Eig. 20.— Transverse Section through the lower part of the Neck, to
show the arrangements of the Cervical Fascia (Diagrammatic}.

a, Trapezius; 5, sterno-mastoid ; c, depressors of hyoid hone; d, platysiua;
e, anterior spinal muscles ; /, scalenus anticus ; cj, carotid artery ; ft, external
jugular vein ; i, posterior spinal muscles; t, trachea, with gullet behind and
thyroid body in front.

Chap, ix.] The Neck. 143

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 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 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 superficial
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 pericardium. (2) The prevertebral 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 cesophagus. Laterally, it joins the
carotid sheath, and is then prolonged outwards and
downwards 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

144 Surgical Applied Anatomy. [Chap. ix.

the 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 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 medias-
tinum 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 downwards into the mediastinum. (4) An
abscess immediately 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

Ch ap. i x . ] The Neck, i 4 5

the strongest fasciae in the body, the deep cervical fascia
a ad the fascia lata " (Hilton's " Eest and Pain ").

The apex of the lung extends into the neck,
and reaches a point from 1 to 2 inches above the
anterior end of the first rib. A point between the
sternal and clavicular heads of the sterno-mastoid and
\ an inch above the clavicle will mark its highest
limit. It lies behind the clavicle, anterior scalene
muscle, and subclavian vessels. The right lung com-
monly extends higher up than the left.

The pleura has been opened in careless operations
on the subclavian artery, and has also been torn in
dragging deep-seated tumours from the base of the
neck. The pleura and lung have been wounded in
stabs of the neck and by fragments of bone in severe
fractures of the clavicle. Cervical abscesses have opened
into the pleura, and, apart from this, pleurisy has followed
inflammation of the cellular tissue at the root of the
neck.

Hernia of the lung into the neck has occurred during
violent coughing, an appreciable tumour being produced
(Dr. Knox, Lancet, vol. i. ; 1885).

Cervical ribs.— These structures have led to
many errors in diagnosis, have been mistaken for ex-
ostoses, and where the subclavian artery is carried
over them have led to the diagnosis of aneurism. They
are met with at all ages and in both sexes, and represent
the cervical ribs of lower vertebrates. As a rule, one
such rib is found on either side of the seventh cervical
vertebra ; sometimes it is movable, sometimes it is
ankylosed to the vertebra and its transverse process.
A vestige is always present in the fcetus. It may be
very short, and represented only by a head, neck, and
tubercle. Such forms have been mistaken for exostoses.
It may be long, and may then end free, or be joined
to the first rib, or the first costal cartilage by ligament,
or even by cartilage. In such instances the subclavian
artery passes over the cervical rib, and its distinct
pulsation under such circumstances has led to the
diagnosis of aneurism. To the longer form of cervical

K

146 Surgical Applied Anatomy. [Chap. ix.

ribs the scalenus anticus, and the scalenus medius,
may be attached.

In thin subjects the rib forms a distinct projection
in the neck.

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 homicidal, most fre-
quently 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
the mouth freely opened. In any case where the attach-
ments of the tongue are divided the organ is apt to
fall back upon the larynx and produce suffocation.

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.

In wounds of the neck the great vessels often escape

Chap ix." The Neck. 147

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. Dieffenbaeh 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-
rnastoid 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
wourids made with equal force in any other part of the
neck.

In some cases of gunshot wound the vessels -trem
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 -ide, 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.
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 con-

148 Surgical Applied Anatomy. [Chap, ix.

siderable portions of the brachial plexus without in-
volving 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 wTho 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.
A bursa lies between the thyro-hyoid membrane and
the posterior surface of the hyoid bone. It may, when
enlarged, form one of the cystic tumours of the neck.

The larynx and trachea. — The position of the
larynx in the neck is influenced by age. In the adult
the cricoid cartilage reaches to the lower part of the
sixth cervical vertebra. In a child of three months
it reaches the lower border of the fourth cervical, and
in a child of six years the lower border of the fifth ver-
tebra. At puberty it attains the adult position. The
upper end of the epiglottis in the adult is opposite the
lower border of the third cervical vertebra. In a child
of. three months it reaches the lower border of the atlas,
and at six years the lower border of the axis (Symington).
With the laryngoscope the following parts may be made
out : The base of the tongue and glosso-epiglottic liga-
ments ; the superior aperture of the larynx, presenting
in front the epiglottis, at the sides the aryteno-epiglot-
tidean 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 clown 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

chap, ix.] The Neck. 149

anterior wall of the trachea. If the glottis be very fully
dilated the openings of the two bronchi may be dimly
seen.

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 advances.
Ossification commences in the thyroid and cricoid car-
tilages at about the age of 20, and in either cartilage
the process commences in the vicinity op the crico-
thyroid joint. The arytenoid ossifies later. Ossifica-
tion of the laryngeal cartilages is more marked in males
than in females. The larger cartilages are liable to be
fractured by violence, as by blows, throttling, etc. The
thyroid is the one most frequently broken, and usually
in the median line. The posterior superior angle of the
thyroid cartilage marks the position of the pyriform
fossa, a wide recess, above and external to the aryteno-
epigiottic folds. Foreign bodies may be arrested in this
fossa.

The rima 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 in-
terior 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 1 inch (23 mm.) from
before backwards ; from side to side, at its widest
part, it measures about one-third of the length ; this
diameter may be increased to one-half of the length
in extreme dilatation. In the female and in the male
before puberty the anteroposterior diameter is from
17 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 submucous tissue most abundant, in the following
parts, taken in order of degree : The aryteno-
epiglottidean folds, the mucous membrane of the
ventricle, the false cords, and the laryngeal aspect of

150 Surgical Applied Anatomy, ichap. ix.

the epiglottis. These are the parts that become most
congested and swollen in acute laryngitis ; and the
serious condition known as cedema of the glottis depends
mainly upon effusion into the lax submucous tissue in
the aryteno-epiglottidean folds. The mucous membrane
is firmly bound to the true vocal cords and covered by
stratified epithelium, while the rest of the larynx is
lined, like the trachea, with ciliated epithelium. Owing
to the nature of its covering and exposure to friction
the true vocal cord is not an uncommon site of epi-
thelioma. 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 long time 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 ven-
tricle. It is in these parts, therefore, that the changes
in chronic glandular laryngitis, or dysphonia clericorum,
are most marked.

Excision of the larynx. — The entire larynx
has been removed for carcinomatous disease, but the
operation, although not immediately fatal, has not been
followed by very satisfactory results. It is removed
through an incision in the middle line. In this in-
cision are divided the platysma, the fascia, and the
anterior jugular vein. The larynx is separated from
its connections, the following structures being divided :
sterno-thyroid, thyro-hyoid, stylo-pharyngeus, palato-
pharyngeus, and inferior constrictor muscles, laryngeal

Chap, ix.] The Ateck. 151

branches of superior and inferior thyroid arteries,
superior and inferior laryngeal nerves, hyo-epiglottic
and glosso-epiglottic ligaments. The larynx is
then separated from the trachea, and is dis
sected off from below up. In separating the gullet
and pharynx there is great risk of " button-holing "
the former tube. Extirpation of half the larynx is
attended with less risk, and in early cases with the cancer
limited to one vocal cord it may be sufficient to remove
the corresponding parts of the thyroid, cricoid and
arytenoid cartilages.

The lymphatic vessels of the upper half of the larynx
follow the superior laryngeal vessels and pass to the
upper deep cervical glands. A small lymphatic gland,
the first to become the seat of secondary cancerous
deposit, is situated below the horn of the hyoid on the
thyro-h void membrane. (Fig. 21, p. 164.) The lymphatics
of the lower half of the larynx accompany the inferior
thyroid vessels and pass through lymph glands by the
side of the trachea.

Tracheotomy and laryiigotomy. — The trachea
is about A\ inches in length, and from f to 1 inch in
its extreme width. It is surrounded by an atmosphere
of very lax connective tissue, which allows a considerable
degree of mobility to the tube. The mobility of the
trachea is greater in children than in adults, and adds
much to the difficulties of tracheotomy. In this pro-
cedure 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 further 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

152 Surgical Applied Anatomy. [Chap. ix.

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 2f inches (7 cm.). The full distance
in a child between three and five years is about 1^ 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 dia-
meter 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 tubes below 12 mm. are for children,
and are divided into four sets.

-kt -. ( with a clia- } .-. \ is suitable for )ni„^T,„_„„i

Ino 1. < , j. > b mm. \ i --I i o \ 1* to. 4 years of age.

( meter of ) ( children from )

No. 2. ,, 8 mm. „ 4 to 8 ,,

No. 3. ,, 10 mm. „ 8 to 12

No. 4. ,, 12 mm. ,, 12 to 15 ,,

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

In performing tracheotomy it is most important that
the head be thrown as far back as possible, and that
the chin 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 reader may be reminded that 12 mm. = about h an
inch, and 6 mm., therefore, = about j of an inch.

Chap, ix.] The Neck. 153

the following parts are met with. Beneath the integu-
ment 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 interfascial space at the upper
border of the sternum. Sometimes there are many
communicating branches right in front of the tracheo-
tomy 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
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 vari-
able 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 innominate
vein ; and lastly, abnormal branches of the superior
thyroid artery may cross the upper rings of the wind-
Pipe.

The evil of wounding the thyroid isthmus is greatly
exaggerated. I have frequently divided this structure
in performing tracheotomy without any inconvenience
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. by injection
thai would cross the isthmus). The difficulty of
tracheotomy in infants depends upon the shortness
of the neck, the amount of the subcutaneous fat, the

154 Surgical Applied Anatomy. [Chap, ix

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, too, 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 one case, in an infant, the end of a trache-
otomy tube pressing on the front of the trachea produced
an* ulcer that opened the innominate artery (Brit. Med.
Jour., 1885). In introducing tire cannula, if the tracheal
wound be missed, it is easy to thrust the instrument
into the lax tissue beneath 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 \ an inch in
vertical height in well-developed adult su bjects, 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 immediately
under the centre of tlie trachea than has the left tube,

Chap, ix.] The Neck. 155

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 clanger
of inhaled foreign substances depends 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 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. Foreign bodies have been
removed from the right bronchus through a tracheotomy
wound. In this way MacCormac removed from the
bronchus the blade of a tooth forceps.

The thyroid body. — Each lobe should measure
about 2 inches in length, about \\ inches in breadth,
and f 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. Of its three surfaces, the anterior
is covered by the infra-hyoid muscles, its inner rests
on the larynx and trachea, while its outer covers the
carotid sheath. Its prominent posterior border is in
contact at its lower part with the recurrent laryngeal
nerve and oesophagus. Each lobe extends from about
the middle of the thyroid cartilage to the sixth ring
of the trachea. 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 (bronchocele, 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 circumstance is of the utmost value in the
diagnosis of bronchocele from other cervical tumours.

156 Surgical Applied Anatomy, [Chap. ix.

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. The enlarged gland is apt to press
especially upon the veins of the neck, producing engorge-
ment of the face and head, upon the sterno-mastoid
muscle, and the other muscles named, upon the cervical
nerves, and particularly the recurrent laryngeal. In
some cases of dyspnoea produced by rapidly growing
bronchoceles, Bonnet has proposed subcutaneous
section of the 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 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
connection with the interference with the movement
of the larynx in deglutition, serve to explain the difficulty
in swallowing often noticed in bronchocele.

The isthmus of the thyroid gland is developed from
a diverticulum which is protruded from the ventral
wall of the pharynx in the embryo between the man-
dibular and hyoid parts of the tongue. The foramen
caecum of the tongue represents the spot where the
diverticulum leaves the pharynx. From this foramen
a duct (the thyro-giossal) may be found to lead to
accessory gland masses about the hyoid bone. In the
vicinity of this bone accessory glands and small cysts
lined with epithelium are not infrequently met with.
These glands, together with the so-called pyramid or
middle lobe, are the remains of the neck of the primitive
diverticulum. The pyramid, which is nearly always
connected to the hyoid bone by the levator thyroidese,
exists in 79 per cent, of the subjects examined

chap, x.] The Neck. 157

(Streckeisen). The lateral lobes are developed from the
fourth visceral clefts. The median diverticulum occa-
sionally fails to join one of the lateral, in which case the
isthmus is partially absent. Small accessory thyroid
bodies are frequently present.

The parathyroid bodies appear to play an essential
part in the function of the thyroid. They are of the
size of small peas, and have a structure similar to that
of the suprarenal bodies. Two are usually found on
each side, one at the lower pole of the lateral lobe, the
other behind the lobe amongst the terminal branches of
the inferior thyroid artery.

Atrophy of the thyroid gland, or its destruction
by disease, is apt to lead to a general condition of the
body known as myxcedema. The condition closely
resembles cretinism, especially as met with in goitrous
subjects. Myxoedema may follow the entire excision
of the gland by operation, and has been produced in
monkeys by experimental removal of the same. One
prominent feature in myxcedema is the swelling of
the subcutaneous tissues from an accumulation therein
of a mucinoid substance. " The probable function
of the thyroid gland, as established by experiments
and clinical observation, concerns, in the first place,
the control of the mucinoid substances in the tissues
of the body, and albuminoid metabolism to some extent ;
and in the second place, hsemapcesis, i.e. manufacture
of blood corpuscles " (Victor Horsley).

Vaso-motor nerves reach the thyroid through the
lower part of the cervical sympathetic chain, and by the
same course nerves pass upwards to the eye. These
nerves appear to be connected centrally, probably in
the medulla, for in certain conditions enlargement of
the thyroid is accompanied by protrusion of the eye
(exophthalmic goitre). The lymphatics of the thyroid
are numerous, and pass to the deep cervical and superior
mediastinal lymph glands.

In excision of the thyroid gland a Y-shaped median
cut is usually made that divides the skin, fascia, platysma,
and auterior jugular veins. The sterno-hyoid. sterno-

158 Surgical Applied Anatomy. [Chap.. ix.

thyroid, omohyoid, and portion of the sterno-mastoid
have usually to be divided. The tumour is carefully
separated. The capsule that invests the vascular gland
must not be torn through. The thyroid vessels are
ligatured in situ before the removal of the mass. The
superior thyroid meets the gland at the apex of the
lateral lobe and is there secured. The inferior thyroid
artery enters the lower part of the lobe at its posterior
aspect. In securing this vessel, and in liberating the
lower part of the tumour, the recurrent laryngeal nerve
is in great danger of being damaged. The thyroidea
ima artery exists in 10 per cent, of all cases.

The gullet commences opposite the sixth cervical
vertebra, and pierces the diaphragm opposite the tenth
dorsal vertebra. The point is marked on the back
by the overlapping spine of the ninth dorsal vertebra.
By placing the stethoscope a little to the left of this
spine fluid may be heard to enter the stomach. 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 care-
fully 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 commence-
ment, one about 2f inches from that point, and a third
where the tube passed through the diaphragm. The
diameter at each of these points was a little over ^ an
inch (14 mm.) ; the diameter elsewhere was about f of
an inch (17 mm. to 21 mm.). By forcible 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 1 inches
(35 mm.). It follows that foreign bodies when swallowed

chr.p. ix.] The Neck. 159

are must apt to lodge either at the commence merit
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 following
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 azygos 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. 47 and 49, pp. 353 and 361.)

Xow, 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 afterwards 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. 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 intervertebral 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 usually 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

160 Surgical Applied Anatomy, tckap. ix.

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 sensory nerve supply of the oesophagus comes
mainly from the fifth dorsal segment of the cord (Head).
In cases of cancer or burns of the gullet pain is referred
to the skin of this segment (see Fig. 39, p. 295).

The operation of flesophagotoiny 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 sterno-
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, thoracic duct, or the recurrent nerve. The
gullet, when exposed, is opened by a vertical incision.

In oesopliagfostomy an 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 performing
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 in some twenty-
six cases in which the operation has been already per-
formed 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 resistance

chap, ix.] The Neck. r 6 i

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 aneurysmal disease from the
aorta, although in many cases they have an independent
origin. It is in the neck that the treatment of aneurism
by the distal ligature is most often carried out. There
is no 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 intervening 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) shrinks in con-
sequence. Wardrop's operation, or the distal ligature
of large branches for the relief of aneurism of a main
trunk, is now, perhaps, quite limited as to its performance
to the ligature of the carotid and subclavian arteries
for innominate aneurism. 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
subclavian arteries arise at an angle to that axis, and
it is upon this fact that reasons have been founded for

1 62 Surgical Applied Anatomy. [Chap. ix.

selecting the vessels of the right side (Bar well). 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 fre-
quency 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 of
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.

The vertebral artery has been ligatured with doubt-
ful benefit in cases of epilepsy. It is surrounded by
vasomotor nerves derived from the inferior cervical
ganglion, which also are necessarily tied. The artery
is reached- through an incision made along the posterior
border of the sterno-mastoid muscle just above the
clavicle. The " carotid tubercle " {see page 136) is then
sought for, and vertically below it lies the artery in the
gap between the scalenus anticus and longus colli
muscles. The procedure is surrounded with considerable
difficulties.

Dr. Bright and Dr. Bamskill have stated that dis-
ease 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 suboccipital 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 com-
municating branch may serve to explain the symptom
noted. In some of Dr. RamskiU'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 innominate artery

chap, ix.] The Neck. 163

has been temporarily compressed through an incision
made in the median line near to the vessel. The posterior
aspect of the artery is exposed and compressed by the
finger against the sterno-clavicular articulation.

In cases of bleeding from branches of the external
carotid it is better, when possible, to ligature the trunk
of that vessel in preference to securing the common
carotid. The latter procedure has a high death rate
(50 per cent.), due (1) to brain mischief, following the
lessened blood stream through the internal carotid, and
(2) to secondary haemorrhage, due to the very free
anastomosing channels.

Air in veins. — The veins of the neck are under
the influence of the respiratory movements. The
veins do not collapse owing to attachments to the
surrounding fasciae. During inspiration these vessels
become more or less emptied ; during expiration
they become enlarged and turgid. With greatly im-
peded breathing they may attain formidable size.
Since ether usually causes some respiratory difficulty,
it is seldom administered in operations on the neck.
The only other veins that are under the influence of the
aspiratory power of the thorax are the axillary vein
and its larger tributaries. When any one of these vessels
is wounded, and the wound is for the moment dry, air
may very readily be drawn into it during the inspiratory
act, just as air is drawn into the trachea. The air causes
embolism of the pulmonary capillaries.

The lymphatic glands of the head and
neck are numerous, and arranged in the following sets
(Fig. 21) :-

(1) Submaxillary glands, 10 to 15 in number, situated
at the lower border of the jaw beneath the cervical fascia ;
(2) the supra-hyoid, 1 or 2 in number, situated between
the chin and hyoid bone near the middle line ; (.3) paro-
tid or pre-auricular set, situated in and over the parotid
gland ; (4) post-auriciilar, or mastoid, 2 to 4 in number,
situated over the mastoid process ; (5) occipital, 3 to 5
in number, over the insertion of the complexus muscle ;
(6) superficial cervical glands, often absent, situated

164

Surgical Applied Anatomy. [Chap. ix.

over the sterno-mastoid along the external jugular vein ;
(7) laryngeal, 1 to 3 in number, below the great horn

Fig. 21. — Showing the position of the Lymphatic Glands of the Head and
Neck. The outlines of the sterno-mastoid (s.M.) trapezius (trai\),
internal jugular, subclavian, and right innominat veins are shown.

l, Submaxillary glands, 1' area drained ; 2, suprahyoid elands, 2' aren drained :
3, parotid glands, : V area drained ; 4, post auricular glands, 4' area drained ;
5, occipital glands, 5' area drained; 6, in front of external jugular vein,
marking position of the superficial cervical glands ; 7, laryngeal gland ; 8, 8, 8,
upper deep cervical glands; 9,9,9, lower deep cervical glands: 10, gland
receiving lymph from thyroid ; ll, superior mediastinal glands: 12, axillary
glands.

Chap, ix.] The Neck. 165

of the hyoid ; (8) the upper deep cervical set, 10 to 20
in number, .situated over the upper part of the internal
jugular vein and bifurcation of the common carotid
artery ; (9) lower deep cervical set, surrounding the
terminal parts of the internal jugular, subclavian, external
jugular, and transverse cervical veins. This set becomes
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 arc 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 incited by injury, and perhaps by ex-
posure 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 = occipital and post-auricular
glands. Frontal and parietal portions = parotid glands
(Fig. 21).

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 = deep 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

1 66 Surgical Applied Anatomy. [Chap. ix.

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

In the removal of the deep cervical glands a number
of structures are liable to be wounded. The glands
frequently become firmly adherent to the internal
jugular vein ; the uppermost glands surround the
spinal accessory nerve ; the superficial cervical nerves
pass among those of the lower deep cervical set ; the
thoracic duct has been wounded in removing glands
from the left supra-clavicular fossa.

Branchial fistiilae — 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 foetus between the branchial
arches. The arches are usually described as five in
number. The first lays the foundation for the lower
jaw and malleus. 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 in-
wards or backwards and upwards towards the pharynx
or oesophagus " (Paget). Their length is about \\ 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. About some of these fistuhe, or in
spots where they commonly open, flat pieces of cartilage
may be found. The more prominent of these have been
termed supernumerary auricles. Certain dermoid cysts
of the neck arise from unobliterated branchial spaces,

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

Chap, ix.] The Neck. 167

and it would appear also that certain polycystic con-
genital tumours, occurring as one form of " hydrocele
of the neck,"' may be developed from an imperfectly
closed cleft. 1 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).

His has shown that many branchial fistuke and
cysts are formed from the cervical sinus. The cervical
sinus is produced in the neck of the embryo by a rapid
growth in the second and third arches which causes them
to grow backwards and overlap the fourth and fifth.
The piece of epi'blast thus included in the neck usually
disappears, but it may persist and give rise to a cyst
or, if open, to a fistula. It is to be remembered that the
branchial clefts are only depressions in the wall of the
pharynx, not complete fissures. Hence fistuke rarely
communicate with the pharynx

i68

$art ih

CHAPTER X.

THE THOEAX.

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 inspiration
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 atmo-
spheric pressure upon the external wall of the chest
must produce some effect, being unbalanced by a like
pressure upon the inner chest wall. In children, and
especially in rickety children, the thorax is very pliable

chap.'x.] The Thorax. 169

and elastic, and if a constant impediment exists to the
entrance of air, as afforded, for example, by the 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."

Deformities of the chest result from abnormal
curvatures of the dorsal part of the spinal column. The
ribs are firmly bound to the vertebras by the costo-
vertebral and costo-trans verse ligaments, and hence
alteration in the position of vertebras is attended by
changes in the costal series. When the spinal muscles
are no longer able to keep the vertebras firmly erect,
the spinal column yields under the weight of the upper
half of the body. In scoliosis of the spine not only is a
lateral curvature formed, but the vertebras undergo a
rotation at the same time. The vertebral bodies move
towards the convexity and their spines towards the
concavity of the curvature (Fig. 22). The ribs on the
concave side are carried forwards on the transverse
processes and their angles open out, the side of the
chest becoming flattened behind. On the other side
(convex) the angles are unduly prominent, for the ribs
are carried backwards at their vertebral extremities
and bent inwards in front. The transverse diameter
of the chest thus becomes oblique (Fig. 22). On the
concave side the intercostal spaces are diminished in
size, the ribs even coming into contact, while on the
convex side the spaces are increased in size. The thoracic
viscera are necessarily distorted in shape and altered
in position.

The sternum. — The upper edge of the sternum
corresponds to the disc between the second and third
dorsal vertebrae, and the sterno-xiphoid joint to the
middle of the ninth dorsal. In the foetus at full term
the upper edge of the sternum is opposite the middle
of the first dorsal vertebra (Symington). A trans-
verse ridge may be felt upon its anterior surface that.

I7°

Surgical Applied Anatomy. [Chap, x.

corresponds to the junction of the manubrium 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

r d

A.R 0

Fig. 22. — Showing the changes in the Thorax which follow Scoliosis of
the Spine. (After Redard.)

a.p.d., An tern-posterior axis of the vertebra ; t.d., transverse diameter of
the chest: s., sternum.

are ossified and the chest more rigid, the tendency to
fracture is increased. The sternum is most often found
fractured in connection 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 usuallv transverse, and

Chap, x.] The Thorax. T71

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 not
united at all, it follows that the lesion is in many cases
a dislocation rather than a fracture. The manubrium
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 watchmaker, caused
the second piece of the sternum to glide backwards
behind the manubrium. Here, probably, 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 requiring
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 abscesses pass deeply into the thorax.
These holes result from imperfect union of the right
and left sternal bars, out of which the sternum is formed.
In the case of E. Groux, the bone was separated ver-
tically 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. If a

172 Surgical Apt lied Anatomy. [Chap. x.

horizontal line be drawn round the body at the level of
the inferior angle of the scapula, Avhile the arms are at
the side, the line would cut the sternum in front at the
attachment of the sixth cartilage, would cut the fifth
rib at the nipple line, and the eighth 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 cor-
responds to the sixth. The longest rib is the seventh,
the shortest the first. In 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 approxi-
mate 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, 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
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

Chap, x.] The Thorax. 173

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 vio-
lence, as during coughing, and in violent expulsive
efforts such as are incident to labour. In such instances
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 expiration,
and can be increased in width by bending the body
over to the opposite side.

Paracentesis 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 space be selected
there is danger of wounding the diaphragm, especially
upon the right side. If the eighth or ninth space is
selected the incision is made just external to the line
of the angle of the scapula. 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,

174 Surgical Applied Anatomy. [Chap. x.

owing to the thick covering of muscles upon the thoracic
Wall m 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 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.

Removal of ribs. — In order to obtain a free
opening into the pleural cavity a portion of one or even
two ribs may be excised.

In some cases of long-standing empyema with open
sinus all that part of the bony wall of the thorax which
corresponds to the outer boundary of the suppurating
cavity is removed in order that the cavity may collapse
and be in a position to close. This latter measure is
known as Estlander's operation, or thoracoplasty. In
some instances portions of as many as nine ribs have
been excised, and the total length of bone removed
has reached 50 to 60 inches.

In removing a rib the bone is entirely bared of
periosteum with the rugine, and the excision is extra-
periosteal. Imthis way the intercostal vessels are not
exposed, and, if divided subsequently, can be readily
secured when the ribs are out of the way.

Chap, x.] The Thorax. 175

The internal mammary artery runs parallel
to trie border of the sternum, and about h 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
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 second
rib above to the sixth below, and from the side of the
sternum to the mid-axillary line (Stiles). In cases of
retained lactation the twelve to fifteen irregular lobes
which make up the body of the gland can be felt radiating
outwards from the nipple. The lactiferous ducts,
which correspond in number to the lobes, open at the
apex of the nipple, within which each shows a dilata-
tion or ampulla. Branching processes of adjoining
lobes unite and enclose spaces within the body of the
gland, containing connective tissue and masses of fat.
After the menopause, when the glandular tissue is
absorbed in great part, and during the resting con-
dition, fat forms the greater part of the female breast,
Besides the main body of the gland. Stiles has drawn
attention to numerous peripheral processes which lie
in the surrounding connective tissue.

Although the principal part of the breast rests on
the pectoralis major, quite one-third of the gland
crosses the outer border and rests on the serratus
magnus within the axilla. It also covers the origins
of the obliquus abdominis externus and rectus abdominis.
In excision or inflammation of the breast it is important
to bind the arm by the side to keep the parts from being
disturbed by the pectoralis major. Peripheral processes
of the gland and many of its deep lymphatics enter
the pectoral sheath, hence the removal of this
structure, and even part of the muscle, if complete
extirpation of cancer is to be assured. The loose retro-
mammary tissue which binds the mamma loosely to
the pectoral sheath may be the seat of abscess, or some-
times of a bursal cyst.

176 Surgical Applied Anatomy. [Chap. x.

The nipple is situated on the fourth intercostal
space, about § of an inch from the junction of the ribs
with their cartilages. It contains erectile and muscular
tissue, and is richly supplied by cutaneous branches
of the third and fourth spinal nerves. The skin is
pigmented, thin and sensitive, and often the seat of
painful fissures and excoriations. In painful diseases
of the breast, tender areas occur over the fourth
and fifth spinal segments (Fig. 39, p. 295) (Head).

The breast is developed by a solid invagination of
epiblast at the point afterwards marked by the nipple.
About the sixth month of fcetal life the primitive
mammary bud branches out in all directions within
the subcutaneous tissue. Thus it comes about that
the subcutaneous fascia is condensed around the gland,
forming its capsule. The retro-mammary part of the
capsule is connected at the interlobular spaces with
the superficial layer, which in turn is fixed to the skin
by subcutaneous bands, or skin ligaments.

It is through lymph channels that cancer spreads,
and those of the breast, which is one of the commonest
sites of cancer, are of especial importance if complete
eradication of the disease is to be obtained. The lymph
vessels are arranged in the following sets : (1) Peri-
lobular, round the acini and lobules ; (2) periductal,
round the lactiferous ducts ; (3) interlobar, situated
in the interlobar septa and joining (4) the retro-
mammary network with (5) the superficial mammary
in the anterior part of the capsule. If the interlobar
septa are invaded by cancer they contract, and through
their cutaneous attachments cause depressions in the
skin ; if the process invades the periductal vessels, the
nipple is retracted. The mammary lymphatic system is
connected with the subcutaneous network of vessels, to
which cancer may spread, producing that variety of
the disease known as cancer en cuirasse. Through
communications with the lymph channels of the pectoral
fascia and muscle, cancer of the breast may spread to
these structures. The gland then becomes firmly
fixed to the deeply seated structures. The great bulk

chap, x.j The Thoraa. 177

of the lymph vessels pass from the breast to the
pectoral glands, six to eight in number, situated along
the anterior border of the axilla, and to the central
axillary set, twelve to fifteen in number, situated
beneath the axillary tuft of hair and on the inner
side of the axillary vein. From these two sets the
lymph vessels pass to the deep axillary glands lying
along the front and inner side of the axillary vessels.
The deep axillary glands become continuous with the
lower deep cervical glands. It is mainly along this path
that cancer tends to spread, but vessels leave the inner
segment of the breast and pass to the anterior inter-
costal glands situated in the upper four intercostal
spaces and lying on each side of the internal mammary
vessels, while occasionally a few vessels pjass to the
cephalic gland situated in the hiatus between the deltoid
and pectoralis major muscles. When the normal
channels become clogged with cancerous emboli the
lymph passes by circuitous paths. The subscapidar
glands, surrounding the subscapular vessels on the
posterior wall of the axilla, may become infiltrated ;
through the lymphatics of the arm, which end in the
central axillary glands, the structures round the shoulder
may become the seats of secondary deposit, and through
the communication between the lymph system of one
breast with that of the other, across the sternum, a
secondary deposit may even occur in the opposite breast
(Stiles).

The breast is thinnest along a line drawn from the
sterno-clavicular joint to the nipple. Abscesses situated
beneath the breast not unfrequently make their way
through the gland at some point along this line.
Abscesses of the breast should be opened by incisions
radiating from the nipple, to avoid wounding the
lactiferous ducts.

The intercosto-humeral nerve pierces the central
set of axillary glands. It becomes compressed when
these glands are invaded by cancer, and pain is referred
to the termination of the nerve over the posterior aspect
of the arm above the elbow. Various parts of the

178 Surgical Applied Anatomy. [Chap. x.

brachial plexus may also become involved or the axillary
vein or lymphatics occluded, the arm being swollen
and cedematous in consequence.

The following groups of arteries supply the gland
and are cut in excision of the organ: (1) The long
thoracic, alar thoracic, thoracic branches of the acromio-
thoracic axis ; (2) anterior perforating branches from
the internal mammary at the second, third, and fourth
intercostal spaces ; (3) lateral branches from the second,
third, and fourth intercostal arteries.

Supernumerary nipples and breasts may occur.
They are commonly found in a line between the axilla
and the groin. In the embryonic stage of all mammals
an epiblastic mammary ridge is found in this position.
In man it disappears except at one point, but occasionally
some isolated part may persist and- proceed to form a
breast. Embryology fails to explain the occurrence of
breasts on the buttock or back, where they are
occasionally found.

2. The thoracic viscera.

The Jung. — The apex of the lung rises in the neck
from 1 to 2 inches above the anterior end of the first
rib. Its highest point lies \ an inch above the sternal
end of the clavicle, in the interval between the sternal
and clavicular heads of the sterno-mastoid muscle. The
anterior edges of the two lungs lie behind the sterno-
clavicular articulations, pass obliquely behind the manu-
brium, and meet in the middle line at the junction of the
manubrium with the gladiolus. The edge of the right
lung then continues vertically downwards 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.
Occasionally it does not diverge, but completely covers
the pericardium up to the edge of the sternum. In the
child, owing to the thymus, the lungs are more separated
in front. The right reaches the middle line, but the

char,. x.] The Thorax. 179

left only reaches the left edge of the sternum (Syming-
ton). 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 eleventh
dorsal spine behind. In the mammary line this
would correspond to the sixth rib, in the mid-axillary
line to the ninth rib, and vertically downwards
from the inferior angle of the scapula, with the
tenth rib. The cartilages of the false and floating
ribs lie below the pleural line. The pleura extends
farther down than the lung, reaching in front to the
level of the seventh chondro-sternal union, behind to the
twelfth dorsal spine, and at the sides to a point some
%\ 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. The lowest part of the pleura is only sepa-
rated from the kidneys by the thin layer of the dia-
phragm. The pleura is in relation with the twelfth
rib, but occasionally it descends \ an inch or more below
this point, and may be wounded in operations on the
kidney. It extends lower clown in the child than in
the adult. The left lung descends to a slightly lower
level than the right.

In penetrating wounds involving the pleura, air
may enter the pleural cavity, producing pneumo-thorax,
and this air may be subsequently pressed by the respira-
tory movements into the subcutaneous tissues through
the wound in the parietal pleura, and lead to surgical
emphysema. The cohesion between the smooth pul-
monary and parietal layers of pleura is such that occa-
sionally collapse does not follow, but the intimate connec-
tion between them makes it difficult for the pulmonary
to escape when the parietal layer is wounded. 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 sub-
cutaneous tissues through the pleural wound, thus
producing both pneumo-thorax and emphysema.

It is well to note that emphysema may occur about

180 Surgical Applied Anatomy. [Chap. x.

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 respira-
tory 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, owing to the amount of elastic tissue they
contain, become more or less collapsed ; yet a few cases
have been recorded where the lung has protruded at
the time of the accident through the wound in the
parietes. In such instances 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 protruded
before air could enter the pleural space. It is
noticeable that these recent hernia? are most common
at the anterior part of the chest where the lungs are
the most movable, and the injuries that bring them
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 hemothorax). In some instances the lung
has been ruptured without wound and without frac-
ture to 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 super-
incumbent 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.

Chap. X.]

The Thorax.

isi

Lung cavities resulting from tuberculosis, gan-
grene, or bronchiectasis, have been successfully incised
and drained, and the same measure has been applied
to hydra ted cysts of the lung. Deep incisions in the lung

mkki

Fig. ,23.— Diagram to show the relations of the Heart to the Surface.
{After Riidinger.)

a, Left innominate vein: b, right innominate vein ; c, superior vena cava; d,
right auricle ; e, inferior vena cava ; /, aorta ; g, pulmonary artery; h, right
ventricle ; ?', left ventricle ; j, left auricle.

are followed by less haemorrhage than might be expected
from such a vascular organ.

The trauliea divides opposite the junction of the
manubrium and gladiolus in front, and the fourth
dorsal vertebra behind (Fig. 47, p. 353). In the newly
bom the trachea bifurcates opposite the third vertebra
(Symington).

182 Surgical Applied Anatomy. [Chap. x.

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 escaped 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
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
seventh right chondro-sternal articulation to the apex.
Its apex is opposite the fifth interspace, at the junction
of the ribs, with their cartilages. Its base is opposite
the fifth, sixth, seventh and eighth dorsal vertebra?.
Its left border is represented by an 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 sternum.
The vessel proceeds upward under cover of the second
left outer space and 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 corresponds to the point between the
first and second pieces of the sternum. The auriculo-
ventricular orifices are behind the sternum, the right
being opposite the fourth spaces, and the left on a level
with the fourth cartilages. The innominate and left
carotid arteries come off at a spot corresponding to the
middle of the manubrium, and run behind the right and
left sterno-clavicular 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

Chap. The Thorax. iS

j

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 inter-
costal spaces if the knife were kept fairly near to the
sternum. (See Fig. 23, which shows the relations of the
heart and great vessels as given by Rudinger. and which
differs somewhat from the above account.)

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
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 to actual haemorrhage.
Many instances have been recorded to show that the
heart may be very tolerant of foreign bodies in its sub-
stance. 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 6 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).
Wounds of the heart have been sutured, the insertion
of the stitches causing only momentary disturbance
of its action. 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.

184 Surgical Applied Anatomy. [Chap. x.

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 extent to which
the pericardium is left uncovered by the left pleura
varies in extent, bat as a rule it may be tapped at any
point in the fourth and fifth intercostal spaces, not
further than an inch from the sternum, without clanger
to the pleura.

The niediastina. — 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 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 sympathetic (Figs.
47 and 49, pp.353 and 361). The numerous lymphatic
glands which surround the trachea, bronchi, and ceso
phagus are often the seat of tuberculosis. They become
adherent to these organs and may ulcerate into them.

Krabbel reports a case of fracture of the ninth dorsal
vertebra associated with rupture of the thoracic duct.
The patient died in a few days, and the right pleura
was found to contain more than a gallon of pure chyle.

}3art Hi.

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
process, and scapular spine are all subcutaneous, and
can be readily felt. In the upright position, when the
arm Jiangs 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. 24).

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 front of the arm. A

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

1S6 Surgical Applied Anatomy. [Chap. xi.

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 ths 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 prom-
inence 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, therefore, 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 acromion 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 dislocations by manipula-
tion, the condyle being used as 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

Chap, xi.] The Region of the Shoulder. 1S7

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 possible
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. The upper border of the
scapula lies on the second rib, its lower angle on the
seventh.

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
and deltoid muscles is usually to be made out. In it
run the cephalic vein and a large branch of the acromio-
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 for-
wards, 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 humerus, in fractures of the clavicle
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 dec})

i88 Surgical Applied Anatomy. [Chap. xi.

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. It is most deep when the arm is raised from
the side at an angle of about 45°, and when the muscles
forming the borders of the space are in a state of con-
traction. As the arm is raised above the horizontal
line the depression becomes shallower, the head of the
bono, 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 central set lies beneath the
axillary tuft of hair.

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 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 sub-
scapular artery corresponds to the lower border of the

chap xi.] The Region oe the Shoulder

189

subscapulars muscle along which it runs, but the posi-
tion of this border can only be approximately indicated
on the living or un dissected subject.

The circumflex nerve and posterior circumflex
artery cross the humerus in a horizontal line that is

2 1 v

2 J- V n m

' / / ' ! \

l s

Fig. 24. — Horizontal Section of the Body just below the Upper Border
of the Manubrium (Braune).

it. Manubrium ; b, head uf humerus ; c, clavicle ; d, first rib ; e, second rib ; /, third
dorsd vertebra ; g, spine of second dorsal ; h, pect oralis major; i, deltoid ;
/.infraspinatus; k, subscapulars ; I, coraeo-brachialis and biceps: m, pec-
toralis minor; n, serratus magnus; 0, intercostals ; p, semispinalis and
umltifldus spina; ; q, biventer cervicis and complexus; r, longissimus dorsi ;
?, splen;us colli : t, rnomboideus ; u, trapezius ; v. sterno-tbyroid ; w, sterno-
hyoid ; t, thymus ; l, lung ; 1, left innominate vein ; 2, left carotid arterj ;
,-i, left subclavian artery : 4, vertebral artery ; 5, left subclavian vein ;
G, cephalic vein ; ', phrenic nerve ; 8, vagus ; 9, transverse scapular artery.

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 scapula? artery crosses the axillary border of
the scapula at a point corresponding to the centie of
the vertical axis of the deltoid muscle. These various
indications uf the positions of the main branches of

igo Surgical Aptlied Anatomy. [Chap, xi.

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 con-
tusion, 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 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 first 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 resistance 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. Fortunately, 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 case
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

chap. xi. i The Region of the Shoulder. 191

arrested. Behind the clavicle the following structures
may be noted, viz., the innominate, subclavian, and
external jugular veins, the subclavian, suprascapular,
and internal mammary arteries, the cords of the brachial
plexus, the phrenic nerve and nerve of Bell, the thoracic
duct, the omo-hyoid, scalene sternohyoid 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.

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 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 impairment of the arm move-
ments than would be imagined.

The clavicle forms the sole direct bony connection
between the upper limb and the trunk, and in severe
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 lad
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 communicated 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. The bone breaks at this spot for the

ig2 Surgical Applied Anatomy. [Chap.'xi.

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 position of the coraco-clavicular ligaments is no
doubt of the greatest import in localising the fracture
in this position, since a clavicle experimentally subjected
to longitudinal compression does not break at this spot
(Bennett). 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 displacement. (1) It is carried directly down-
wards. 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. Since
the line of action of the trapezius muscle is altered by
the fracture, that muscle is no longer able to keep the
shoulder up, and its altered action therefore contributes
to the downward displacement. (2) It is carried directly
inwards by the muscles that pass from the trunk to the
shoulder, viz. the trapezius, the levator anguli scapuhe,
the rhomboids, the latissimus dorsi, and especially by
the pectorals. To these may be added the subclavius.
(3) The fragment is rotated in such a way that the
outer end projects forwards, the inner end backwards.
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 dis-

Chap, xi.] The Region of the Shoulder. 193

placement 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 displacement, 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 im-
portant action of the scapula in remedying the dis-
placement 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
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 displacement 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

N

1 94 Surgical Applied Anatomy. [Chap. xi.

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 condition 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, circumstances that greatly favour subperiosteal
fracture.

A reference to the relations of the bone will show
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 injury, while due to the original
accident, was yet independent of the broken clavicle.
Paralysis of the biceps, brachialis anticus and supinator
longus, muscles supplied through the upper cord, may
result from heavy weights being carried on the shoulder.
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 without 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 sur-

Chap, xi.] The Regiox of the Shoulder. 195

rounded by the ligaments of the sternal joint, and
cannot, therefore, be well separated by accident.*

Sterno-claviculai- joint. — Although this is
the only articulation that directly connects the upper
limb with the trunk, yet it -is possessed of such con-
siderable strength that luxation at the joint is com-"
paratively rare. The amount of movement in the
joint depends to a great extent upon the lack of adapta-
bility 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 of the clavicular
surface. 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
immediate 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 joint is supplied by the suprasternal nerve.

The movements permitted at this point are limited,
owing to the anterior and posterior ster no-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 substantial than is the posterior
band. Its weakness serves in part to explain the fre-
quency of the dislocation forwards.

Movement of the clavicle backwards on the sternum^
is checkedjby the anterior ligament, while the passage
of the head of the bone is resisted by the powerful pos-
terior band. The movement is also opposed by the
rhomboid ligament. To produce, therefore, a dislocation

* 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 m situ. The rmiscle producing the
accident was apparently the pectoralis major.

196 Surgical Applied Anatomy. [Chap. xi.

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, and in a less direct manner by
the two remaining ligaments of the joint. Thus it
happens that dislocation 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 Decomes 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 articu-
lation. 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 medias-
tinum. The relations of this joint to the great vessels
at the root of the neck should be borne in mind. In
one case reported bjr 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 circumstance may be explained
(1) by the constant slight movement in the part, which
prevents the diseased structures from being kept at rest,

chap, xi.] The Region of the Shoulder. 197

(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-clavicnlar 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, carrying 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 liga-
ment. The head is found in the connective tissue behind
the sterno-hyoid and sterno-thyroid muscles. In this
position it may cause severe dyspncea, 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 innominate vein as to
produce semi-coma (Fig. 24, p. 189). 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
of retaining the clavicle in position after it is replaced.
Acromioclavicular 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.

198 Surgical Applied Anatomy. [Chap. xi.

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 displace-
ment of the clavicle upwards on to the acromion. The
capsule that surrounds the joint is lax and feeble, 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. The effects of shock at this joint are lessened
by the presence of a partial fibro-cartilage which projects
between the bones from the upper part of the capsule.

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 movements of the
extremity. The scapula (and with it, of course, the
arm), as it glides forwards and backwards upon the
thorax, moves in the arc of a circle whose centre is at
the ster no-clavicular joint, and whose radius is the
clavicle. As the bone moves forwards it is important,
for reasons to be immediately 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 should be main-
tained 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

Chap, xi.] The Region of the Shoulder. 199

stretched forwards, and a blow given with the limb in
that position, or a fall upon the hand under like con-
ditions, 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 articulation of the shoulder, and of weakness
in certain movements in the limb.

Dislocations of the acromio - clavicular
joint. — The clavicle may be displaced upwards on
to the acromion or downwards beneath it. Pollaillon
has collected thirty-eight cases of the former luxation,
and six only of the latter. This disproportion is, in
the main, explained by the direction of the articulating
surfaces of the joint, Both luxations are usually due
to direct violence. The dislocation upwards is very
commonly only partial, and is associated only with
stretching and some trifling rupture of ligaments. In
the complete form, where the end of the clavicle rests
entirely upon the 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 dis-
location downwards, also, there is a rupture of the
capsule, with extensive tearing of the conoid and trape-
zoid 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 Lone
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,

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

2 o o Sur gica l Applied Ana to my. [ chap, x i .

-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 infraspinatus and teres minor muscles arc 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 infra-spinous fossae,
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
infraspinatus 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
injuries the angle may slip from beneath the muscle
and appear as a marked projection. This lesion is
productive 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, epiphyseal centres
for the acromion. Ossification appears in them about

chap, xi.] The Region oe the Shoulder. 201

puberty, nnd the entire epiphysis joins with the rest
of the bone from 1 ho 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 five bodies out of forty
Symington found the acromial epiphysis united to the
spine by a fibrous union, and from the statistics of other
observers it appears that this is the case in quite 10 per
cent, of adults. In fractures of the process much dis-
placement 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, displacement 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. The supra-glenoid
tubercle, from which the long head of the biceps takes
it^ origin, is part of the coracoid epiphysis. In spite
of the powerful muscles attached 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 oft" by muscular
violence.

Among the more usual fracture-; of the body of the
scapula is a transverse or oblique fracture of its blade
below the spine. Owing to the infraspinatus, sub-
scapulars, and other muscles being attached to both frag-
ments, 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

2 O 2 Sl/P GICA L A PPL I ED A NA TOM V. [Chap. XI .

suprascapular notch. The smaller fragment will, there-
fore, 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 he
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 spongy parts of the bone, viz.,
the spine, the neck, the inferior angle. The bone may
be removed entire, with or without amputation of
the upper limb. An inter-scapulo-thoracic amputation
is usually performed for malignant tumours which
involve structures in the neighbourhood of the shoulder
joint. In this operation the upper extremity, including
the scapula and the clavicle beyond the origin of the
sterno-mastoid, is removed. An elliptical incision is
made in front and behind the shoulder, the upper end
of the ellipse lying on the clavicle, the lower at the angle
of the scapula. The operation is commenced at the
clavicle so as to secure the axillary vessels. The artery
is tied before the vein so that the limb may continue
to empty its blood into the circulation. The main
vessels to be noted in connection with this operation
are the suprascapular at the superior border of the
bone, the posterior scapular about the vertebral border,
the subscapular running along the lower border of the
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 surgically
as a passage between the neck and the upper limb.
Axillary tumours and abscesses may spread up into

CI

lap,

XL] The Region or the Shoulder.

20'

the neck, and in like manner cervical growths and
purulent collections may extend to the arm-pit. The
skin forming the hase of the axilla is provided with
many short hairs and with numerous sebaceous and
sudoriferous glands. In this integument small super-
ficial 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
clothing. Owing to
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 in-
unction as applied
in syphilis. Beneath
the skin and super-
ficial fascia? is the
axillary fascia, and
beyond this dense
membrane is the
axillary space. The
connective tissue
with 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
immense 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

ig. 25.— Vertical Sect ion through the Asilla
and Shoulder-joint (Rudinger).

Scapula; 2, humerus; •", clavicle; 4, acromion :
«, trapezius; b, supraspinatus ; c, subacromial
bursa and deltoid; <i, circumflex artery and
nerve ; e.latissimusdorsi ; /. coraco-bracbialis

and biceps; p, subscapuiaris ; h, serratus
mngnns; f, axiUarj nrterj ■ j, axillary vein.

204 Surgical Applied Anatomy, tchap. xi.

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 pos-
terior fold. It is thinnest under the axillary hairs.

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 fascise, the latter separating it
from the axillary space. Such an abscess undermines
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 fascia?. (2) A puru-
lent collection in the axilla may soon fill that space and
distend it entirely. Its progress 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 magnus and the subscapularis muscles. There

Chap, xi.] The Region of the Shoulder. 205

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
l)etween 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 humerus. 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 probably be wounded in the incision above named.
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 four sets. (1) The greater number
are placed to the inner side of the axillary vein beneath
the axillary tuft of hair. This central set of glands
receives the lymph from the upper extremity and breast.
Pain in the axilla which follows whitlow or any septic
infection of the arm is due to inflammation of this
group, which is pierced by the inter-costo-humeral nerve.
(2) The deep axillary set lies along the axillary vessels.
It receiver the lymph from the central set and become-:
continuous with the lower deep cervical glands in the
subclavian triangle (Fig. 21, p. 164). (3) Other glands lie

206 Surgical Ajpplied Anatomy. {Chap. xi.

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 central set of glands.
These glands will be the first to be enlarged in certain
breast affections, and after blistering and other super-
ficial inflammations, etc., of the chest and upper abdomen.
Paulet has seen them affected in inflammation of the
hand. The axillary process of the female breast is in
contact with this set. (4) 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 and breast. 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 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 complete removal of axillary glands is an opera-
tion 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 fre-
quently been wounded or excised 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
comites of the brachial artery. This union commonly

Chap, xi.] The Region of the Shoulder. 207

takes place at the lower border of the subscapular muscle,
and the vein is therefore shorter than the artery. Some-
times 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,
OS many transverse branches cross that vessel to unite
the veins that lie on either side of it. The axillary vein.
b?ing comparatively near the heart, is readily influenced
as regards its contained blood by the inspiratory move-
ment. 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 con-
dition when wounded. This connection with the fascia
is supposed by some to account in part for the furious
bleeding that occurs from this vein when it is divided.

The vein is more often wounded than is the artery,
it being larger, more superficial, and so placed as to more
or less overlap the arterial trunk. On the other hand.
in injury to the vessel 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 part 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

2oS Surgical Applied Anatomy. [Chap. xi.

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. The anterior internal
thoracic nerve appears between the vein and artery
as it passes to the pectoralis minor. It also may
be useful occasionally as a guide.

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

fchap. xi.] The Reg/on of the Shoulder. 209

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 localisation 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.

b 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 con-
tusion 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 readilv understood that

210 Surgical Applied Anatomy. [Chap. Xi.

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 Vich 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 connection 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).

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 articulation 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,

i 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,
though not in actual contact (Fig. 25, p. 203). 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 acromial vault four

Chap, xi.] The Region of the Shoulder. 211

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 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 significant, 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, us
is the case in the hip-joint. The inner part 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 one behind.
It is between these two projections that the humeral
head can be felt through the axilla.

Of the bursa about the joint, the subacromial bursa
is the one most frequently the seat of disease. This sac,
when distendedwith fluid, maybe mistaken for the results
of chronic inflammation of the joint (Fig. 25, p. 203).

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 abduc-
tion, for in this posture the bursal 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, abduction must press the
bursa very forcibly under the acromion, and so cause

2i2 Surgical Applied Anatomy. [Ciiap. xi.

pain. In elderly people the sac sometimes communicates
with the joint. The subscapular bursa is in free com-
munication with the capsule of the joint in front.

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. The intracapsular part
of the tendon may disappear in cases of chronic rheu-
matic arthritis, owing to friction against the abraded
articular surface of the humerus. It acquires an attach-
ment to the bicipital groove in such cases.

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 muscular and 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 \ 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 distension of
the capsule was reached the humerus became slightly

chap, xi.] The Region of the Shoulder. 215

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 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 rotation in and slight
projection backwards of the arm. The inner part of
the epiphyseal cartilage is just within the capsule, the
outer, anterior, and posterior parts are entirely sub-
periosteal. It happens, therefore, that the pus in sup-
purative epiphysitis will find its way into the joint.
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 subscapulars, 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 culs-dc-sac 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 pari of the axilla.
Purulent collections beneath the deltoid are rearlv

214 Surgical Applied A a atomy. [Chap. xi.

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 infra-
spinous muscles. In one recorded case, pus that had
escaped from the shoulder-joint 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 articu-
lation for its strength mainly upon muscles. The upper
limb and shoulder are also peculiarly exposed 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, down-
wards 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

Chap, xi.] The Region of the Shoulder. 215

of the capsule. The fibres of this 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
and by the weight of the unsupported limb (subcoracoid
form) ; and lastly, the direction 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 fre-
quency of the subcoracoid 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 backwards, and by the very trifling opposi-
tion offered to the passage of the head forwards when
compared with the substantial obstacles in the way of its
passage backwards 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 con-
stantly present. Stretching of the deltoid involves
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 the axilla, since the head,
having left the glenoid fossa, must occupy some part
comprised within that circumference. Again, Dr, Dugas

2 1 6 Surgical Applied Anatomy. [Chap. xi.

"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
ithorax (a condition 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 impossibility."
This depends upon the fact that in consequence 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 and
severe pain or loss of muscular power. 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, especially
in the subglenoid and subspinous forms of dislocation.

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 faces the empty glenoid cavity (Fig. 26).
The subscapulars muscle is stretched over the head
of the humerus, and is usually in some part torn. The
supraspinatus, infraspinatus, and teres minor are
stretched or torn, or the great tuberosity may even
be wrenched off. The coraco-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 down-

Chap. XL] The Region of the Shoulder.

217

wards and outwards. It is sometimes, although rarely,
torn from its groove. The deltoid is put upon the
stretch. The prominence formed by the numeral
head in the front of the axilla depends to some degree
upon the amount of rotation. If the bone be rotated
out the projection 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 al-
ways carried a little
downwards, some
lengthening must in
all cases really exist ;
but with the ordin-
ary method of
measuring the limb
this lengthening
may be replaced by
a normal measure-
ment, or even by
apparentshortening.
if the head of the
bone be carried a
good deal forwards
and inwards, and
thelimb 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. Subglenoid.-- -The head is below, and a little
in front of and internal to, its normal position. It
cannot go directly downwards, owing to the situation
of the long head of the triceps, but escapes in the interval

Fie. 20.

-Subcoracoid Dislocation of the
Humerus.

2i8 Surgical Applied Anatomy. [Chap. xi.

between that muscle and the subscapularis. The
articular head rests on the anterior aspect of the tri-
angular 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 prevents 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 supraspinatus
will be torn. The infraspinatus will be stretched or
torn, and the two teres muscles will not be much affected
unless there be considerable abduction 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 flattening 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.

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 corresponding
to the posterior lip of the glenoid 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. 27).
The subscapularis 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 it. The
supraspinatus is 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,

chap, xi.] The Region of the Shoulder.

2 10,

and the adduction forwards, that are usually observed,
those movements being more or less unopposed. The
circumflex nerve is often-
torn.

In reducing disloca-
tions, especially such as
are of long standing,
serious damage may bo
inflicted on the axillary
structures. The axillary
artery suffers most fre-
quently, 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 of the displaced
bone, and to be, there-
fore, torn when those
parts are disturbed.

Fractures of the
upper end of the

humerus. — 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 connect the frag-
ments. 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 comparatively dense upper
fragment to be driveD into the wide surface of cancellous
exposed od the upper surface of the lower fragment.

Fi£

—Subspinous Dislocation of
the Humerus.

220 Surgical Applied Anatomy. [Chap. xi.

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 pro-
jection of the deltoid. It may be possible to detect
the impaction 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 to-
wards the anterior and inner side of the articulation,
brought about mainly by the muscles attached to the
bicipital groove. In no case could the two bone-ends
overlap.

2. Separation of the upper epiphysis. — The
lower border of this epiphysis is represented by a hori-
zontal 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 trans-
verse 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 fragment 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.

Chap. XL; The Rl 7LDER.

:: I

Surgical neck. — The surgical neck is situated
between the bases of the tuberosities and the insertions
of the latissirans dor-i 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 infra-Bpinataa and teres minor. The upper
end of the lower fragment is drawn upward- by the

. —a ..j.utaiiou a*. Shonkter-joini (flap-method) ^Agatz).

..■-id cavity; I, deltoid : <:. lima head . ..-•. - , peel _-.s major; e,
bicepe and coracobrachial - - - -- ;,tricep«;

l, axillary ves.-eli : ■:, circumflex vessels ; 3. brai.;.

deltoid, biceps, coraco-braclnali<. and triceps, inwards
by the muscles attached to toe bicipital groove, and
forwards by the great pectoral Tims, it forms a pro-
jection in the axilla, and the axis of the limb is altered
so that the elbow projects from the side. This displace-
ment, however, is by no me. stank Pean. A:..
and others maintain that the usual deformity is a pro-
jection of the upper end of the lower fragment forwards,
and that this deviation is due to the nature and direction

222 Surgical Applied Anatomy. [Chap. xi.

of the violence, and not to muscular action. In some
cases there is no displacement, the broken ends being
retained in situ, probably, by the biceps tendon and the
long head of the triceps. In at least one instance (Jar-
javay) 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
conclusion " that complete 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 joint.— "Flap
method " • " deltoid flap." In the outer flap are only
the deltoid and a few small vessels derived from the
acromio-thoracic and the two circumflex arteries. The
cephalic vein and descending branch of the acromio-
thoracic artery are in the inner flap. The anterior and
posterior borders of the 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 del-
toid, and not far from the angle 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 XI J.

THE AKM.

The arm, upper arm, or brachial region is considered
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 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 conspicuous. It runs from
the bend of the elbow to the axilla, and indicates gener-
ally the position of the basilic vein and brachial artery.
The outer groove is shallow, and ends above at the in-
sertion 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 pre-
cisely the middle of the shaft of the humerus, is on
the same level with the insertion of the coraco-brachialis
muscle, andmarkstheupper limit of the brachialis anticus.
It corresponds also to the spot where the cylindrical
part of the humeral shaft joins the prismatic portion,
to the point of entrance of the nutrient artery, and to
the level at which the musculo-spiral nerve and superior
profunda artery cross the back of the bone.

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 super-
ficial, and can be felt in its entire extent. In its upper
two-thirds, it lies on the inner aspect of the shaft of tie
humerus, and can be compressed against the bone
by pressure in a direction outwards and slightly Lack

224 Surgical Applied Anatomy, [chap xll.

wards. In its lower third the humerus lies behind it,
and compression, to be effectual, should be directed
backwards.

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.
The nutrient artery enters the bone at its inner aspect
opposite the deltoid insertion, and the anastomotic
vessel comes off about 2 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 cutaneous nerve is be-
neath 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 amputations' 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 dissected up. The looseness of the sub-
cutaneous tissues favours greatly the spread of inflam-
matory processes, while its comparative thinness allows
of the early manifestation of ecchymoses.

The limb is completely invested with 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

chap, xii.j The Arm.

22

margins of the humerus, running from the deltoid
insertion to the outer condyle on the one side, and from
the coraco-brachialis 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 hemorrhagic 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 compartment 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-spiral 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 con-
siderably 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 brachial 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 con-
siderable extent by the biceps muscle. Compression
,of the brachial, unless performed carefully with tin-

226 Surgical Applied Anatomy. [Chap. xii.

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.

Abnormalities in the arrangement of the brachial
artery are so frequent (they occur in 12 to 15 per cent,
of arms) as to be of surgical importance. It is not
unusual to find a collateral branch (vas aberrans) arising
from the upper part of the brachial or lower part of the
axillary, passing down the arm, superficial to the median
nerve, and ending in the radial or sometimes the ulnar
artery. The vas aberrans may replace the brachial,
in which case the artery will be found superficial instead
of deep to the main vessel, and the profunda vessels
arise from the remnant of the real brachial artery.
This superficial brachial vessel may pass under the
supra-condyloid process, a hooked projection of bone
which occasionally springs from the inner aspect of
the humerus, 2 inches above the epicondyle.

chap. xii. j The Arm. 227

The musculo-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 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 ot the humerus 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 frac-
tured 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

228 Surgical Applied Anatomy. [Chap. xn.

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 dis-
placements just noted may be met with, but usually
they are quite independent 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 move-
ment 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 maintained that the bulk of that move-
ment 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 con-
spire 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 the substance of the triceps,

Chap. XII. j

The Arm.

229

and immediate contact of the bones may be consequently
prevented.

Amputation through the middle of the
arm. — Circular method : The parts divided in this
amputation are fully shown in Fig. 29. Flap method :
Two flaps of about equal size and shape may be cut
antero-posteriorly, the arm being well rotated outwards.
In the anterior flap
would be the biceps
and the greater part
of the brachialis anti-
cus, with the musculo-
cutaneous nerve be-
tween 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
the inferior profunda
artery, are also found
in this flap, about the
inner angle of the

stump. The basilic ^•«^fS2K?5fteSSS,ltfli,ie
vein and internal
cutaneous nerve lie
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 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.

middle of the Arm (Braune).

Biceps; b, coraco-brachialis : c, brachialis
amicus ; d, triceps ; 1, brachial artery ; 2, me-
dian nerve; 3, ulnar nerve; 4, musculo spiral
nerve.

230

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 re-
current 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." 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
1 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.

chap, xni.] The Region of the Elbow. 231

At the apex of the V-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 coro-
noid 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 prom-
inent 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 inwards. 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 obliquity of the joint surfaces between the
ulna and humerus, it follows that the fore-arm, when
in extension, 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 rn
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

232 Surgical Applied Anatomy. [Chap. xiii.

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 (Fig. 31, p. 243). The
prominence of the condyles forms a capital point oVappui
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 con-
dyle. 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. Be-
tween 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 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 corre-
sponds 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 point
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

chSp. xiii.] The Region of the Elbow.

m

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. 30).
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 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 abruptly, 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 different level, for the greater part
of its course. As regards size, the median basilic is

Fig. 30.— The Left Elbow
from in front.

a, Basilic vein; b, cephalic
vein; c. on the ulna ooints
to median basilic vein;

d, on the radius points to
median cephalic vein;

e, radial vein; /, median
vein; g, posterior ulnar
vein.

234 Surgical Applied Anatomy, tchap. xm.

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 also are abnormal. The deviation is more usual
in the veins on the radial than in those on the ulnar
side of the limb. Thus 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
and transfusion. The reasons for its selection are these :
it is usually the largest and most prominent of the veins,
and 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 excellent pro-
tection to the brachial artery during phlebotomy. The
density of that membrane varies, and 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,

chap, xin.] The Region of the Elbow. 235

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-cuta neons nerve, espe -ially to the inclusion
of those filaments in a scar left by the operation. The
cutaneous branches of this nerve lie over the median
cephalic vein. These peripheral fibres being irritated,
the muscles supplied from the same segment of the cord
(biceps and brachialis anticus) are caused to contract
by reflex action. Hence the bent arm. In one case
he cured a bent arm following bleeding by resecting
the old scar, which on removal was found to have in-
cluded 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 upper limb.

The brachial 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. The artery may divide
in the lower third of the arm. and in such cases the
ulnar artery may pass over the bicipital fascia. Aneur-
isms 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 become
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. It passes on a groove
behind the internal epicondyle. The nerve may pass
in front of the internal condyle, and an instance is
reported where the nerve slipped forward over that

236 Surgical Applied Anatomy. [Chap. xin.

eminence whenever the elbow was bent(Quain). In cases
where an abnormal brachial passes beneath a supra-
condyloid process the median nerve goes with the artery.
In exposing the ulnar nerve (for nerve stretching, etc.)
behind the elbow the nerve may be found quite covered
by an occasional muscle, the epitrochleo-anconeus.

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
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 wo aid
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°.

Bur see. — Of the bursas about the joint the large
subcutaneous bursa over the olecranon is very com-
monly found enlarged and inflamed ; and when inflamed
may lead to extensive mischief in the limb. Its enlarge-
ment 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

Chap, xin.] The Region of the Elbow. 237

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 liga-
ments of the part. From its rigidity, its extended
attachment, and the fact that it serves to limit not
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 separation 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 that the posterior liga-
ment is lax and thin. Some swelling is also soon noticed
about the line of the radio-humeral joint, and fluctuation
in this situation serves to distinguish joint effusion
from simple enlargement of the bursa 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,

.:>

8 Surgical Applied Anatomy. [Chap. xin.

holds the greatest amount of fluid when it is semi-flexed.
As regards muscular 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 cor-
responding to the distribution of that nerve. The
upper epiphysis of the radius and the greater part of
the lower epiphysis of the humerus are intrasynovial,
i.e. come within the capsule of the joint. The com-
paratively small upper epiphysis of the ulna is only
partly within the capsule (Fig. 31, p. 243).

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 £w&afao?is.-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 movement
of the elbow, and the width of the articulation from
side to side is considerable. The antero-posterior liga-
ments 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

chap, xii i.] The Region of the Elbow. 239

extension the hold of the coronoid process upon that
bone is even less. In a lateral direction, however,
movement has but a very 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 displacement 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 when
in the antero-posterior direction, and partial when the
luxation is lateral.

Some more detailed notice mav now be taken of

240 Surgical Applied Anatomy. [Cha.-.. xm.

the only two forms of dislocation at the elbow that
are at all common.

(1) Displacement of both bones back-
wards.— 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 lateral 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 orbi-
cular 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.

(2) Dislocation of the radius forwards. — This
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 an-
nular ligaments are torn. There would seem to be a
lack of evidence in support of Hamilton's statement
that " sometimes the auterior and external lateral
are alone broken, the annular ligament being then

chap, xi ii. j The Region of the Elboiv. 241

sufficiently stretched to allow of the complete dislocation."
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.

Sprain of the elbow. — Mr. J. Hutchinson,
jun., has shown that in young children, under five
years, forcible traction of the limb in the supinated
position may cause the radius to slip downwards, away
from the orbicular ligament, which is displaced up-
wards. Flexion of the elbow in the pronated position
restores the ligament to its normal position. It is
clear that this displacement is the anatomical basis
of the common sprain of the elbow met with in young
children, and usually due to violent traction of the
hand. The oblique ligament, which passes from the
ulna downwards and outwards to the radius below the
insertion of the biceps and the supinator brevis resists
such a displacement.

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 frac-
tures 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 ole-
cranon 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

Q

242 Surgical Applied Anatomy. [Chap. xm.

carried backwards by the triceps, and upwards by that
muscle, the biceps, and the brachialis antic us. 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 condjdes, 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 ^ 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, back-
wards, and inwards, the ulna going with it.

In the fracture of the external condyle the line com-
mences 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. Fractures
of the inner epicondyle are, however, quite common,
the joint remaining free (Fig. 31). This epicondyle
exists as a distinct epiphysis, which unites at the age
of eighteen, and which at any time before that age may

Chap, xiii.] The Region of the Elbow.

243

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. In such cases the ulnar
nerve, which lies behind the process, is often damaged.

CAP;

Fie, 31.

i. Lower Epiphysis of the Humerus
from behind.

a, Centre for internal epicondyle; b,c,d,
united centres for the trochlea, capi-
telluni, and external epicondyle;
e, k, epiphyseal line; cap., lino
(stippk'dj at which capsule is at-
tached.

ii. Section of Upper Extremity of
the Ulna, showing the small size
of its epiphysis.

cap., Attachment of capsule; o, epi-
physis of olecranon.

6. The lower epiphysis (Fig. 31). The line of this
epiphysis is irregular, running across the bone
between 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 seventeenth year. Thus, after the
age of seventeen 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,

244 Surgical Applied Anatomy. [Chap. xm.

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 separation 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 con-
stricted, and is usually transverse in direction. The
amount of displacement effected by the triceps varies,
and depends upon the extent to which the dense peri-
osteum about the process and the ligaments that are
attached to it are torn. The olecranon is developed
mainly from the shaft of the ulna (Fig. 31). There is a
small epiphysis, however, at the summit of the process
which joins the rest of the olecranon at the age of seven-
teen. It is a mere shell of bone. In young subjects
this scale-like epiphysis may be separated by violence, or
the cartilaginous olecranon may be dissevered from the
rest of the bone. The common fracture of the adult
olecranon does not follow the epiphyseal line.

Fracture of the coronoid process is an
extremely rare accident. It is impossible to understand
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 projec-
tion 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

Chap, xin.] The Region oe the Elbow. 245

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. It is
a mere disc of cartilage joining the shaft at the age of
seventeen. When the neck is broken the upper end
of the lower fragment is drawn well forwards by the
biceps muscle.

Resection of the elbow may be performed in
many ways. In all procedures there is danger of
injuring the ulnar nerve, and some little difficulty
often in clearing the prominent internal condyle. If
the knife be kept close to the bone, no vessel of any
magnitude should be divided. The muscles most dis-
turbed are the triceps, anconeus, supinator brevis,
extensor carpi ulnaris, extensor carpi radialis brevior,
and brachialis anticus. It is most important to pre-
serve the periosteum over the olecranon, so that the
triceps may still have some attachments to the fore-
arm. 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. By the
subperiosteal method the periosteum is carefully peeled
off from all the parts to be resected, and is preserved.
By this means the triceps retains a hold upon the ulna,
and the restoration of the joint is more complete. The
functions of the joint may be well restored after re-
section, especially when performed by the subperiosteal
method, but it would appear that after no method
are the anatomical details of the joint reproduced. Thus,
in a successful case, the new joint will assume the bi-
malleolar form, and will resemble the ankle rather than
the elbow joint. The humerus throws out two malleoli
on the sites of the normal condyles, and in the concavity
between them the ulna and radius are received. Be-
tween the ulna and the humerus new ligaments form
and a new annular ligament for the radius is also
developed.

246
CHAPTER XIV.

THE FOEE-AEM.

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 development 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,
outwards and forwards, and due to the crossing of the
extensors of the thumb. In the middle of the posterior
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 subcu-
taneous throughout its entire extent, and can be readily
examined. The upper half of the radius is too deeply
placed to be well made out, but the 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 a point in front of the styloid process of the
radius. The pulse is felt between the styloid process

Chap, xiv.] The Fore-arm. 247

and tendon of the flexor carpi radialis wheie the artery
rests on the lower extremity of the radius. The middle
and lower thirds of the ulnar artery follow a line from
the inner condyle 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 por-
tions of the artery, each about \\ 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 less of bloccl he
had experienced, copious bleeding took place from this
single unsecured end of the vessel, and it, of course,
had also to be tied.

There is a singular absence of large blocd-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 hands-breadth below
the olecranon there is almost an entire absence of
superficial veins.

The median neive passes between the two heads

248

Surgical Applied Anatomy. [Chap. xiv.

of the pronator teres, and may possibly be compressed
by that muscle when in vigorous action. In this way
may be, perhaps, explained 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. — Transverse sections
of the limb at various levels show that the radius and

ulna are in all parts
7 nearer to the posterior

than the anterior
aspect of the extremity
(Figs. 32 and 33).
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
found mainly at the
sides and in front.
The lower the section
proceeds down the

profundus' digitorum.; >,. extensor carpi lj^V, the less will the
ulnaris; I, extensor indicis ; w, extensor umui lliC ie&!5 Wlil W1C
minimi digiti ; n, extensor communis cdgi- 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
two are most nearly of equal strength. The proximity
of the two bones, and especially of the ulna, to the
posterior aspect of the limb permits them to be easily

Fig. 32.— A Transverse Section through,
the middle of the Fore-arm (Braune).

a Radius; b, ulna; c, supinator longus ; d,
flexor lonsrus pollicis: e, flexor carpi radi-
alis ; /, palmans longus ; g, flexor sublimis
digitorum; h, flexor carpi ulnaris ; i, flexor

toriu ; o, extensor ossis and extensor
secundi internodii pollicis; q, extensor
carpi vadialis brevior ; r, extensor carpi
radial is longior : s, pronator radii teres ;
1, radial vessels and nerve ; 2, ulnar vessels
and nerve.

chap, xiv.] The Fore-arm. 249

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 under-
stood, moreover, that in compound fractures, due 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 the ulna, and the meta-
carpal bone of the ring-finger. Pronation is mainly
checked by the lower and middle parts of the interosseous
membrane, the posterior radio-ulnar ligament, the inner
part of the posterior ligament of the wrist, and the
opposition of the bones. Supination 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 contact 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. In using a screw-driver
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 inserted by
supination rather than by pronation.

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

250 Surgical Applied Anatomy. [Chap. xiv.

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 forewarn!. — 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 superficial 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.
Malgaigne reports a case where both bones were broken
by muscular violence in a patient while shovelling
earth. Here the bones probably were broken between
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 pro-
duced by the united action of the flexors and extensors.
The displacement varies greatly, and depends rather
upon the direction of the violence than upon muscular
action. Thus Hamilton says : " I have seen the frag-
ments 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 pronators, 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

Chap. xiv. The Fore-arm. 251

fragment 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 pronator 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 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 quadratus.

The displacement, however, in all cases is influenced
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 fragments, 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

252

Surgical Applied Anatomy. [Chap. xiv.

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 common
after fracture of the fore-arm than after fracture in any
other part.

Amputation of the 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 follow-
ing manner : On the face
of the anterior flap would
be seen from without in-
wards the supinator longus
(cut the whole length of
the flap), then the flexor
sublimis (cut to a like
extent), and, lastly, the
flexor carpi ulnaris. Be-
tween the supinator longus
and the flexor sublimis
the divided end of the
pronator teres is seen ; and
between the flexor sublimis
and the skin would lie the
flexor carpi radialis and
the palmaris longus. The
latter would appear as a
tendon at the inner border
of the flap. In the angle be-
tween the two flaps would
be found in front of the radius a little of the flexor longus
pollicis, and in front of the ulna, the flexor profundus,
the latter cut much the longer. Quite close to the radius,
and for the most part behind 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 see nT from
without inwards the extensor carpi radialis longior

Fig. 33 — A Transverse Section
through the lower third of the
Fore-arm. (Braune).

a, Radius ; 6, ulna ; c, supinator longus :
d, flexor longus pollicis ; c, flexor
carpi radialis; /, palmaris longus
g, flexor sublimis digitorum ; h
flexor carpi ulnaris ; i, flexor pro
fundus digitorum ;j, pronator quad
ratus ; k, extensor carpi ulnaris

1, extensor indicis ; ra, extensor
minimi digiti ; n, extensor com-
munis digitorum; o, extensor se-
cundi internodii pollicis; p, exten-
sor primi internodii pollicis; q,
extensor carpi radialis brevier ; r,
extensor carpi radialis longior.with.
in front of it, the extensor ossis
metacarpi pollicis; l, radial vessels:

2, ulnar vessels ; 3, median nerve.

chap, xv.j The Wrist and Hand. 253

and brevior, the extensor communis, the extensor 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 immediately in front
of the interosseous membrane. The posterior inter-
osseous vessels will be cut long, and will be found between
the superficial and deep muscles.

Fig. 33 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 out 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 \ 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 brevis pollicis. These are very
distinct when the thumb is abducted, and the slit-like
interval between the 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 will be found absent in
quite 10 per cent, of wrists examined. It is rendered
most prominent when the wrist is a little flexed, the
fingers and thumbs extended, and the thenar and hypo-
thenar eminences as much approximated as possible.
A little to its outer side is the larger but less prominent

254 Surgical Applied Anatomy. [Chap. xv.

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
artery.* The vense comites surround the artery, and
when distended alter the character of the pulse (Hill).
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 pro-
duces 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.
The ulnar nerve grooves the radial side of the pisiform bone.
At the back of the wrist the following tendons can
be readily distinguished from without inwards : the
extensor longus pollicis (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 prominent 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 ulnar 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 pronation,
however, the process is rendered less distinct, while
the head projects prominently on the posterior part of

* Sometimes the superficialis volae 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. 255

the wrist, and is found to lie between the tendons of
the extensor carpi ulnaris and extensor minimi digiti.

The ivrist 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 articu-
lation. 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 h 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
neck of the os magnum in the line of the third meta-
carpal bone (Tillaux), and is not quite f of an inch below
the arch of the wrist joint. It is about \ 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 concave
in the centre where the skin is adherent to the palmar
fascia. This " hollow of the hand " is of somewhat
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 projection
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 seen, especially
when the first phalanges are extended, and the second
and third are flexed. These correspond to the fatty
tissue between the flexor tendons and the digital slips

256

Surgical Applied Anatomy. [Chap. xv.

of the palmar fascia. The grooves that may he seen
to separate the elevations correspond to those slips.

Fig. 34. — Surface Markings on the Palm of the Hand.
The thick black lines represent the chief creases on the skin.

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

Chap, xv.j The Wrist and Hand. 257

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 gives 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 metacarpophalangeal
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 corre-
sponds 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 phalangeal joints, the highest is single
for the index and little finger and double for the other
two. It is placed nearly f of an inch below the corre-
sponding 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 metacarpophalangeal articula-
tion obliquely. The free edge of the web of the fingers,

258 Surgical Applied Anatomy. [Chap. xv.

as measured from the palmar surface, is about f of an
inch from the metacarpophalangeal joints. The super-
ficial palmar arch may be represented 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 \ and \ an inch nearer the
wrist, and its position may be accurately marked by a
line drawn from the base of the fifth metacarpal to the
base of the second. The digital arteries bifurcate about
\ an inch above the clefts between the fingers.

The dorsal surface of the hand. — On the outer side
of the wrist, when the thumb is extended, a hollow is
obvious between the extensores ossis metacarpi and
brevis pollicis and the extensor longus pollicis. 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 runs the internal division
of the terminal branch of the radial nerve. In the
floor of the " snuff-box " are the scaphoid bone and the
trapezium. The extensor longus pollicis 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 all be well made out.
The latter articulation is situate on the floor of the
" tabatiere." On the back of the hand the various
tendons and the surface veins, too, can all be clearly
distinguished. Between the first and second meta-
carpal 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 hand. — 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

chap. xv. j The Wrist and Hand. 259

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 profuse ness 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 excep-
tion 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 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
lacunae. Cutaneous ligaments bind the skin down at
the creases of the palm and fingers. 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 practic-
ally impossible in the palm and on the anterior aspect
of the ringers, while they may be very extensive on the

260 Surgical Applied Anatomy. [Chap. xv.

dorsum. In like manner oedema 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 in-
flammation of the part extremely painful, owing to the
tension that is so readily produced, whereas inflam-
mation in the lax tissues of 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 especially the palm, is singularly free
from surface veins. Indeed, the great bulk of the blood
from the hand is returned by the superficial veins on
the dorsum of the fingers and hand.

The lymphatics of the palm are, moreover, scant and
very minnte, whereas on the dorsum 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 clue to impeded circulation,
to retardation in the return of venous blood, and perhaps

chap, xv.] The Wrist and Hand. 261

also to imperfect oxygenation of that blood. It is most
often met with in congenital heart disease, in phthisis,
empyema, chronic lung affections, and certain thoracic
aneurisms. 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
indicates the portion of nail formed during the illness,
and by watching its movement the rate of growth of
the nail can be estimated. 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 explains the
intense pain felt when a foreign body is 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, render it well suited to withstand
the effects of pressure. The fascia gives slips to each
finger ; each slip sends fibres to join the digital sheaths
of the tendons, the skin, and the superficial transverse
ligament. In the disease known as Dupuytren's con-
traction, the palmar fascia, and especially its digital
slips, becomes contracted. One or more or all of tl e
fingers may be involved in the contraction. The first
phalanx is drawn or flexed towards the palm, and later
the second phalanx becomes bent also. The skin is
drawn in towards the fascia, since the two structures
are normally connected with one another. Experiment
shows that by dragging upon the fascia the first phalanx
can be readily bent, and also, hut with less ease, the
second phalanx. The middle part of the palmar fascia,
represents the tendon of the palmaris longus in the hand.

262

Surgical' Applied Anatomy. [Chap. xv.

The structures of the palm are divided into three
spaces by the fasciae (Fig. 35). Thus the muscles of
the thenar and hypothenar eminences are both enclosed
in a thin fascia proper to each. 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 is a third space, which is roofed in by

Fig. 35.— Horizontal Section of the Hand through the middle of the
Thenar and Hypothenar Eminences (Tillaux).

a, Metacarpal bone ; 6, first dorsal interosseous ; r, palmaris brevis; e7, abductor
min. digiti ; e, flexor brevis min. dig. ; /, opponens min. dig. ; g. flexor brevis
poll.; /!, abductor poll.; i, opponeus poll.; j, adductor poll.; k, flexor long,
pol. ; I, dorsal interossei ; m, palmar interossei ; n, flexor sublimis ; o, flexor
profundus ; p, super fie. volse ; q, median nerve, and (on inner side) ulnar artery
and nerve; r, deep palmar arcb ; l, palmar fascia; 2, outer septum; 3, inner
septum ; 4, deep fascia of palm.

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 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 fingers, give passage to the
flexor tendons, while the remaining three correspond
to the webs between the fingers, and give passage to
the lumbricales and the digital vessels and nerves.

Chap, xv.] The Wrist and Hand. 263

When pus, therefore, forms on 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 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 fascia? enclosing the thenar and hypothenar " spaces "
(Fig. 35).

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 synovial sheaths beneath the ligament,
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 fibrous sheaths for the flexor tendons
extend from the metacarpophalangeal joints to the
upper ends of the third phalanges. The pulp of the
third phalanx, therefore, rests practically upon the
periosteum. Opposite the finger joints the sheaths
are lax and thin, and spaces may occair between the
decussating fibres of the sheaths, through which the

264

Surgical Applied Anatomy. [Chap. xv.

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. 36).
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 amputation 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 accident-
ally or intentionally divided.

The tendons accurately fill the fibrous
sheaths. A gangliform growth on the
tendon as it enters the sheath, or a
constriction of the sheath with an in-
equality in the tendon, gives rise to the
condition known as " snap " finger. Such
a digit cannot be extended by will, but
when pushed a little way " springs back
with a snap like the blade of a pocket
knife " (Abbe). " Congenital contraction "
of the little finger is very common
in a slight, degree. In marked cases, the proximal
phalanx is hyper-extended and the middle flexed. Lock-
wood found in such a case that the condition was due
to a contraction in the fibrous sheath in front of the
joint. Contracted finger following whitlow is due to
an adhesion of the tendons to their sheath. Paralytic
contraction of the flexor muscles also brings about
permanent contracture of the fingers.

Synovial sacs and sheathso — There are
two synovial sacs beneath the annular ligament for
the flexor tendons, one for the flexor iongus pollicis,
the other for the flexor sublimis and profundus tendons.

c

Fig. 36. — Hori-
zontal Section
through middle
of Second Phal-
anx (Tillaux).

a, Flexor tendon ;
b, fibrous sheath
of tendon ; c, ex-
tensor tendoi ;
d. digital artery
and nerve.

chap, xv.] The Wrist and Hand. 265

The former extends up into the fore-arm for about
\\ inches above the annular ligament, and follows its
tendon to its insertion in the last phalanx of the thumb.
The latter rises about \\ 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
\ to \ 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 1^ inches above the annular ligament.
The arrangement explains the well-known surgical
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 corresponding to the ligament.
The two synovial sacs beneath 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 intervening tendon
sheath over that bone. In this affection the bone
often necroses and conies 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

266 Surgical Applied Anatomy. [Chap. xv.

remains sound, and is probably preserved by the in-
sertion 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 unite to the shaft until
the eighteenth or twentieth year.

The tendons do not lie free within the sac, but are
bound to it by folds of synovial membrane in much
the same way as the bowel is bound to the abdominal
parietes by its mesentery. These folds may be ruptured
in severe sprains, when the nutrient vessels for the
tendon, which are contained in them, may be torn.
Rupture is followed by effusion into the sac. These
folds are almost absent within the digital sheaths, the
slight ligamenta longa and brevia, near the insertion
of the tendons, being the sole representatives. Synovial
sacs are lined by a squamous epithelium, and have ex-
tremely free communication with the lymphatic vessels
of the part. Hence the free absorption of infective
matter from such cavities.

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 brevis pollicis. It runs from a point about
f of an inch above the radial styloid process to the first
carpo-metacarpal joint. The other sheaths reach above
to the upper border of the annular ligament, that for
the two radial extensors, however, beginning about
^ an inch above the ligament. The sheaths for the
extensor 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.
The synovial lining and folds of these sheaths are injured
in Colles' fracture of the radius. The tendons become
adherent to their sheaths and fixed unless this be pre-
vented by passive movements of the tendons.

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.

Chap, xv ] The Wrist and Hand. 267

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 penetrating
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
haemorrhage from either of the palmar arches cannot be
checked by ligature of the radial or ulnar artery alone,
on account of the connection 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
communicates with the anterior interosseous artery
above, and with the deep palmar arch, by the recurrent
vessels below. The posterior carpal arch communicates
with 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 vessels. 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 interosseous 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

268 Surgical Applied Anatomy. [Chap. xv.

note that the deficiency is most common in the super-
ficial 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 amputation
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
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 prox-
imity 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.

Chap, xv.] The Wrist and Hand. 269

The former structure limits extension, and the latter
flexion ; and in connection with this arrangement 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 that
the middle finger is, from its great 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 into 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 extensor
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
lust finger joint without at the same time bending the

270 Surgical Applied Anatomy. [Chap. XV.

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. In the condition
known as " mallet " finger the distal phalanx is fixed
in a flexed position. The condition is due to a partial
or complete rupture of the extensor tendon of the
finger, commonly the result of a blow over the terminal
knuckles.

Colles' fracture.- — This name is given to a
transverse fracture through the lower end of the radius,
from \ to 1 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 end of
the radius is very cancellous, while the shaft contains
a good deal of compact bone. At about J 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 Professor 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 ; (6) rotation backwards of the carpal
surface on the transverse diameter of the fore-arm ;
(c) rotation through the arc of a circle, the centre of
which is situated at the ulnar attachment of the tri-
angular 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

Chap, xv.] The Wrist and Hand. 27 1

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 the 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 backwards.
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 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. (6) 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' fracture. 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 fragment. By means of this
rotatory displacement, the tips of the two styloid pro-
cesses come to occupy the same level, or the radial process
may even mount above the ulnar. In nearly every
case there is some penetration 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

272 Surgical Applied Anatomy. [Chap. xv.

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 broken in the usual position of a Colles1
fracture, but the lower fragment was carried forwards
instead of backwards. According to R. W. Smith
and others, the peculiar deformity is produced by mus-
cular 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 ac-
knowledged 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 displacement.

There is no special anatomical interest attaching
to fractures of the carpus, metacarpus, or phalanges.

Dislocations. — (l) At the ivrist joint. — So
strong is this articulation, for the reasons above given
(page 268), that carpo-radial luxations are extremely
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, 01^ fractures of the

Chap, xv.] The Wrist and Hand. 273

adjacent bones. The luxations of the carpus may be
either backwards or forwards, the latter being extremely
rare. They 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.

There are five articular synovial cavities connected
with the carpus. They occur in the following
situations : (a) Between the carpus and fore-arm
bones ; it may communicate with the lower radio-
ulnar cavity through the triangular nbro-cartilage ;
(b) between the unciform and the fourth and fifth
metacarpals ; (c) between the metacarpal of the thumb
and trapezium ; (d) between all the carpal bones and
extending to the carpo-metacarpal joints of the second
and third digits; (e) between the pisiform and
cuneiform bones. Hernial protrusions and gangliform
growths from these synovial membranes are frequently
seen on the dorsum of the carpus.

(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 movement
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." Some-
thing was felt to give way in the hand, and the head
of the os magnum was found to be dislocated backwards.

Dislocations at the metacarpophalangeal 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

274 Surgical Applied Anatomy. [Chap. xv.

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 Vidal 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 attach-
ments, falls between the joint surfaces, and interposes
an effectual obstacle to reduction. Dupuytren ascribes
the difficulty to the altered relations 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." Mr. Jonathan
Hutchinson, junr.., has recently investigated some
cases and found that reduction is prevented by the
fibro-cartilaginous plate. The plate is firmly attached
to the phalanx and is dislocated with it. When sub-
cutaneously divided on the extensor aspect of the thumb,
the dislocation may be reduced with ease.

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 the cir-
cular method. (See the author's " Operative Surgery.")
In the dorsal wound would be cut the following ten-
dons : the extensores loiigus, indicis, communis, minimi
digiti, and ulnaris, the radial nerve, and the dorsal

Chap, xv.] Tub Wrist and Hand. 275

branch of the ulnar nerve. The two radial extensors
will be cut short in the radial angle of the wound, as
will also be the extensores ossis and brevis. The radial
artery will be divided close to the radius. In the palmar
wound would be found the ulnar artery, the superficialis
vola3, the ulnar and median nerves, the opponens, 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), and
the tendons of the flexor sublimis and flexor carpi radialis.
The tendons of the flexor profundus and flexor longus
pollicis are usually cut short close to the bones.

Amputation of the thumb at the carpo-meta-
carpal joint by flaps. In the palmar flap would be
cut the abductor, the short and long flexor, the op-
ponens, and adductor pollicis. The extensores ossis
and brevis would be cut short in the posterior angle
of the flap. The extensor longus 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.

Nerve supply of the upper limb. — The symp-
toms which follow a lesion to the nerves of the upper
limb depend on the point injured. If the fifth spinal
nerve be crushed between its origin in the spinal cord
and its exit from the intervertebral foramen, either
from fracture or caries of the cervical vertebra?, the in-
jury is followed by paralysis, partial or complete, of the
deltoid, biceps, brachialis anticus, and supinator longus,
while a strip of skin on the outer side of the limb from
the deltoid to the styloid process of the radius is insensi-
tive to touch or paiti (Fig. 3$). Injury to the . ord ju-t
above the origin of the eighth cervical vertebra will leave
the skin of the ulnar half of the arm anaesthetic, while
the muscles of the fingers, hand, and wrist, and some of
those at the elbow and shoulder, will lie paralysed. The
fibres for the innervation of the various groups of arm

276 Sc/R GICA L A PPL I ED A NA TO MY. [Chap. XV.

muscles pass out in quite an orderly manner by the fifth
cervical to the first dorsal nerve from corresponding
segments of the cord. Those for the abductors of the
shoulder pass out by the fifth ; for the adductors by
the sixth and seventh ; for the flexors of the elbow
by the fifth and sixth ; for the extensors by the
seventh and eighth ; for the extensors of the wrist
and fingers by the sixth and seventh ; and those for
the flexors by the eighth and first dorsal. It is important
to remember that a cervical spinal nerve makes its exit
from the canal opposite the origin of the next spinal
nerve.

The following is Dr. Herringham's account of the
usual spinal origin of the fibres in the nerves of the
upper limb, and of the usual supply of the chief muscles.
(The figures indicate the fifth, sixth, seventh, and eighth
cervical nerves, and the first dorsal nerve.)

Nerves. — Nerve of Bell, 5, 6, 7 ; suprascapular, 5
or 5, 6 ; external cutaneous, 5, 6, 7 ; internal cutaneous,
1 or 8, 1 ; nerve of Wrisberg, 1 ; circumflex, 5, 6 ;
median, 6, 7, 8, 1 ; ulnar, 8, 1 ; musculo-spiral, 6, 7, 8,
or 5, 6, 7, 8.

Muscles. — 3, 4, 5, lev. anguli scap. ; 5, rhomboids ;
5 or 5, 6, biceps, brachialis ant., supra- and infra-
spinatus, teres minor ; 5, 6, deltoid, subscapularis ; 6,
teres major, pronator teres, flexor carpi rad., supin.
longus and brevis, superficial thenar muscles ; 5, 6, 7,
serratus magnus ; 6 or 7, extensores carpi rad. ; 7,
coraco-brachialis, latiss. dorsi, extensors at back of
fore-arm, outer head of triceps ; 7, 8, inner head of
triceps ; 7, 8, 1, flexor sublimis, flexores profund., carpi
uln., long, poll., pronator quad. ; 8, long head of triceps,
hypothenar muscles, interossei, deep thenar muscles.

In the cutaneous nerve supply of the fingers, it must
be remembered that on the palmar aspect the thumb,
the two outer fingers, and the radial side of the ring
finger are supplied by the median, the remaining
one and a half fingers by the ulnar (Fig. 37). On the
dorsal aspect the thumb is supplied by the radial, the
index and middle fingers are supplied (as far as the base

277

■ i • •
5\\ / \

\ 7 i

• \8]

9 i 10

Fig. 37.— Cutaneous Nerve Supply of Upper Limb.

.interior aspect : 1, Cervical plexus; 2, circumflex ; 3, cxt. cut. otmusc. spiral ;

4, ext. cutaneous ; 5, median ; 6, ulnar j 7, int. cutaneous ; 8, n. of WfiBberg.
Posterior aspect : 1, Cervical plexus; 2, circumflex; 3, int. cut. of muse, spiral ;

Mntercosto-numeral : 5, n. of wrieberg; 6, int. cutaneous; 7, ext. cut. of

muse, spiral ; 8. exr. cutaneous; 9, ulnar ; 10. radial.

278 Surgical Applied Anatomy. [Chap. xv.

of the second phalanx) by the radial, and over the second
and third phalanges by the median. The little ringer
and the ulnar side of the ring finger are supplied by the
ulnar. The radial side of the ring ringer, as far as the base
of the second phalanx, is supplied by the radial, and the
rest of this side of the digit by the median (Fig. 37).
The cleft between the middle and ring fingers is occa-
sionally supplied by the ulnar, or partly by the ulnar
and partly by the radial. The roots and spinal segments
to which these nerves belong may be ascertained from
Fig. 38. The roots are distributed in order of origin,
the fifth cervical beginning on the radial or outer side
of the shoulder and the second dorsal, or sometimes the
third, ending on the ulnar or inner aspect of the upper
arm. The hand is mainly supplied by the seventh. The
neighbouring spinal nerves, as is also the case with
ordinary terminal branches, overlap widely in their
distribution. The area of ansesthesia is much less than
the area of anatomical distribution. The pain referred
along the ulnar half of the arm in cases of angina
pectoris and aneurism of the aorta is due to the common
origin of the cardiac and aortic sympathetic nerves,
and those for the ulnar segment of the arm from the
first dorsal segment of the spinal cord (Head).

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 perhaps explained by
the high origin of the bicipital nerve from the spinal
cord.

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

TIN

--D.III.

s --D.II.

O U

Fig. 38.— Showing the Sensory Distribution of the Spinal Nerves in the

Upper Limb.

The dotted line* indicate approximately the area of each nerve. No attempt
is made to show the extent to which the root areas overlap. (For the
nerves aupplying cacti an a ate Fig. 37.)

280 Surgical Applied Anatomy. [Chap. xv.

attempts are made to extend the fingers, the interossei
and mmbricales alone act, producing extension of the
last two phalanges and flexion of the first. Supination
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 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 phal-
anges 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 extension
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 sensibility
is impaired over the cutaneous area supplied by the
nerve (Erb).

After complete division of any one of the three
great nerves of the upper limb, the loss of sensation
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 im-
pressions are returned by another route. Thus are
explained those cases where the median has been sutured
after accidental division, with the effect that within a
few hours sensation has returned to the cutaneous
parts supplied by the nerve. Such return of sensation

chap, xv.] The Wrist and Hand. 281

is probably due to the supplementary action of the inter-
lacing nerve fibres bound up with other trunks, and not
to the " immediate union of a divided nerve," as was at
one time announced.

Epiphyses ol" the upper limb, — The epiphyses
about the elbow join the shafts of their respective bones
at 17 years (except the tip of the internal condyle, which
joins at 18). The epiphyses at the shoulder and wrist
extremities of the bones join at 20. The nutrient canals
of the three bones run towards the elbow. The nutrient
artery of the humerus comes from the brachial or inferior
profunda, those of the radius and ulna from the anterior
interosseous.

The nerve supplying the humerus is the musculo-
cutaneous. The radius and ulna are supplied by the
anterior interosseous of the median.

2»2

£art $V.

The Abdomen and Pelvis.

CHAPTER XVI.

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 accommo-
date any abdominal structure (strictly so called), but
can scarcely provide room for the pelvic organs them-
selves. Thus in infancy the bladder and a great part
of the rectum are virtually abdominal viscera. After
long-continued distension, as, for example, after preg-
nancy, ascites, etc., the abdomen usually remains unduly
prominent and pendulous.

In examples of prolapse of the mesentery the upper
part of the abdomen becomes sunken in and the lower
part unduly prominent. (See page 320.)

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

chap. xvi. j The Abdomen, 283

almost vertical when the patient is in the recumbent
posture. This change 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 cartilage
to the pubic spine. In the adult it would be placed
about 3 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 " linea? trans-
versa?," 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 foetus at birth it is below that point.
It corresponds in front to the disc between the third
and fourth lumbar vertebra?, and behind to the tip
of the third lumbar spinous process. It is situated
about \ of an inch to 1 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
horizontal line with the upper edge of the great tro-
chanter. It is very distinct in thin subjects. In the
obese it is entirely lost beneath the pubic fat. In such
individuals, however, it can be detected, when the
subject is a male, by invaginating the scrotum so as to
pass the finger beneath the subcutaneous fat. In the
female the position of the process may be made out by

284 Surgical Applied Anatomy. [Chap. xvi.

adducting the thigh and thus mating 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 ringer
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 spinee 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 spinse,
and may consequently 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 f 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 Poupart's ligament will
correspond to the course of the common and external
iliac arteries. The first 2 inches of this line would cover
the common iliac, the remainder the external.

The cceliac axis comes off opposite the lower part
of the twelfth dorsal vertebra, at a spot about 4 or 5
inches above the navel, and that corresponds behind
to the twelfth dorsal spine. The superior mesenteric

Chap, xvi.] The Abdomen. 285

and suprarenal arteries are just below the axis. He
renal vessels arise about \ 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 1 inch
above the umbilicus. The deep epigastric artery follows
a line drawn from the middle of Pou part'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 the 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
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 trans-
ferred to the column when the articulation is rendered
useless.

After the skin has been stretched, from any gross
distension 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

286 Surgical Applied Anatomy. [Chap. xvi.

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 accumu-
lation of fat is perhaps more marked beneath the skin
of the abdomen than it is elsewhere. A layer of fat
6 inches in depth has been found in this region in cases
of great corpulence. The superficial 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 and
the pubic spine it has no attachment, but passes down
into the scrotum and becomes the dartos tissue.
Extra vasated urine that has reached the scrotum may
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 thickness
in different subjects. In cases of great 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-

Chap, xvi.] The Abdomex. 287

ments can be watched ; in instances of obstruction of
the pylorus the movements of the dilated and hyper-
trophied stomach can often be seen. 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 mus-
cular 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
firmly contracted will probably do no injury to the
viscera unless violence be extreme. The rigid muscular
wall acts with the efficacy of a dense indiarubber 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 concerned, 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. 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. If the blow be anticipated
also the body will probably be abruptly bent and the
viscera be — as it were — removed from danger.

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

288 Surgical Applied Anatomy. [Chap. xvi.

for an incision. Except in some operations on the
kidney, stomach, or gall bladder, incisions are seldom
so placed. In most cases it is a question of either
opening the abdomen in the middle line or in one of
the iliac regions. Below the navel the two recti muscles
are almost in contact, and here the linea alba can scarcely
be said to exist. 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 sub-
peritoneal tissue may grow. If of fair size these little
masses may be mistaken for irreducible hernise. Similar
growths of fat may extend through the inguinal or
femoral openings, and constitute the so-called " fatty
hernise."

The fibrous ring of the umbilicus is derived from
the linea alba. To this ring the adjacent structures,
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.

The umbilicus represents the point where the lateral
abdominal walls finally close. At the sixth week the
opening is funnel-shaped and contains the yolk sac and
a fold of the bowel to which it is attached. This con-
dition may persist and give rise to a congenital hernia
of the umbilicus. 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. Eunning down
from the umbilicus in the middle line is also the remains
of the urachus. In the foetus, the spot where the three

chap, xvi.] The Abdomen 289

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 covering
from them. These hernise are fortunately rare, for in
certain instances they extend some way into the cords,
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 also the vein, appear
to start from the lower border of the cicatrix. In adult
hernias, 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.

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 1 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 fasces 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

* The congenital hernia must be distinguished from the
infantile umbilical hernia so commonly met with after separa-
tion of the cord. For an account of these congenital hernia?,
see paper by the author in the Lancet, vol. i., 1881, p. 323.

290 Surg/cal Applied Anatomy. [Chap. xvi.

persistent duct, when it occurs, is known as Meckel's
diverticulum, and springs from the ileum from one
to four feet above the ileo-csecal valve. This foetal
relationship also explains the presence of a fibrous cord
which is sometimes seen connecting Meckel's diverti-
culum with the umbilicus. It may cause strangulation
of the bowel.

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 intersections, and are said to be
more common in the upper part of the rectus. When
the fibres of the muscle are contracted the "tumour "
is obvious, hut when they relax it disappears. The
phantom tumour, however, is not always a matter
of little moment. It may be associated with grave
disease within the abdomen, and be clue to reflex mus-
cular contraction, the starting point of such reflex act
being in the viscera.

I have, for example, seen a conspicuous phantom
tumour in the upper part of the right rectus associated
with cancer of the stomach, with ulcer of the duodenum,
and with malignant disease of the peritoneum.

Other vanishing tumours depend upon distension
of the intestines by flatus or by faecal matter. In great
distension of the abdomen the fibres of the rectus 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.
I In women, as a result of many pregnancies, the recti

Chap, xvi.] The Abdomen. 291

may become separated. The separation is usually I clew
the umbilicus, and the condition is known as divarication

of the recti.

Luschka quotes a case in which the separation of the
muscles was so great that the interval between them
took in almost the whole of the anterior wall of the
abdomen. The recti muscles were found in the flanks.

The lateral muscles of the front abdominal wall
are separated from one another by layers of loose con-
nective tissue. These extensive layers favour the spread
of interstitial abscesses of the abdominal parietes. Such
abscesses w ill be guided in their course by the attachments
of the muscles between which they spread, and will be
limited by the semilunar 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
haemorrhagic or emphysematous collections between
these muscles.

Between the abdominal parietes and the perito-
neum is a layer of loose connective tissue, the sub-
serous connective tissue. The looseness of this
layer greatly favours the spread of abscess, to the pro-
gress 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 has been of 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 May with the finger through
the subperitoneal tissue, and by actually stripping the
serous membrane from its attachments. Ligature of the
iliac vessels at the present day is usually effected through
a direct incision which opens the peritoneal cavity. The
method just detailed belongs to pre-antiseptic days.
The laxity of the subserous laver also favours lliat

292 Surgical Applied Anatomy. [Chap. xvi.

stretching of the peritoneum which occurs under
certain circumstances. Sarcomata are not unfrequently
met with in the subserous or retroperitoneal connective
tissue, and when so placed the laxity of that tissue allows
them to spread readily, especially when they attack the
retroperitoneal tissue lining the posterior walls of the
abdominal cavity.

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 embedding of
small foreign bodies, such as pieces of glass, etc., which,
hidden between the muscular layers, may well be over-
looked. 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 constant respiratory movements of the belly
walls do 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 pro-
truded 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 early
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,

Chap, xvi.] The Abdomen. 293

the last two intercostal vessels, the epigastric branch
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, extending from the axilla to the groin,
uniting the axillary and femoral veins, is often ren-
dered in this way very prominent. The surface abdom-
inal veins may take no part as alternative blood channels
in cases of obstruction of the inferior vena cava.
Clinical experience shows that these veins may lie also
enormously varicose in instances where the inferior
cava is quite patent. In one case under my care there
Avas 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, while
that in the veins of the subumbilical region runs to the
groin.

Schiff has shown that certain small veins con-
nect the portal vein with the epigastric veins at the
umbilicus.

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
belowr to the glands of the groin.

IMerves. — The abdominal wall is supplied by the
lowest seven dorsal or intercostal nerves, and by the
first lumbar nerve. These nerves run obliquely to
the long axis of the abdomen downwards and inwards
from the sides to the middle line and hence are damaged
more extensively in vertical than in oblique incisions.
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 important
to note that they supply not only the abdominal integu-
ment, but also the muscles of the belly, viz., the rectus,

294 Surgical Applied Anatomy, pchap. xvi.

the two oblique muscles, and the transversalis. The
segments of the spinal cord which supply the skin also
innervate the underlying muscles, an association of
great importance (Fig. 39). 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 indica-
tion 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 were supplied
from different segments 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. 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, its spinal centre becomes excited and
the muscles at once contract and the belly becomes
rigid. It will be noticed that six of the abdominal
nerves supply intercostal muscles, and are thus
intimately associated with the movements of respiration.
The abdominal muscles are of course concerned in the
same movements. These associations are illustrated
when cold water is suddenly dashed upon the belly.
The subject of such experiment at once 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.

Chap XVI.]

Thi'. Abdomen.

295

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

Fit

39. — Showing approximately the areas of skin supplied by spina
nerves on the anterior surface of the trunk.

The areas are marked on the right side by dotted lines, and the number ol t lie

si>in;il nerve by which caeh is supplied, is indicated. The nerves are shown
on the left side.

Issue from the vertebral canal. This injury may show
itself by modified sensation in the parts supplied by
such nerves. Thus in Pott"> disease the patient often
complains of a sense of tightness about the abdomen,
as if a cord were tied around it. Tins sense of con-

296 Surgical Applied Anatomy. [Chap. xvi.

striction 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, develope,
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 cir-
cumstance in the course of spinal bone disease. A
case came under my notice in which a man complained
of intense and abiding pain over the stomach. The
pain was made worse by food and as all means used
failed to relieve it, the abdomen was opened by an
exploratory incision. Nothing abnormal was discovered.
A little later it became evident that the pain was clue
to a malignant tumour situated in the bodies of the
dorsal vertebrae. There had never, before the operation,
been any suspicion of spinal 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 and the tenth nerve
is nearly in a line with the umbilicus. The position of
the areas supplied by each spinal nerve on the trunk
is shown in Fig. 39. The umbilicus may be at the
upper or lower border of the area of the tenth, according
to the individual. A spinal root may be cut and yet
scarcely a trace of anaesthesia result owing to the
overlapping of the nerve distributions.

The nerves of the body wall have still more
important associations. The spinal segments with
which they are connected are also in communication

Chap, xvi.] The Abdomen. 297

with the viscera of the abdomen and thorax through
the sympathetic system. Hence diseased conditions
in the abdominal viscera give rise to disturbances in
the spinal segments, with which they are connected,
and the brain, being accustomed to localise
pain only along the spinal nerves, makes a
mistake and refers the pain along the spinal nerve of
the segment disturbed. Not only is pain referred, but
the skin supplied from the disturbed spinal segments"
becomes tender, and through a study of these, Head has
been able to localise the visceral centres, thus affording
the surgeon a means for increased accuracy of diagnosis.
The abdominal viscera are supplied from the sixth
dorsal to the first lumbar spinal segments, the nerves
passing to their destinations through the rami com-
municantes, splanchnic nerves and sympathetic plexuses
of the abdomen. Xo visceral nerves escape by the
second, third or fourth lumbar nerves, hence these
an- never the seats of visceral referred pains. The
pelvic visceneare supplied from the fifth lumbar to the
third or sometimes fourth sacral nerve through the
nervi errigentes.

The following are the segments with which each
viscus is connected (Head) : — Stomach, G, 7, 8, 9 D. ;
intestine, 9, 10,11, 12 T). ; rectum, 2, 3, t S. ; liver
and gall bladder 7, 8, 9, 10 D. ; kidney and ureter, 10,
11, 12 D., 1 L. ; prostate, 1<), 11 I)., "5 L., 1, 2, 3 S. ;
epididymis, 11, 12, 1 ]). ; testis and ovary, 10 1). ;
appendages, 11, 12 D., 1 L. ; uterus, 10, 1 1, 12 D., 1 L.,
3, \ S.

Pain referred to districts supplied by the lower
abdominal 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.

* Head regards cacti area as supplied by a segment of the
spinal cord, and not necessarily by one spinal nerve. The areas
he has demarcated on the trunk, with some exceptions, correspond,
however, very closely with the anatomical distribution of spinal
nerves.

298 Surgical Applied Anatomy. [Chap. xvi.

It may be noted that some of these nerve disturbances,
especially the sense of a constricting band, are common
in certain affections of the spinal cord, such as locomotor
ataxia, etc.

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 inconsistent
with any but very brief existence. In many 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 congenital exomphalos,
which may vary in severity from a small hernia to a
protrusion of the whole of the more movable viscera.
One of the most remarkable deformities is that known
as extroversion of the bladder. Here, not only is a part
of the belly wall absent, but also a part of the genito-
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.

chap, xvi.] The Abdomen. 299

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 ll inches in length. It
represents the track followed by the testis in its descent.
Ij 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
>peak 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 inguinal 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
muscles, while below it is the angle formed by the union
of Poupart's ligament with the transversalis 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 hernia1 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 invag-
inating the scrotum with the point of the finger, and
then pissing 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

* 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 wliose testicle had been removed
in infancy, and in whom the external ring was so small as to be
scarcely recognisable.

300 Surgical Applied Anatomy. [Chap. xvi.

about | an inch above the middle of Pouparts liga-
ment.

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 present
three fossae, an external to the outer side of the epigastric
artery, an internal between the urachus and the hypo-
gastric 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 infundibuliform 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

Chap, xvr.] The Abdomen. 301

opposite 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 infundib ali-
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
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 intercolumnar 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 detects 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.

302 Surgical Applied Anatomy. [Chap. xvi.

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
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, the protrusion being, indeed, at the semilunar
line. 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 defects in the "vaginal process."
The descent of the testis. — 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 in-
guinal 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 testis is guided to its final resting
place by the gubernaculum, a band of muscular fibres.
This band is attached below to the anterior abdominal
parietes, to the pubes near the root of the perns, to the

Chap, xvi.] The Abdomen. 303

bottom of the scrotum, and to the tuber ischii and
sphincter ani (Lockwood). The last-- named attachments
serve to explain the occasional passage of the testis beyond
the scrotum into the perineum (testis in perineo). In
one example of this condition I found it necessary to
divide a band passing from the tuber ischii to the testis
before I could place the gland in the scrotum.

Following the gubernaculum upwards, it is attached,
first of all, to the vaginal process, which, therefore,
descends before the testis, then to the gland and epi-
didymis, and, lastly, to the peritoneum about the bowel
(caecum, ileum, or mesentery on the right side, and
sigmoid flexure on the left side). The latter connec-
tions serve to explain the condition of infantile hernia,
in which a bag or diverticle of peritoneum is drawn
down into the scrotum after the testis (Lockwood).
This diverticle can then become the sac of a hernia.

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 be-
comes obliterated in two places, at the internal ring
and at a spot just above the epididymis, the obliteration
usually beginning at the higher point first. Supposing
obliteration to have taken place at these two points,
the vaginal process between them will he 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.

(l) When the vaginal process is entirely open, gut
can readily descend at once into the scrotum. Such a

304 Surgical Applied Anatomy. [Chap-xvi.

condition is called a congenital hernia, Here the

intestine is found to occupy a large sac of the peri-
toneum, the open orifice of which is placed at the in-
ternal inguinal ring. The neck of the sac is long and
narrow, the parts around have not been disturbed to
permit the bowel to pass, and the actual sac itself is
very thin. It is on account of these anatomical con-
ditions that the effects of strangulation fall as a rule
heavier upon this form of hernia than upon the corre-
sponding acquired form. The term " congenital " is
misleading, as the hernia is very rarely present at birth,
although it is common in early life.

(2) When the process is closed only at the internal
ring the unduly large tunica vaginalis is found to ex-
tend up to that orifice. Behind this processus or tunica
vaginalis a diverticle of peritoneum is drawn down into
the scrotum by the gubernaculum, and becomes the
sac of a hernia (Lockwood). This is known as an in-
fantile or encysted hernia. In such a case the
tunica vaginalis lies in front of the sac, and therefore three
layers of peritoneum would have to be cut through be-
fore the gut could be reached. The term " infantile "
was given to this rupture because the first cases re-
ported were met with in infants ; the term " encysted,"
because the hernial sac was considered to be enclosed by
the sac of the tunica vaginalis. 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 peri-
toneum that separates the large tunica vaginalis from
the general peritoneum at the internal ring gives way,
and the gut at once passes into the cavity beyond, and
so appears in the condition of a congenital hernia.

The infantile hernia also includes cases in which
the sac descends behind an entirely unclosed vaginal
process.

(3) In the last-named circumstance a tubular pro-
cess of peritoneum leads down as far as the top of the
testicle and there ends, the normal tunica vaginalis

Chap, xvi.] The As do me?:.

v^D

being beyond. Hernia into this process is called a
hernia into the funicular process.

In the first of these forms the testicle is quite en-
veloped in the hernia. In the second and third forms,
as well as in the acquired form, it is to be felt quite dis-
tinct 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 he nor-
mally 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 developes,
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 lie opened up,
and an at temp; 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, therefore, the mesentery
must become lengthened, and it is a question whether
or not an abnormally long mesentery may exist as a
congenital defect, and so predispose the patient to rup-
ture. More information is required upon the subject.

The inguinal eanal 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,
and offers such slight inducement to the formation of
a rupture, that acquired inguinal hernia is as ran?

u

306 Surgical Applied Anatomy. [Chap. xvi.

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 herniotomy 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 impossible to distinguish
the various layers of tissue that cover the hernia, the
only one, as a rule, that is recognisable 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 well as upwards. It should be remem-
bered that the incision required to relieve a constriction
is, if properly 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

Chap, xvi.] The Abdomen. 307

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 hernial protrusion of some kind. The canal
is funnel-shaped, about \ an inch in length, and ends
opposite the saphenous opening. Femoral hernias 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 \ 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 sub-
cutaneous fasciaa of the groin afford it ample opportuni-
ties 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

o

08 Surgical Applied Anatomy. [Chap. xvi.

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 con-
ceived 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 superficial
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 posterior wall of the crural
sheath and 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 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 round 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

Chap, xvi.] The A boom ex. 309

vessels about the ring there is also a pubic vein, which,
ascending from the obturator vein in the thyroid fora-
men, 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 lie 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 lie placed
when the taxis is being attempted. In herniotomy
the incision is made along the inner side of the tumour,
and is so arranged that its centre corresponds to about
the upper part of the saphenous opening. The con-
striction is usually at the neck of the sac, and caused
by Gimbernat'a ligament. It is divided by an incision
directed upwards and inwards.

Obturator hernia. — In this form the gut,
pushing before it the peritoneum, the sub-peritoneal
fat, and the pelvic fascia, escapes through the obturator
canal. The direction of this canal is, from behind,
downwards, forwards and inwards.

Beyond the canal the hernia may pass between the
obturator membrane and the obturator externus muscle
and remain deeply placed, or it may make its way through
the muscle or emerge above it and lie then covered
by the pectineus and adductor brevis. The obturator
artery is, us a rule, at the outer and posterior part of
the sac. It is very rarely in front of it. The obturator
nerve is generally found to the outer side of the sac,
less commonly it is in front of it. The proximity of
the nerve renders it very liable to Ik? pressed upon,
a id pain along the nerve is often a marked feature
of the rupture. The hernia presents beneath the
pectineu3 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 i< generally a conspicuous

310 Surgical Applied Anatomy. [Chap. xvi.

symptom. The obturator externus may be made
tense by rotation inwards of the slightly abducted thigh.
This hernia is much 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 remarkable 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 and the rectum. In the ischio-
rectal hernia the protrusions take place into the ischio-
rectal fossa. 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; it has been mistaken for a cyst. In sciatic
hernia the gut escapes through the great sacro-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 288), 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 quad-
ratus 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 of injury)
come through the fascia lumborum and internal oblique
muscles, since those structures form the floor of the
triangle. The hernia may escape through the " upper
lumbar triangle " — a gap near the last rib where the
aponeurosis of the transversalis is covered only by the
latissimus dorsi. Macready {Lancet, Nov. 8th, 1890)
has collected twenty-five examples of this hernia.
Diaphragmatic hernice may be congenital or acquired.
The former variety is by far the more common, and is

Chap, xvi.] The Abdomen. 3 1 1

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 dis-
lodged, then the transverse colon, omentum, small
gut, spleen, liver, pancreas, and kidneys, in the order
named (Leichtenstern). 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 hernia? are more common in males.

Posterior abdominal parietes. — The lateral
and posterior walls of the abdomen are lined inside with
two fascia?, the transversalis and iliac. The transversalis
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 the
points corresponding to the psoas origin. Above, it is
attached to the ligamentum arcuatum internum, and
on the outer side to the anterior layer of the lumbar
fascia along the outer edge of the psoas. Below, the
fascia encloses the iliaeus, 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.

312 Surgical Applied Anatomy. [Chap. xvi.

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 resistance, it would be in-
disposed to spread, since its movements would be against
gravity. Thus it happens that collections so placed
point either just above the iliac crest or Poupart's liga-
ment, or run down along the spermatic cord and dis-
tend the inguinal canal.

The iliac fascia encloses the ilio-psoas in a very dis-
tinct 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 subfascial abscesses
in this region. The osseo-aponeurotic space is practic-
ally 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
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

Chap, xvi.] The Abdomen. 313

iliac fossa, 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 dissecting off
the peritoneum. Clinically, however, such collections
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 transversalis fascia.'.
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 caecum 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 t lie 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 fa?cal matter escaped by the groin.
Retro-peritoneal abscesses in the pelvis (pelvic cellulitis)
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 lie well to note that the common and
external iliac vessels, the lymphatics, and the ureters
are outside the iliac fascia, and rest upon its abdominal
surface, while the anterior crural nerves and abdominal
parts of the Lumbar nerves are within theosseo-apbneur-
otic 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 tic lumbar spine be involved the matter
can pass directly into the substance of the muscle.
which it will more or less entirely destroy. U the mis-
chief be in the dorsal -pine, the matter gravitates along

314 Surgical Applied Anatomy. [Chap. xvi.

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-
menta 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 vertebrae and from the
corresponding transverse processes) : it then splits and
distends the fibres, so as to form a cavity for the re-
ception of the pus . . . and the psoas at length is con-
verted 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
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 trans versalis muscle and fascia
lumborum, the erector spinse and quadrat us lumborum.
The external oblique and latissimus dorsi muscles

chap, xvi.] The Abdomen. 315

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 in-
ternal oblique, and its inner half or two-thirds is over-
lapped by the erector spina?. 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 extravasations 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.

Between the last rib and the iliac crest is stretched
the dense fascia lumborum, the posterior aponeurosis
of the transversalis 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
spina? 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
spina?. 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 spina?.

316 Surgical Applied Anatomy. [Chap. xvi.

The author's operation for caries of the
lumbar vertebrae.— The lumbar vertebrae, and,
possibly, the last dorsal, may be reached by an incision
through the loin. A vertical cut is made along the
outer edge of the erector spinas muscle. The fibres of
that muscle having been drawn aside, the middle layer
of the fascia lumborum is incised, and the quadratus
lumborum is exposed. This muscle is divided vertically,
and then the front of the vertebrae may be reached by
introducing the finger under the psoas muscle. Through
this incision the author has removed the whole of the
body of the first lumbar vertebra that had been separated
as a sequestrum. {Med.-Chir. Trans., 1884.) The
lumbar arteries are avoided by keeping close to the
transverse process of the vertebrae. Through this
incision a psoas abscess may be most conveniently
opened.

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..
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 inflammatory
changes. Large abscesses may, for instance, form
about the kidney and discharge themselves through
the skin without any peritonitis being induced. Spon-
taneous perforation of the small intestine must involve
the i)eritoneum, while, on the other hand, the caecum
and descending colon may become perforated, and the
matter escape into the subserous tissue without the

Chap, xvii.] The Abdominal Viscera. 317

serous membrane being in any way involved. It is

noteworthy in connection with bacterial infection that
it is singularly easy to set 14) inflammation of the perito-
neum if the membrane be approached from its inner
surface, hut comparatively difficult if it, be approached

from without. Thus a small puncture of the membrane
may, on the one hand, lead to fatal peritonitis, while,
on the other, it may be extensively torn from its attach-
ments (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 mem-
brane may lead to inflammation, while the outer surface
may be bathed with pus for a long while (as in large
perirenal abscesses) without any peritonitis being-
produced. Inflammation of the peritoneum may lead
to the formation of a great variety of hands 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 gradually.
This is frequently seen in cases of gradual distension
of the bowel, in the formation of the sac in hernia, and
in the growth of retro-peritoneal tumours. Abrupt
stretching of the membrane leads to certain rupture of
it. The parietal peritoneum may be ruptured by
violence without damage to any of the viscera.

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 has an inclination to the left side. This
depends upon the fact that the omentum is developed
from the meso-gaster, and accounts for the fact that
hernise containing omentum are much more common
on the left side. The omentum, like the 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 inflam-

318 Surgical Applied Anatomy. [Chap. xvii.

niatory and hemorrhagic extravasations, by matting
the bowels together and forming spaces between them.
In perforation of the bowels from disease, an opportune
adhesion of the omentum over the aperture may
prevent escape of the intestinal contents.

Large masses of tissue may be nourished through
an adherent omentum. Thus when the proper blood
supply of an ovarian tumour has been cut off by twisting
of its pedicle, the growth may be nourished through
the omentum, if that structure is adherent to it.
Rutherford Morrison proposes to relieve congestion
of the portal circulation by setting up an anastomosis
between the omental vessels and the systemic circulation.
When an adhesion between the omentum and parietal
peritoneum is produced artificially, large anastomotic
vessels open up and communicate with the vascular
network beneath the parietal peritoneum, thus possibly
relieving tension in cases of obstructed portal circula-
tion. In cases of obesity fat collects conspicuously in
the great omentum. In hernias the omentum generally
contracts adhesions to the sac, and becomes irreducible,
or it may form a kind of second sac about the gut itself
(" omental sac "). The end of the omentum, by be-
coming 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. — The parietal attachment of the
mesentery is liable to some variation. The point at
which this attachment commences above is practically
constant. It corresponds with the ending of the duo-
denum, is about on a level with the lower border of the
pancreas, and is just to the left of the second lumbar
vertebra. {See page 332.) From this point the

chap, xvii] The Abdominal Viscera. 319

insertion of the mesentery follows an oblique line that
runs downwards and to the right, crossing the great
vessels, and then ending in a somewhat uncertain
manner on the right iliae fossa. Its right or upper
layer is continuous with the under layer of the trans-
verse meso-colon, and with the peritoneum that invests
the ascending colon. Its left or lower layer joins with
the serous membrane that encloses the descending colon,
that forms the sigmoid mesentery, and that descends
over the lumbosacral eminence into the pelvis. The
parietal attachment of the mesentery measures, as a
rule, about o' inches. From its oblique attachment
it follows that, when haemorrhage takes place in the
abdomen on the right side of the mesentery, the blood
first is conducted into the right iliac fossa, when on the
left Bide, into the pelvis. This may explain the circum-
stance that collections of blood are more common in the
right than in the left iliac fossa.

The length of the mesentery from the spine to the
bowel varies in different parts of the canal ; its average
length is 8 inches. The longest part is that which goes
t<> the coils of intestine that lie between a point 6 feet
from the duodenum, and a point 11 feet from the same
part of the gut (Author).* Such coils will, therefore,
include 5 feet of the intestine, and the mesentery here
nn\ reach the length of 10 inches. These coils are apt
to bang in the pelvis, and may be easily herniated. The
length of the mesentery plays an important part in
hernia. If the fresh body of an adult be opened, and
the condition of the viscera and peritoneum be normal,
it will be found that it is impossible to drag a loop of
small intestine through the femoral canal (artificially
enlarged) on to the thigh, or down the inguinal canal
into the scrotum. In fact, no coil can, in any part,
be drawn out of the abdomen below a horizontal line
on a level with the spine of the pubes. It is evident,
therefore, that in femoral or scrotal hernia the mesen-
tery must be elongated or its attachments lowered.

* Scr " The Anatomy of the Intestinal Canal and Peritoneum
in Man," by the Author. London, 1885.

320 Surgical Applied Anatomy. [Chap. xvii.

The mesentery is relatively longest in infancy and
childhood, and a freer escape of the intestines from
the abdomen is allowed in subjects under puberty.
The disposition of the membrane permits also a freer
downward excursion of the bowels on the right side,
and this has been offered as an explanation of the un-
due frequency of right-sided inguinal hernia? in child-
hood (Lockwood).

The root of the mesentery, and, indeed, the whole
of the peritoneum covering the posterior abdominal
wall, may glide a little downwards and constitute a
" prolapse of the mesentery." This condition has been
fully investigated by Mr. Lockwood, who states that
it seldom occurs before middle age, that it causes the
mass of the intestines to incline to the left and thus
encourages double and left-sided hernia?. These hernia?
are well known to be more common after middle
age.

Mr. Lockwood states that in acquired hernia the
mesentery is found to have had its attachments lowered
rather than to have been increased in length.

Certain holes are sometimes found in the mesentery,
through which intestine has been strangulated. Some
of these holes, especially those that are slit-like, are
due to injury, others are due to congenital defect of
the mesentery. I have shown that the latter holes
are round, are in the mesentery of the lower ileum,
and occupy an oval area, circumscribed by an anasto-
motic arch between the ileo-colic branch of the superior,
mesenteric artery and the last of the intestinal arteries.
This area is often the seat of atrophied peritoneum,
and shows an absence of fat, of visible blood-vessels,
and of glands. It would be easy for a knuckle of gut
to be forced through the thinned membrane, which is
sometimes already cribriform.

For an account of " mesenteric hernia," see page 334.

Hernia? have occurred through the foramen of
Winslow.

I have described a strangulated hernia in this position
which was exposed by operation.

Chap, xvii.] The A bdomina l Viscer a. 321

The Stomach.

Above.

Liver, small omentum, diaphragm.

In front.

(From left to right)

diaphragm, abdominal

wall, liver.

Stomach.

Behind.
Transverse meso-colon,
pancreas, crura, solar
plexus, great vessels,
spleen, left kidney,
and capsule.

Below.
Great omentum, transverse colon, gastro-splenic omentum.

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
elevated and carried forwards, the anterior surface is
turned upwards, and the posterior downwards (Fig.
48, p. 356). The direction of the rotation depends upon
the fixity of the smaller curvature. When distended,
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 1 inch from the sternum (Fig. 40).
The pylorus, when the viscus is empty, lies just to the
right of the middle line, from 3 to 4 inches below the
sterno-xiphoid articulation, 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 3 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.
41). 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 tenth cartilage has a distinct tip and plays over
the cartilage of the ninth rib, producing under the
finger a special crepitus. The fundus of the stomach
occupies the left dome of the diaphragm and reaches
on the left side as high as the level of the sixth sterno-

322

Fig. 40.— Diagram showing the Kelations of the Viscera to the Parietes

(Anterior view).

s, Stomach ; l, liver ; k, kidney ; tc, transverse colon ; os umbilicus.

Chap, xvn.] The Abdominal Viscera. 323

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. 43, p. 337). The near proximity of the heart
to the stomach is illustrated by a case where a thorn
(of the Prunus spuwsa), ^ an inch long, had been
swallowed and had then found its way through the
diaphragm and pericardium into the wall and cavity
of the right ventricle.

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 hernial In the condition
known as ptosis of the stomach the whole organ is dis-
placed downwards. The stomach is fixed to the liver
and to the diaphragm (round the cardiac orifice) by
fcEe gastro-hepatic omentum, and in such cases of ptosis
this band is said to be found stretched.

The viscus is susceptible of enormous dilatation
when the pylorus is obstructed. The distended organ
may reach as low as Poupart's ligament.

The stomach rests behind on the lesser sac of the
peritoneum, which plays the part of a bursa to it. Gastric
ulcers rarely perforate into the lesser sac. but when
they do the contents can only escape by the foramen
of Winslow, and may not be seen when the abdomen
is opened. The sac is opened by perforating the great
omentum at the greater curvature of the stomach.

The Stomach lias been frequently wounded. In
mosl cases a fatal result rapidly follows upon these

324 Surgical Applied Anatomy. [Chap. xvii.

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 punctured 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. This was illustrated many times
in the Boer war, the viscus having been perforated by
a Mauser bullet. 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 parietes, 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 experiments. In this
man the abdominal parietes in front of the stomach
were torn away by a gunshot wound, 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

325

ITig 41.— Diagram to show the Eelations of the Viscera to the Parietes

(Posterior view).

s, Stomach; L, liver; K, kidney; sp, spleen; B, rectum.

326 Surgical Applied Anatomy. [Chap. xvn.

found to contain thirty-one entire spoon-handles, each
about 5 inches long, four half-handles, nine nails, half
an iron shoe-heel, a screw, a button, and four pebbles.
The whole mass weighed 2 lb. S oz. The patient was
a lunatic. The pyloi'us has an average diameter of
16 mm. This about corresponds to the diameter of
a sixpenny-piece. It is normally in a closed state, and
should be capable of taking the fore-finger when open.
In spite of the narrowness of the pylorus, large sub-
stances that have been swallowed have been passed
by the anus without trouble. Among these may be
noted a metal pencil-case 4|- inches long, 10 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 extracted from the middle of the thigh
six months after it had been swallowed, and like instances
are recorded elsewhere.

The lymphatics of the stomach pass mostly to the
glands situated between the layers of the small omentum
along the lesser curvature of the stomach. Some also
pass to the glands scattered along the greater curvature
of the stomach. In cancer of the pylorus, the glands
along the lesser curvature are the first to become affected,
and from these the disease spreads to the cceliac glands
near the commencement of the thoracic duct. Owing
to a free communication between the lymphatics of
the pylorus, pancreas, and liver, the disease frequently
involves these organs.

Gastrotomy and gastrostomy. — Gastrotomy
consists in opening the stomach through the anterior
abdominal wall for the purpose of removing a foreign
body, for making an examination, or for dealing with a
simple or malignant ulcer ; gastrostomy, in opening the

chap, xvii.] The Abdominal Viscera. 327

stomach in a like situation with the object of establishing

a gastric fistula through which the patient may be fed
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. 40). In the empty condition five-
sixths of the stomach lies beneath the left hypochondriac
region, only part of the pyloric end being exposed in the
triangular area. The incision in these operations must
be situate in this triangle, and may be made either parallel
to, and about two fingers1 breadths from, the free border
of the costal, or along the left semilunar line. In the
former incision the three flat muscles of the abdomen are
cut through. In gastrostomy 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. The opening must needs be very small.

Resection of the pylorus. — The pylorus is
frequently the seat of cancer. As a means of relieving
the patient, the whole of the diseased pylorus has been
removed, and the divided ends of the stomach and
duodenum united by sutures. The situation of the can-
cerous 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 diseased part has
to be isolated and the omental connections of the right
end of the stomach freely divided. The vessels that
are almost certainly divided are the pyloric, the gastro-
epiploica dextra, and the gastro-duodenal. The opera-
tion has not been attended with much success. The
cancer is apt to become diffuse, to spread to adjacent
tissues, and to lead to early lymphatic invasion of the
greater and lesser omenta.

Gastrectomy. — Considerable portions of the

328 Surgical Applied Anatomy. [Chap. xvii.

stomach have been excised in cases of cancer, and the
entire organ has been removed (total gastrectomy)
for the same cause. Up to the time of writing some
fifteen examples of this operation have been recorded
with more or less immediate death in five. Schlatter's
original case of gastrectomy, performed in 1897, died
in fourteen months from secondary deposits. Eicord
published a case in which he removed the whole stomach,
the first piece of the duodenum, and part of the pan-
creas. The patient was alive and well eleven months
after the operation (Gaz. des Hopitaux, March 22nd,
1900). It has yet to be shown that the operation is of
genuine value. There is difficulty in uniting the gullet
to the small intestine ; both vagi nerves are divided
as they emerge through the diaphragm, and the solar
flexus is apt to be roughly handled ; the operation is an
extreme test for a weakened patient, and the after con-
ditions of those who survive is not free from distress.
There is, however, less disturbance of digestion than
would be imagined.

Other operations on the stomach. —
Many other operations are performed upon the
stomach which call merely for mention in this place.
One of the most useful and the most frequently per-
formed is gastroenterostomy. Here an opening (or
stoma) is made between the stomach and the upper
part of the jejunum. The operation is performed in
cases of stenosis of the pylorus, in cases of dilatation
of the stomach without much stenosis, in certain ex-
amples of ulcer, and in many other conditions. In the
operation of pyloroplasty, a non-malignant stricture of
the pylorus is divided and the pyloric passage thus made
free. In gastroplication certain conditions of dilated
stomach are dealt with by taking in a fold or pleat in
the stomach wall and in thus lessening its capacity.

The small intestines.* — The average length of
the small intestine in the adult is 22j feet, the ex-

* The account of the intestines is derived from the Author's
work "On the Intestinal Canal and Peritoneum in Man."
London. 1885.

chap, xvii.] The Abdominal Viscera. 329

tremes being 30 feet and 15 feet. In the fcetus, at
full term, the lesser bowel measures about 9^ feet. It
is roughly reckoned that the first 8 or 9 feet of the
adult bowel belongs to the jejunum, and the remaining
12 or 13 feet to the ileum.

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 jejunum is wider than the ileum (its diameter
being \ 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 light, the lines of the valvuhe 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 of 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 often jejunum. The coils of small
intestine occupy no certain position in the abdomen.
In the fcetus, and during the earliest part of extra-
uterine life, the bulk of the small intestine is placed to
the left of the middle line. This is on account of the
relatively large size of the liver, to the weight of which
the lesser bowel no doubt acts as a counterpoise. In
the majority of adult bodies the small intestine is dis-
posed in an irregularly curved manner from left to right.
The gut, starting from the duodenum, will first occupy
the contiguous parts of the left side of the epigastric
and umbilical regions ; the coils then fill some part of
the left hypochondriac and lumbar regions ; they now
commonly descend into the pelvis, re-appear in the left
iliac quarter, and then occupy in order the hypogastric,

33© Surgical Applied Anatomy. [Chap. xvii.

lower umbilical, right lumbar, and right iliac regions.
Before reaching the latter situation they commonly
descend again into the pelvis.

Much interest attaches to the coils of small in-
testine that are found in the pelvis. These are the
coils that are apt to become involved and adherent in
cases of pelvic peritonitis, and that would probably
form the protrusion in most cases of obturator, sciatica,
and pudendal hernia. No small intestine occupies the
foetal pelvis. The amount found in the adult pelvis
depends mainly upon the state of distension of the
bladder and rectum, and upon the position of the
sigmoid flexure. The coils that are most usually found
in this position belong to the terminal part of the ileum,
and to that part of the intestine that has been already
alluded to as possessing the longest mesentery (page 319).
The ileum is the part of the intestine that is most fre-
quently found in inguinal and femoral hernias. It is
also the part most usually involved in cases of strangula-
tion by internal bands, by holes in the mesentery, etc.

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
punctured wound of the small gut does not lead to
extravasation of contents. The muscular coat contracts
and closes the little opening. Thus, in excessive tym-
panitis 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 becomes everted or protruded
through the wound and effectually plugs it. Gross
found that a longitudinal cut in the small bowel 2|-
lines in length was immediately reduced to a wound
If lines in length by muscular contraction, and that the

Chap, xvii.] The Abdominal Viscera. 331

eversion of the mucous membrane in addition to this
contraction entirely sealed the opening. Even the
opening made in the intestine — for example, in the
jejunum — by the penetration of a Mauser bullet may be
attended by no escape of contents. A contracted empty
piece of bowel becomes nearly twice as long when
distended.

Owing to the greater power of the circular layer
of muscle a longitudinal wound gapes more than a
transverse wound, and, in consequence of the greater
muscular development of the jejunum, wounds of that
part gape more than do those of the ileum. Trans-
verse 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 peri-
toneal cavity. Extravasation followed, and thus the
worm was the immediate cause of the man's death.

The calibre of any portion of the small intestine
depends mainly upon the condition of its muscular wall.
The tube may become much contracted when empty.
In peritonitis and in certain other conditions the muscular
coat is paralysed and the bowel becomes intensely dilated
by gas (tympanitis).

Meckel's diverticulum. — From one to four
feet from the end of the ileum is sometimes seen a
diverticulum (Meckel's) that represents the remains of
the vitello-intestinal duct (page 289). It may be expected
in 2 per cent, of the bodies examined. 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

332 Surgical Applied Anatomy. [Chap. xvn.

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 obstruc-
tion in many ways. Its end may contract adhesions,
and beneath the bridge thus formed a loop of bowel
may be strangled. It may twist itself about a piece of
intestine so as to form a knot round it. It may, from
its adhesions, so drag upon the ileum as to cause
" kinking " of the tube at its point of origin. In more
than one case it has been found in an external hernia.
It may become invaginated and start an intussusception
of the bowel.

The duodenum and fossa duodeno-
Jejunalis. — The first portion of the duodenum is
nearly horizontal. It measures about 2 inches in
length and passes backwards from the pylorus to near
the upper end of the right kidney. The second
portion, about 3 inches in length, descends vertically
in front of the inner border of the right kidney to the
level of the third lumbar vertebra. The third portion,
some 5 inches in length, crosses from right to left in front
of the third vertebra, and then ascends for a short
distance on the surface of the left psoas muscle, to end
in the jejunum to the left of the second lumbar vertebra.
The first portion, which is movable, is invested by peri-
toneum, in the same manner as the stomach. The
second part is covered by peritoneum in front only,
except at the spot where it is crossed by the trans-
verse colon. The third part is also covered by peri-
toneum only on its anterior aspect, this membrane being,
however, free of the gut where the superior mesenteric
vessels cross it.

The first portion has found its way into hernise in
company with the stomach, but the second and third
parts are never herniated. The end of the duodenum,
the duodeno-jejunal bend, is very firmly held in place
by a band of fibrous tissue that descends upon it from
the left crus of the diaphragm and the tissue about
the cceliac axis. This band is called the suspensory
muscle of the duodenum (Treitz). It serves also to

Chap, xvii.] The Abdominal Viscera. 333

support the mesentery. No matter to what extent
the stomach may be displaced by distension, or the
intestines disturbed by a like cause, the position of the
duodeno-jejunal bend will be found to remain unaltered.
All sections of the duodenum have been ruptured by
violence. Owing to its large non-peritoneal surface,
the bowel, if approached from behind, may be wounded
without opening the peritoneum (Fig. 47, p. 353).

In connection with the spread of disease by con-
tinuity of tissue, it is w^ell to note that the duodenum
is in relation with the liver, gall bladder, pancreas,
transverse colon, spine, right kidney, bile duct, portal
vein, gastro-duodenal and superior mesenteric vessels,
aorta and vena cava.

In the duodenum are Brunner's glands, which are
sometimes the seat of a perforating ulcer in cases of
burns. They are mostly seated in the first segment
of this bowel, and the perforation, therefore, usually
opens into the peritoneal cavity. A diverticulum is
sometimes present. The liver and pancreas are both de-
veloped as epithelial buds from the duodenal part of
the canal in the embryo. Congenital strictures of the
intestine are not uncommonly placed in the duodenum.

The peculiar vertical curve of the duodenum closely
resembles that of the syphon trap used in drains. Mr.
Mayo Collier has pointed out that this part of the bowel
probably acts as a real syphon trap, and so prevents
the regurgitation of intestinal gas into the stomach.
The duodenum of the horse appears to act also in this
manner.

Passing from the front of the terminal (ascending)
part of the duodenum, a fold of peritoneum is often seen,
that joins the parietal peritoneum to the left of the piece
of gut in question. This fold marks off a fossa of tri-
angular outline, the orifice of which is directed upwards.
I have found the fossa in about 50 per cent, of the bodies
examined. It is called the fossa duodciio-je jimalis ;
it is usually large enough to lodge the tip of the finger,
and its opening lies just below the duodeno-jejunal bend
(Fig. 42). This fossa is the anatomical cause of mesen-

334

Surgical Applied Anatomy. [Chap. xvii.

teric, meso-colic, meso-gasti'ic, or retro-peritoneal hernia.
The commencement of the jejunum presses into the
fossa, enlarges its cavity, and ultimately separates the
peritoneum from its posterior attachments. More
and more of the small intestine passes into the increasing
pouch, until at last, as in the case reported by Sir Astley
Cooper and many others, nearly the whole of the small
intestine may be found lodged in an enormous median
retro-peritoneal sac, the mouth of which is the orifice

Fig. 42. — The Fossa Duodeno-jejunalis (Treves).

of the fossa duodeno-jejunalis. The duodenum can be
seen to enter the sac and the end of the ileum to leave
it. The sac usually extends downwards on the left
side, and may reach the promontory of the sacrum.
These hernise vary in size, but are as a rule large. The
ccecum and ascending colon have their normal position,
but the transverse' and descending parts of the colon
are stretched over and displaced by the sac. The renal
artery is behind the hernia, and the inferior mesenteric
artery is in front of it and to the left. A branch of this

chap, xvn.] The Abdomixal Viscera. 335

vessel, the colica sinistra, is near to the orifice of the
sac in its lower part.

Operations 011 the small intestine. — Entcr-
otomy is the operation of opening the small intestine
above some obstruction that threatens to be fatal or in-
superable. The incision is made in the linea alba, below
the umbilicus, or in one or other iliac region, as is con-
sidered more convenient. An incision some 2 or 3 inches
in length will probably suffice. The peritoneum having
been opened, a knuckle of small bowel close above the
obstruction is seized, is secured to the parietal wound,
and then opened. The small intestine has also been
opened to remove impacted foreign bodies and large
gall stones. In such cases the intestinal wound is
usually closed immediately. Enterectomy. — Portions of
the small intestine have been resected with success for
various diseased conditions. In one case more than
two yards of the small intestine were cut away on account
of multiple stricture. The patient, a young woman,
made an excellent recovery. Resections have also
been successfully performed in cases of bullet wound
or stab involving the lesser bowel, and in other injuries.
Tumours of the gut have been removed by a partial
resection. Non-malignant strictures of the bowel have
been treated by incision and dilatation.

The bowel above an obstruction has been connected
to the bowel below an obstruction by the operation
called intestinal anastomosis or short circuiting.

In uniting divided intestine by suture (enteroraphy)
it is essential that the serous coat of the ends of the
bowel should be brought together. This is best effected
by the suture known as Lembert's, with the addition
of a special and separate line of sutures for the mucous
membrane. Experience shows that if leakage occurs
after resection or suture of intestine it will most likely
occur along the attachment of the mesentery. This
circumstance is thus explained by Mr. Anderson. The
two layers of the mesentery diverge as they approach
the bowel, and so leave a triangular space, the base
of which, averaging about Aths of an inch in width

336 Surgical Applied Anatomy. [Chap. xvn.

is formed by the uncovered muscular tissue. It is the
existence of this bare piece of intestine that renders
adjustment of the serous coat at the attachment of the
mesentery a matter of some difficulty.

The ileo-csecal region. — The caecum is, to a
certain extent, rudimentary in man, as it is also in
the carnivora. In herbivorous animals it is of great
size, and appears to serve as a reservoir for the elabor-
ation and absorption of food. It has been said that
the caecum in man exists as an anatomical protest
against vegetarianism. The appendix persists as the
remains of the larger ceecum of lower mammals. In
the human foetus it can be seen to be but the narrowed
extremity of a capacious ceecum. The foetal type of
ceecum, which is very characteristic, may persist
throughout life. From the point of view of evolution
the appendix would appear to be becoming obliterated.
Like other functionless parts that persist as develop-
mental relics, it is very frequently the seat of disease,
and it is worthy of note that such disease tends to cause
the entire obliteration of the part (as after many forms
of so-called appendicitis).

It must be understood that the term caecum is applied
to that part of the colon that lies below the entrance
of the ileum. The average breadth of the adult ceecum
is 3 inches, its average length (vertical measurement)
2 \ inches.

The ceecum is usually lodged in the right iliac fossa,
and is so placed that its apex corresponds with a point
a little to the inner side of the middle of Pou part's liga-
ment. When distended with gas or feecal contents
it occupies the whole of the right iliac fossa. A point
1^ inches above and internal to the anterior superior
iliac spine lies over the ileo-ceecal valve.

A slightly distended ceecum so located may be
emptied by flexing the thigh upon the abdomen. The
ceecum is always entirely invested by peritoneum. Its
posterior surface is never in connection with the areolar
tissue of the iliac fossa (Fig. 43). The peritoneum
is reflected from the commencement of the ascending

chap, xvii.] The Abdominal Viscera.

337

colon on to the posterior parietes below the level of
the iliac crest, A mobile caecum may hang over
the pelvic brim, or occupy the pelvis, or even find its
way into an inguinal hernia of the left side.

The caecum is not infrequently found in an
inguinal or femoral hernia of the right side (caecal
hernia). Such hernia? are, except in a few rare
instances, provided with a proper and complete
peritoneal sac.

Foreign bodies that have been swallowed 'are

ME5C COLON

ILEO-COUC FOSSA

BLOODLESS FOLD

RE.TRO-CAECAL FOSSA

ILEO-CAECAL FOSSA

Fig. 43.— The peritoneal fossae of the ileo-csecal region.

very apt to lodge in the caecum, and in that situation
may cause ulceration and even perforation of the
bowel, producing one form of typhlitis.

In cases of faecal retention, also, the largest accumula-
tion of faecal matter is very usually met with in the
caecum, and upon that part of the 1 towel when distension
is extreme the greatest strain usually comes.

Stercoral ulcers (ulcers due to the pressure and
irritation of retained fasces) are more often met with
in the caecum than in any other part of the colon.
Solitary follicles are numerous in the mucous membrane
of the caecum. Intestinal concretions also are not
uncommon in this part.

The caecum is susceptible of enormous distension,

w

3$S Surgical Applied Anatomy. [Chaj>. xvil.

provided that it be gradually effected, and, in certain
instances, a dilated caecum has been found to occupy
a large part of the abdominal cavity. When the abdo-
men is opened in any doubtful case of intestinal obstruc-
tion, the condition of the caecum is of great value in
pointing to the seat of the obstacle. In stenosis 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 appendix varies in length. Its average
measurement in the adult is 4 inches, the extremes being
1 inch and 6 inches. Its position varies, although, as a
rule, it is seen to lie behind the end of the ileum and
its mesentery, and to point in the direction of the spleen.
It frequently also lies behind the caecum. I have seen
the appendix so placed with reference to the bowel
that it would have been encountered in a right lumbar
colotomy. In such cases the appendix has been pushed
behind the caecum and caught in the meso-colon during
the later months of foetal life, when the colon migrates
from the neighbourhood of the liver to the right iliac
fossa. The appendix may hang within the pelvis and,
in inflammatory conditions, contract adhesions to the
ovary or other pelvic structures. I have found an
inflamed appendix adherent to the liver and another
in the left iliac fossa. It has found its way down both
the right and the left inguinal canals.

The tip of the process may adhere to a neighbouring
peritoneal surface, and thus form a " band," beneath
which a piece of small intestine may be strangulated.

Foreign bodies occasionally lodge in the appendix,
and it is very often found to be occupied by a faecal
concretion or calculus. These substances excite inflam-
mation, and, as a result, the appendix may become
perforated. Troubles in the vermiform process are the
most frequent causes of perityphlitis, a term applied to
localised inflammation of the peritoneum in the vicinity
of the caecum.

From the position of the appendix it will be under-
stood' how it has happened that inflammation of the

Chap. Xvii.r The Abdominal Viscera. 339

organ, has been mistaken for ovaritis, for peri-renal
inflammation, or even for hip disease. In appendicitis
there is often pain down the right thigh and stiffness of
the right hip. The mesentery of the appendix (Fig. 43),
which contains an artery derived from the ileo-colic,
may be so short as to produce obstructive kinks in the
appendix. The mucous lining is so crowded with solitary
Lymphoid follicles as almost to occlude its lumen. In
some forms of appendicitis these follicles are involved.
They are surrounded by lymph spaces, from which
vessels pass to the lymph glands in the mesentery,
and others pass upwards behind the ascending colon
(Lockwood). It is probably through these latter vessels
that infection passes from the appendix and gives rise
to abscesses in the subdiaphragmatic region. The
muscular coat of the appendix is scanty, and through
breaks in it the submucous tissue communicates with
the subserous. Inflammation of the mucous membrane
may therefore spread without hindrance to the
peritoneum.

It is in the ileo-csecal region that intussusception
most frequently occurs. In this condition one part of
the intestine is prolapsed or " telescoped " into the lumen
of an immediately adjoining part. In the ileo-ca?cal
variety (the commonest form) the narrow ileum, and
subsequently the csecum, are prolapsed into the colon.
The ileo-Ccecal valve forms the summit of the protrusion
or intussusceptum. By a gradual increase of the con-
dition the intussusceptum bowel may at last reach
the rectum, and the ueo-eaecal valve has, in fact, been
recognised protruding from the anus. In the ileo-colic
variety (the rarer form) the end of the ileum is pro-
lapsed through the valve. The valve and the csecum
remain in their normal situations, and the summit of
the intussusceptum is formed only by the ileum.

There are three fairly constant peritoneal fossa?, which
are sometimes the seat of hernia, in the ileo-ca?cal region
(Fig. 43). They are (1) the ileo-colic, situated between
the ascending colon and termination of the ileum ;
a fold containing the anterior caeca! artery bounds it

34° Surgical Applied Anatomy. [Chap. xvii.

above ; (2) the ileo-caecal fossa, between the termination
of the ileum and the caecum ; it is bounded in front by
the bloodless fold and behind by the mesentery of the
appendix ; (3) the retro-caecal fossa, behind the caecum ;
it is bounded on the right by the lower termination
of the ascending meso-colon.

The large intestine. — From the caecum 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. It crosses the belly transversely, so that its lower
border is on a level with the umbilicus (Fig. 40, p. 322).
In cases of faecal accumulation, the outline of the colon,
with the exception of the two flexures above named,
may be distinctly defined. In distensions 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) comparatively 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 descending 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 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 2 1- inches, of the latter 1^ 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 tendency to stricture iucreases as one proceeds
downwards from the caecum to the anus. A stricture

chap, xvii.] The Abdominal Viscera. 341

is frequent in the descending colon, less frequent in the
transverse colon, while in the ascending colon it is com-
paratively rare. Strictures are not uncommon about
the flexures of the bowels.*

When gradually distended the colon may assume
enormous dimensions, and it will be readily understood
that in some cases of great faecal accumulations 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 \\ inches above and 1 inch to the inner
side of the left nipple. Whe n the faecal collection had bee n
removed it returned to its normal position. Thus it-
happens that a distended colon is often associated with
shortness of breath, with palpitation, and other thoracic
symptoms.

The ascending and the descending colon are placed
vertically. The average length of the ascending colon
in the adult (as measured from the tip of the caecum
to the hepatic flexure) is 8 inches. The average length
of the descending colon (from the splenic bend to the
commencement of the sigmoid flexure) is 8 \ inches.
The descending colon is very little liable to variation.
In cases of non-descent of the caecum the ascending colon
may be absent (page 345). I have pointed out that in
52 per cent, of adult bodies there is neither an ascending
nor a descending meso-colon, and that a meso-colon
may be expected on the left side in 36 per cent, of all cases,
and on the right side in 26 per cent. These points are
of importance in connection with the somewhat uncom-
mon operation of lumbar colotomy. The breadth of
the meso-colon, when it exists, varies from 1 to 3 inches.
The line of attachment of the left meso-colon is usually
along the outer border of the kidney, and is vertical.
That of the right meso-colon is, as a rule, less vertical,
runs along the inner border of the kidney, and crosses
its lower end obliquely from right to left.

The transverse colon has an average measurement

* See " Intestinal Obstruction." By the Author. London.

IS'.!'. I.

342 Surgical Applied Anatomy. [Chap. xvii.

of 20 inches. It is not quite horizontal, since the splenic
flexure is on a higher level than the hepatic flexure,
as well as posterior to it. Faecal masses lodged in the
transverse colon have given rise to many errors in dia-
gnosis. In some instances this part of the colon is dis-
placed towards the pelvis, so that V- or U-shaped bends
are produced. In such cases the point of the V or U
may reach the symphysis pubis, while the two colic
flexures occupy their proper situations. These devia-
tions are described in detail in my work on Intestinal
Obstruction.

The right-hand part of the transverse colon is in
intimate 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 transverse colon often finds its way into
an umbilical hernia, and has been found to be concerned
in many of the cases of hernia into the foramen of
Winslow.

The sigmoid flexure. — The segments of gut termed
the sigmoid flexure and " the first part of the rectum "
form together a single simple loop that cannot be divided
into parts. This loop begins where the descending colon
ends, and ends at the commencement of the so-
called " second part of the rectum ; " at a spot, in fact,
where the meso-rectum ceases, opposite about the third
piece of the sacrum. This loop, when unfolded, describes
a figure that, if it must be compared to a letter, resembles
the capital Omega. It may well be termed the Omega
loop, and the term rectum be limited to the short piece
of practically straight gut, that is now described as the
second and third parts of the rectum. The average
length of the loop in the adult is Yl\ inches. The two
extremities of the loop are about 3 or 4 inches apart.

Chap, xvii.] The Abdominal Viscera. 343

If tliey are approximated to one another, as by contract-
ing peritonitis at the root of the sigmoid meso-colon,
a kind of pedicle is established, about which the loop
may readily become twisted. Such a twist of the bowel
constitutes a volvulus of the sigmoid flexure ; and it
may be here said that volvulus of the intestine is more
commonly met with in this loop than in any other part
of the canal.

The line of attachment of the meso-colon of the
Omega loop (the sigmoid meso-colon) crosses the psoas
muscle and the iliac vessels near their bifurcation ; it
then turns abruptly down, and running nearly vertically,
terminates at the middle line.

In the left wall of this meso-colon, close to the point
where it lies over the iliac vessels, a fossa is sometimes
to be found. It is produced by the sigmoid artery,
and is about 1^ inches in depth. It is called the inter-
sigmoid fossa, and is the seat of sigmoid hernia
(Fig. 44, m.c). Two cases of strangulated hernia in
this fossa have been recorded.

The sigmoid flexure, or Omega loop, when empty,
normally occupies the pelvis. When distended this
piece of bowel may become so enormously dilated as
to reach the liver. The chief examples of extraordinary
dilatation of the colon concern this loop. Faecal masses
are very frequently lodged in the free end of the loop
and certain intestinal concretions have been met with
in the same situation.

I have shown by experiment that the "long tube."
when introduced through the anus, cannot be passed
beyond the sigmoid flexure in ordinary cases, and with
a normal disposition of the bowel.

In cases of congenital absence, or deficiency of the
rectum, the sigmoid flexure is often opened in the
groin and an artificial anus established there. This
operation, known as Littre's operation, is, it must be
confessed, not very successful. One difficulty has been
said to depend upon the uncertain position of the sig-
moid flexure in cases of congenital deformity, it being
sometimes on the right side and sometimes in the pelvis

344

Surgical Applied Anatomy. [Chap. xvii.

at the middle line. It is rarely, however, found in these
positions. Out of 100 post-mortem examinations on
young infants, Curling found the loop on the left side
in eighty-five cases. Out of ten children who were
operated on for imperforate anus, the loop was found in
the left fossa in only one case (Montgomery).

Fig. 44.— Sigmoid Flexure turned upwards to show the Inter-signioid
fossa (Jonnesco).

s v, Sigmoid flexure ; a s, Sigmoid artery : w c, Meso-sigmoid fossa ; a e, external
il:ac artery ; u, Ureter in front of internal iliac vessels.

The sigmoid flexure is the part of the colon opened
in the operation of left iliac or inguinal colotomy. In
performing this operation the length of the sigmoid
meso-colon and the consequent mobility of the coil are of
much importance.

The sigmoid flexure, when empty and contracted, can
be felt through the parietes in moderately thin subjects.

chap, xvii.] The Abdominal Viscera. 345

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-
driuni. 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 a congenital umbilical hernia, or in the
left hypochondriac region (the ascending and trans-
verse parts of the colon being absent), or it may be found
in the right hypochondrium, the ascending colon only
being unrepresented.

The whole of the large intestine has at one time
an extensive mesentery, and in some rare cases this
condition may persist throughout life. When it does
persist, it may lead to one form of volvulus of the bowel.

Lumbar colotomy. — The operation so named
consists in opening the colon in the loin behind the
peritoneum, for the purpose of establishing an artificial
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. The
operation has, however, been almost entirely superseded
by iliac colotomy except in a few uncommon conditions.
The position of the descending colon in the loin may be
represented by a line drawn vertically upwards from
a point \ an inch behind the centre of the iliac
crest (Fig. 50, p. 365). In performing left lumbar
colotomy an ink line may be drawn vertically
upwards from the centre of the crest of the
ilium. 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

346

Surgical Applied Anatomy. [Chap. xvii.

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

Fig. 45.—- Horizontal Section through the Body at the Level of the
Umbilicus. (After Braune.)

a, Spine of the fourth lumbar vertebra ; 6, disc between third and fourth verte-
brae ; c, umbilicus ; d, quadratus lumborum ; e, psoas ; /, external oblique,
with internal oblique and transversalis muscles beyond ; y, rectus ; h, de-
scending colon ; i, transverse colon ; j, aorta ; ft, inferior vena cava ; I,
ureter.

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

Chap, xvn ] The Abdominal Viscera. 347

be cut. At the seat of the operation the descending
colon occupies the angle between the psoas and quad-
ratus lumborum muscles, and the non-peritoneal surface
is exactly represented by that part of the bowel that
faces this angle (Fig. 45). 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 descending
colon. The gut is drawn forwards, stitched to the
wound, and opened by a transverse cut. The width
of the non-peritoneal surface varies from £ths of an inch
to 1 inch in the empty state, and may attain to 2 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 the
intestine can be seen. In this, as in other circumstances,
the large bowel may be distinguished from the small
by its sacculi, its three longitudinal muscular bands,
and its appendices epiploicse. 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 H- inches. The average dia-
meter of the ileum is 1 } inches, and of the csecum and
commencing colon 2.1 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.

Iliac or inguinal colotomy. — In this very
common, excellent, and simple operation the sigmoid
flexure is exposed and opened in the left iliac region.
A line is drawn from the anterior superior iliac spine to
the umbilicus, and an incision some 2 inches in length
is made at right angles to this line and at a distance of
about \\ inches from the point of the bone. The three
muscles of the abdomen and the peritoneum having

348 Surgical Applied Anatomy. [Chap. xvn.

been divided, the loop of the sigmoid flexure is brought
into the wound, is secured, and is (at once or at a later
period) opened.

The caecum may be opened on the right side, and
as a rule the most convenient incision is an oblique one
placed external to the deep epigastric artery.

Colectomy consists in excising a portion of the colon.
The caecum has been removed, and considerable segments
of the rest of the large intestine. The treatment of
cancer of the colon by excision is attended with very
considerable success. Portions of the ascending and
descending parts of the colon have been excised through
an incision in the loin, but colectomy is much more
readily carried out through an anterior wound. I
have reported a case in a young girl, in which I excised
the whole rectum and anus, the sigmoid flexure, and
the whole of the descending colon. The divided trans-
verse colon was brought out at the anus. The child
made a perfect recovery. The parts removed are in
the Museum of the Royal College of Surgeons. The
operation of intestinal anastomoses or short circuiting
is very frequently practised on the colon. Thus, in an
obstruction on the descending colon incapable of removal,
the transverse colon may be united to the sigmoid
flexure.

The liver — The liver is moulded to the arch of
the diaphragm, and lies over a part of the stomach
(Fig. 48). The convex surface is protected on the right
side by the ribs, from the seventh to the eleventh in-
clusive, and in front by the xiphoid cartilage and the
costse from the sixth to the ninth inclusive, the dia-
phragm being interposed. The diaphragm separates
the liver from the thin margin of the base of the right
lung, which descends in front of it. Its pointed left
extremity reaches the position of the apex beat, and in
the early years of life, when the left lobe is relatively
large, it may touch the spleen, a relationship sometimes
met with in the adult. In the subcostal or infrasternal
triangle, the liver lies in front of the stomach and
beneath the anterior abdominal wall. The lower edge,

Chap, xvii.] The Abdominal Viscera.

349

as it crosses the subcostal angle, is represented by
a line drawn from the ninth right to the eighth
left costal cartilage (Fig. 40, p. 322). In the erect posture
the lower edge on the right side is about \ or \
of an inch below the margins of the costal cartilages.

LIVER

CYSTIC DUCT.

FOR. WIN.- I

COM. BILE D

IV ST

LY. GL._

VENA CAVA .

COM. BILE P. i
2V S'

HEAD OF PAN

Fig. 46. — Diagrammatic Representation of the Gall Bladder and Bile Ducts
from the right side.

The position of the portal vein is indicated by x ; or-. BL., gall bladder; coir.
bile d. 1st ST., omental stage of common bile duct: com. bile d. 2nd ST.,
retro-duodenal stage of common bile duct ; hep. art,, bepatic artery giving
off the gastro-duodenal and superior pancreatico-duodenal artery; for. WIN.,
foramen of Winslow; ix. c.c, tip of ninth costal cartilage; 1st ST. d., first
stage of duodenum; 2nd ST. n.. second stage of duodenum; trass, col. ,
section of transverse colon; LY. gl., lymph glands in the gastro-hepatic
omentum.

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 liver reaches
its highest level in the nipple line at a point marked by
the fifth rib. To the left it slopes downwards to the apex

356 Surgical Applied Anatomy, tChap. xvii.

beat, the line crossing the sternum at the insertion of
the sixth pair of ribs. To the right of the nipple line, it
rapidly descends, passing the seventh rib in the axillary
line and the ninth below the angle of the scapula.
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 vertebrse. On
the extreme right the liver descends to the level of the
second lumbar spine (Figs. 41 and 48). The under
surface of the liver is in contact with the stomach, the
first and second parts of the duodenum, the small
omentum, the right kidney, and the beginning of the
transverse colon.

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 retained in shape by, and moulded upon,
the diaphragm above and the abdominal organs below.
When removed from the body the shape is lost which
it possesses clinically. It presents many variations in
form. One of the commonest is a linguiform process,
usually known as RiedeVs lobe, which projects from
the margin of the right lobe under the tenth costal
cartilage. It is found more frequently in women than
in men, and may be mistaken for a floating kidney or
an abdominal tumour.

In the condition known as ptosis of the liver the
organ slides from the dome of the diaphragm, and may
descend to the level of the umbilicus or reach the iliac
fossa. With the descent there is also a rotation on its
transverse axis, so that its diaphragmatic surface comes
almost completely to the front. In such a case the
factors which maintain the liver in position have to be
considered. They are : (1) its fixation to the diaphragm
by the inferior vena cava and the fibrous tissue on the
non-peritoneal posterior surface of the right lobe in the
neighbourhood of the inferior vena cava. This is its
chief support. (2) The peritoneal folds, which include the
right and left lateral, coronary, and falciform ligament,
also attach it to the diaphragm. (3) The muscular

Chap, xvii.] The Abdominal Viscera. 351

abdominal walls. These keep the other abdominal
viscera constant])- pressed against the lower surface of
the liver. It must be remembered that in respiration
the liver plays the part of shuttlecock to the battledore
of the diaphragm and abdominal parietes. In many
women over forty the right lobe of the liver projects
quite 2 inches below the eleventh rib.

The liver is more often ruptured from contusion
than is any other abdominal viscus. This is explained
by its large size, its comparatively fixed position, and
its great friability of structure. Death in such in-
juries usually ensues from hseniorrhage, 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 retrograde current were established. The
hepatic vessels are thin-walled, and it is almost impos
sible to ligature them, except by buried sutures. 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 peritoneal cavities. The intimate
relation of the liver to the transverse colon is illus-
trated by a case where a toothpick, 4 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
iiver to the heart may be illustrated by a case still more

352 Surgical Applied Anatomy. [Chap. xvii.

remarkable. In this instance a loose piece of liver,
weighing 1 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 abdominal wounds, and are
usually easy to reduce. In one instance of such pro-
trusion 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. Considerable portions of
the liver have been removed with success. It is remark-
able from what grave injuries of the liver recovery is
possible. Thus, Dr. Gann {Lancet, June, 1894) reports
the case of a man of 28, who had a harpoon driven
through the whole thickness of the right lobe of the
liver, so that it projected at the posterior border. The
blade was 7 inches long, and had two barbs. It was
removed by operation twenty-eight hours after the
accident, and the patient made a good recovery.

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 from 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
burst in one or other of the following directions, placed
in order of their frequency : (1) Into the right lung ;'
(2) into the bowel ; (3) upon the surface of the body.
Such abscesses have, in rare cases, opened into the
stomach. 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 affections
of the urinary organs, and are equally rare in the pyaemia

353

a—

mm I ,

Fig. 17— View

>f some of the Abdominal Viscera from behind
(Rildinger).

a, Tboracic aorta ; b, oesophagus; c, common carotid artery and internal jugular
vein ; d, root of right lung ; a, inferior vena cava j f, spleen ; g, stomach, and
to its right the liver ; h, pancreas ; i, descending part of duodenuinf opened ;
j. sni'eri >r mesanterie vein joined by splenic above ; k, ascending colon ;(. do-
sccu'ling'olo i ; m superior hemorrhoidal vein joining inferior mesenteric.

354 Surgical Applied Anatomy. [Chap. xvii.

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 perito-
neal cavities, or into any adjacent part of the intestine.

The gall bladder may be absent, as is the case
with some animals, or reduced to a cicatrix from disease.
Its mucous membrane has a peculiar reticulated, honey-
comb appearance. It is often occupied by gall stones.
These concretions are composed mostly of cholesterin,
a normal constituent of bile, and vary in size from a
hemp seed to a hen's egg. The escape of gall stones is
rendered more difficult by the presence of a spiral fold
of mucous membrane in the neck and duct of the gall
bladder. The gall bladder, at its neck, forms an acute
angle with the cystic duct, the spiral fold being necessary
to keep the passage open. In the erect . position the
long axis of the gall bladder is directed upwards and
backwards, and the cystic duct downwards and for-
wards (Fig. 46). The cystic duct lies in the gastro-hepatic
omentum, where it joins the hepatic to form the common
bile duct. It is accompanied by the cystic artery.

A gall stone may be arrested, and require removal,
from any part of the cystic or common bile ducts. The
common bile duct is 3 inches long, and its lumen Ath of an
inch wide, but by the passage of the gall stones it may
become three times its normal diameter. The upper
half of the common bile duct lies in the gastro-hepatic
omentum, in front of the foramen of Winsiow, with the
portal vein behind it and to the right (Fig. 46). The
hepatic artery lies close to it on the left, and its branch,
the superior pancreatico-duodenal, crosses the common
bile duct as it passes to its second or deeper stage. A stone
arrested in the lower half of the duct is difficult of access.
The duct lies buried between the head of the pancreas
behind and the duodenum in front and to the outer
side. It may be necessary in such a case to open the
duodenum and extract the stone through its posterior
and inner wall. Two lymphatic glands lie in the gastro-
hepatic omentum by the side of the bile duct, and have
been mistaken for gall stones when calcified.

Chap, xvii.] The Abdominal Viscera. 355

The gall bladder receives its nerve supply from the
eighth and ninth segments of the cord (Head) through
the great splanchnic and cceliac plexus.

The gall bladder and the bile duct have been rup-
tured alone without rupture of the liver. The injury
is rapidly fatal, owing to the escape of bile into the
peritoneal cavity. Large gall stones are passed direct
into the bowel through a fistulous tract that has been
established between the gall bladder and the intestine.
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 dis-
charged through a spontaneous fistula in the hypo-
gastric region, 5 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. So large a tumour has been
formed that the mass has been mistaken for an ovarian
cyst. The gall bladder as it enlarges tends to follow
a line extending from the tip of the right tenth cartilage
across the median line of the abdomen below the umbili-
cus. 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. Impacted gall
stones have teen removed entire from the bile duct
through an incision so made, or the stone has been
crushed in situ and extracted in fragments.

In cholecystectomy the whole of the gall bladder is
excised and the cystic duct closed. The bile finds its way
into the intestine direct through the common duct.

In cholecystenterostomy a fistula is established be-
tween the gall bladder and the intestine. The operation
is carried out in cases in which there is an insuperable
obstruction in the common duct. The gall bladder thus
takes the place of the common duct.

The spleen. — The spleen is deeply situated in the
left hypochondriac region, and in the normal condition

356

Surgical Applied Anatomy. [Chap. xvn.

cannot be palpated, being quite covered in front by the
cardiac end of the stomach. It 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,

Y\g. is.— Horizontal Section through Upp^r part of Abdomen.
(Riidinger.)

a, Livsr ; b, stomach ; c, transverse colon ; d, spleen : e, kidney* ; /, pancreas ;
g, inferior vena cava ; h, aorta with thoracic duct behind it.

respectively, with the ninth dorsal and first lumbar
spines ; its inner end is distant about l|- inches from
the median plane of the body, and its outer end about
reaches the mid-axillary line " (Quain) (Figs. 41 and
47). It possesses three surfaces, gastric, renal, and
phrenic, well shown in Fig. 48.

A dislocated or floating condition of the spleen is
rare. Its renal surface is fixed firmly to the upper
half of the left kidney ; its gastric surface is kept in
apposition to the stomach by the gastro-splenic omentum ;

chap, xvii.] The Abdominal Viscera. 357

its upper pole is attached near the cardiac orifice of the
diaphragm by a suspensory fold of peritoneum, while
its lower rests on the costo-colic peritoneal fold, and has
the tail of the pancreas and colon in contact with it.
The tension of the abdominal walls exerts a general
pressure on it through the other abdominal organs.
When the spleen enlarges, as in ague, its crenated
anterior border may be felt beneath the tenth costal
cartilage. The movable or floating spleen is met with
only in adults. The organ may be so displaced as to
reach the iliac fossa.

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
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
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
extremely vascular, it follows that ruptures of the viscus
are usually, but not necessarily, fatal from ha?morrhage.
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
some distance, although his spleen, as the autopsy re-
vealed, 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 fart
may serve to explain cases of recovery from limited

358 Surgical Applied Anatomy. [Chap. xvn.

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 track 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 abdo-
men, and in one case a cystic tumour so completely
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 suc-
cessful in cases of abdominal wounds with protrusion
of the viscus. It has also been performed with fair
results in many cases of hypertrophied spleen, and of
wandering spleen. The operation is not justifiable in
cases of leuksemic enlargement of the organ, it having
proved invariably fatal in such instances. In cases of
wounds with protrusion, the spleen is, of course, removed
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 corresponds to
the centre of the cut. Some surgeons prefer an incision
along the outer edge of the left rectus muscle. The
viscus is then slowly pressed out of the wound. The
great difficulty is with the gastro-splenic omentum,
which has to be divided and its vessels secured. In
drawing out the spleen there is much risk of tearing
the splenic vessels, especially the vein. Special care
has to be taken to avoid damage to the pancreas. The
splenic artery, with its large accompanying vein, lies
in the lieno-renal ligament, in contact with the tail
of the spleen below.

The pancreas lies behind the stomach, in front

Ghap. xvii.] The Abdominal Viscera. 359

of the first and second lumbar vertebrae. It crosses
the middle li.ie 0.1 a level with a point about 3 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 little of
surgical interest (Figs. 47 and 48). So closely is it
mixed up with the solar plexus that this structure is
necessarily involved in any operative procedures on the
head and neck. It has, I believe, never been ruptured
alo.ie, 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. Its duct ends
in the ampullated extremity of the common bile duct,
and through it septic infections of the duodenum may
spread to the pancreas. A secondary duct may be
present. It opens an inch nearer the pylorus than
the main duct.

It may become invaginated into the intestine, and
portions of the gland have sloughed off and been passed
i.i the stools.

The common bile duct in its second stage lies between
the head of the pancreas and the duodenum. 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. Cancer of the pylorus may spread to
the head of the pancreas by direct extension. The
lymphatics of the two parts also freely communicate.

The pancreas lies behind the lesser sac of the peri-
toneum, its anterior surface being covered by the
posterior wall of the sac. It lies in front of the aorta,
in the fork between the cceliac axis above and the
superior mesenteric artery below. The portal vein
passes upwards behind the neck of the gland.

Certain remarkable cysts are sometimes developed
in the pancreas. They may attain great size and nearly
fill the abdomen.

360 Surgical Applied Anatomy, [dap. xvii.

The Kidney.

In front.

Right. L .

Under surface of liver. -c, -> / 1^„a

ci ■, , f 1 -, fundus of stomach.

Second part of duodenum. -^ -,. ,

nnimenLBnt nf ^«r«« Descending colon.

Commencement of transverse
colon. Ascending- colon.

Pancreas.

Externally. -mr. 1 Externally.

Liver. JAJUliey. (On left side) Spleen.

Behind.

Lower part of arch of diaphragm.

Quadratus lumborum. Psoas.

Last rib and transverse processes of upper two lumbar vertebrae.

The kidneys are deeply placed, and cannot be felt
or distinctly identified when normal. They are most
accessible to pressure at the outer edge of the erector
spinas, just below the last rib (Fig. 50). The dulness
of the right kidney merges above in that of
the liver, while on the left side it is impossible
to distinguish between the dulness of the kidney
and spleen. The right kidney lies nearly £ of an inch
lower down than does the left ; but even the lower
end of the right gland only just 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. 41 and 49). The
inferior extremity of the left gland is about lj inches
from the iliac crest, that of the right about 1\ inches.
The kidney lies a little lower in the female than in the
male. In many instances in the female its lower end
reaches the iliac crest, and may even go below it. Such
positions are much less common in the male. A vertical
line carried upwards from the middle of Poupart's
ligament has one-third of the kidney to its outer side
and two-thirds to its inner side. The hilum lies about
2 inches from the middle line, and is opposite to the gap
between the first and second lumbar spines. The
kidney has been reached by the finger when the entire

;6r

•Fig. 49.— View of the Kidneys, etc., from behind. (Rudiuger).

(i Pharynx; 6, innominate artery ; c, subclavian artery ; ^oesophagus, with the
aorta and tbnracic duct on one side and tbe azygos vein on tbe <>tl
luugs : r, diaphragm: {/.kidney; ft, on peritoneum, points t«> spermatic \
crossed by ureter; i. os innnminatuni above sacro-iliac-syncbondrnsis ; j,
psoas : k, gluteus metiiue ; l, gluteus maximus ; m, rectum and bud, bemorr*
uoidal artery.

362 Surgical Applied Anatomy. [Chap, xvil

hand lias been introduced into the rectum, but the
procedure has failed to prove of much use in diagnosis.
A skiagram of the kidney is obscured by the shadows
of the last rib and transverse processes of the two upper
lumbar vertebrae.

The anterior surface is but slightly covered by
peritoneum, being only in contact with that membrane
ia 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 membrane
(Figs. 47 and 49). Crossing the posterior surface of
the kidney obliquely from above downwards and out-
wards are branches of the last dorsal nerve and of the
first lumbar artery, together with the ilio-hypogastric
and ilio-inguinal nerves. 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 extravasation of blood and urine that
follows the accident is very often entirely extraperitoneal.
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, hematuria 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 due either 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 quadratus
lumborum, anA then usually makes its way through
that muscle or through the lumbar fascia. It then

Chap, xvn.] The Abdominal Viscera. 363

presents itself at the outer edge of the erector spina?,
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 the pyloric end of the stomach, so that a
communication was established between those two
organs. The perirenal fat is of much surgical import-
ance, as its laxity permits of a ready enucleation of the
organ. It is more abundant behind than in front.
When this tissue has been destroyed or modified by
inflammation, the kidney becomes fixed, and its removal
a matter of great difficulty. This is illustrated by the
removal of a large tuberculous kidney which has been
long diseased.

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 preg-
nancy 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 right

364 Surgical Applied Anatomy. [Chap. xvn.

kidney is far more often movable than is the left, owing
probably to the displacing influence of the liver. The
abdominal walls undoubtedly play a considerable part
in maintaining the kidneys in position by keeping the
other abdominal viscera steadily compressed against
them. The upper third of the kidney rests on the
diaphragm, and with every breath it rises and falls
a little, a movement which must be considered in any
operation to fix the kidney. I have recorded (in con-
junction with Dr. Maclagan) three cases in which a
movable kidney pressed against the neck of the gall
bladder and obstructed the flow of bile. 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 yet its displacement may be
considerable.

The dragging pains which are felt with a movable
kidney are due to a stretching of the renal plexus,
which is connected with the solar plexus and enters
the kidney with the arteries. The kidney receives its
nerve supply from the tenth, eleventh, twelfth dorsal,
and first lumbar segments of the spinal cord through
the small and lesser splanchnics (Head). Pain is re-
ferred along the sensory nerves derived from these
segments.

Abnormalities of the kidney. — One, or less
frequently both, kidneys may be misplaced. The left
is more often out of place than the right, and may be
found over the sacro-iliac synchondrosis, or the promon-
tory of the sacrum, or be discovered in the iliac fossa
or pelvis. The misplaced kidney is often misshaped.
The kidney may exhibit a more or less extreme degree
of lobulation, a condition present in the newly born.
The ureter may be double.

The two kidneys may be fused. " The lowest degree
of fusion is seen in the horse-shoe kidney. The two
kidneys are united at their inferior portions by a flat,
riband-like, or rounded bridge of tissue, which crosses
the vertebral column. In the higher degrees the two
lateral portions approach one another more and more

Chap, xvii.] The Abdominal Viscera.

365

until they reach the highest degree, in which a single
disc-like kidney, lying in the median line, and provided
with a double or single calyx, represents complete fusion "
(Rokitansky). When the two kidneys are united by
a web of connective tissue, the condition is no bar to

EL.

Fig. 50.— Showing the Relationships of the Kidney and Colon in the Lumbar
Region from behind, (Adapted from Merkel.)

p.l., Lower line of pleura ; XX, eleventh ril> ; xu„ twelfth rib ; 12th d.n., twelfth
dorsal nerve; 1st Ln., llio-inguinal and ilio-bypogastric nerves ; a b. vortical
line representing position of descending colon (desc. c) ; q.l.. quadratus lum-

f. horuin; b.s., erector spina?; peritoneum (per it.) is shown reflected from the
front of the kidney to the colun on the right side.

operation. There may be an entire absence of one
kidney. The single kidney may be lateral or median
in position. Henry Morris gives the following estimate
of the frequency of these abnormal conditions. Con-
genital absence or extreme atrophy of one kidney may
be expected in about one in 4,000 cases, the horse-shoe

366 Surgical Applied Anatomy. [Chap. xvn.

kidney in one in 1,600, and the single fused kidney
in one in 8,000 cases.

Operations 011 the kidney. — (1) Nephrotomy.
Incision into the kidney for exploration, or the evacua-
tion of pus. (2) Nephrolithotomy. Incision into the
gland for the removal of a calculus. (3) Nephrectomy.
Eemoval 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 an oblique
incision, such as is used in colotomy (page 345), the
cut, however, being carried a little farther backwards.
In nephrectomy a like incision may be used. The
cut is carried backwards about 1 inch over the erector
spinas, and a part of the quadratus lumborum will
probably have to be divided. The perinephritic tissue
is opened up, and the gland enucleated from the capsule
of fat in which it lies. In some instances the last rib
has been resected to obtain more space for the operation.
The pleura reaches the neck of the twelfth rib and
occasionally it descends as far as the transverse process
of the first lumbar vertebra (Fig. 50). In one case
the twelfth rib was rudimentary, and the eleventh
rib was removed under the impression that it was the
twelfth. The pleura was opened and death ensued.

When the kidney is free from its fatty capsule, the
vessels at the hilum are secured separately by ligatures.
The numerous nerves to the kidney are no doubt included
with the vessels. They constitute a surgical pedicle
of the kidney. At the hilum the vein lies in front,
the artery and its branches next, and the ureter behind
and towards the lower part. The artery is about the
size of the brachial, and usually divides into four, five,
or six branches before it reaches the kidney. This
fact must be borne in mind if the structures at the
hilum are separately secured. Some of these branches
constantly enter the hilum behind the ureter and are
liable to injury in exploration of the pelvis of the kidney.
The vein is also represented at the hilum by" three or
four branches. The renal artery may be represented

Chap, xvii.] The Abdominal Viscera. 367

by two, three, four, or even five vessels. Some may
enter the upper end of the kidney or its anterior surface.
In removing large renal tumours an abdominal incision
is advised, the cut being made either along the corre-
sponding semi-lunar line, and on a level with the diseased
mass, or in the linea alba. The abdominal operation
is the more usual one, and has the advantages of greater
ease and rapidity in performance and gives an opportunity
of examining the condition of both kidneys. In
chronically inflamed conditions of the kidney — as, for
example, in long standing tuberculous disease — the
kidney becomes adherent, and on the right side is apt
to become closely bound clown to the vena cava. Much
care is needed in clearing the great vein when so adherent.
In removing a very adherent kidney the diaphragm
has been torn.

The ureters are strong tubes about 15 inches long,
with thick muscular Avails, and are placed entirely
behind the peritoneum. The average width is that
of a goose-quill. The ureter rests from above down-
wards upon (1) the psoas muscle and the genito crural
nerve ; (2) the common iliac vessels on the left side,
and the external iliac vessels on the right ; (3) after
passing downwards on the internal iliac artery it then
enters the posterior false ligament of the bladder, and so
reaches the bladder wall. In the female it passes through
the base of the broad ligament, where the uterine artery
loops over it f of an inch from the necks of the uterus.
It rests on the roof of the upper part of the vagina before
entering the bladder, and a calculus arrested in that
stage may be distinctly felt. 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 of the small intestine. Several cases are
recorded of rupture of the ureter from external violence.
When such an accident occurs a large urinary collodion
usually forms behind the peritoneum, which, leading

368 Surgical Applied Anatomy. [Chap.xvu.

to suppuration, will produce a fluctuating tumour
beneath the parietes.

The ureter expands in the hilum of the kidney
into a funnel-shaped cavity — the pelvis. This in
turn divides into the calyces. In the pelvis or
calyces calculi are frequently lodged. The calyces
are too narrow to admit an exploring finger. The
ureter has been successfully resected and sutured. It
is supplied by nerves from the renal plexus and by
vessels from the renal, inferior vesical and sub-peritoneal
plexus. Impacted calculi have been removed from
the ureter.

The nerve supply of the abdominal viscera.
— Some account has already been given of these nerves
and the spinal segments from which they are derived
(page 297). The abdominal viscera are mainly supplied
by the sympathetic system through a series of remark-
able 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 communications from the phrenic go
to the hepatic and suprarenal plexuses. Through
these nerves the calibre of the blood-vessels and the
amount of blood in the abdomen are regulated. They
contain not only sensory fibres for the abdominal viscera
but constrictor and dilator fibres for the bowel. It
may be well understood that an impression brought
to bear upon extensive nerve net-works with such wide
central connections 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
associated with these large plexuses. The descending
colon and sigmoid flexure are supplied by the inferior
mesenteric plexus, a cord that has but an indirect con-

chap, xvii.] The Abdominal Viscera. 369

nection with the solar plexus; and this fact may servo
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 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 remarkable 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 tuber-
culosis, 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 scapulae. They com-
monly appear some distance below the angle of the
scapula. The nerves for the stomach are derived princi-
pally from the seventh and eighth and those for the
liver from the eighth and ninth spinal segments. The
skin areas of these segments may become tender when
the organs are diseased and to some point in these areas
pain is referred (Fig. 39). The shoulder tip pain which
often accompanies liver disease is situated in the area
supplied by the fourth cervical segment, but as yet no
satisfactory anatomical explanation has been offered of
this symptom.

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 in the flexure, and in instances
where it has been distended with faeces, such a pain
has been complained of. The pain is conveyed along

37° Surgical Applied Anatomy. [Chap. xvii.

the obturator nerve, which lies beneath the sigmoid
flexure, and could be readily pressed upon by the 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. Although two, or in
some places three, anastomotic arches occur between the
branches of the superior mesenteric artery before they
form a final net-work in the bowel, yet embolism of a
comparatively small branch may lead to gangrene of
the gut (Lockwood).

When it is remembered that the lumbar glands
lie about the vena cava and iliac veins, it will be under-
stood that great enlargement of those bodies may cause
oedema from pressure.

A number of minute but most important anas-
tomoses exist between some of the visceral branches
of the abdominal aorta and certain of the vessels supplied
to the abdominal parietes. These anastomoses are
situated behind the peritoneum, and mostly concern
such viscera as have a fair surface uncovered Iby that
membrane. The visceral branches that join the anasto-
moses are derived from the hepatic, renal, and supra-
renal arteries, and from the vessels supplying the lower
part of the duodenum, the pancreas, the csecum, 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 circumflex iliac trunks. In a case de-
tailed by Professor Chiene (Journ, Anat. and Phys.,

Chap, xvii] The Abdominal Viscera. 371

vol. iii.) the coeliac 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 communications. Rutherford .Morrison
found that anastomotic veins, quite as big as the radial,
were formed between the omental and parietal veins,
when he brought about an adhesion between the
omentum and abdominal wall in a case of dropsy due
to portal obstruction. The anastomosis gives an
anatomical demonstration of the value of local blood-
lettings and of 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
epigastric vein joining with a pervious umbilical vein
in the vicinity of the navel.

Thoo'acic 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 producing any marked symptoms
during life. It has been cut and ligatured during
removal of glands from the supra-clavicular triangle,
with no bad result. Mr. Leaf has shown that the thoracic
duct communicates freely with the azygos veins in the
posterior mediastinum and with the lymphatic vessels
of the right side of the thorax and neck.

372
CHAPTER XVIII.

THE PELVIS AND PERINEUM.

The mechanism ©f the 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 serves
to transmit the weight of the body both in the stand-
ing 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 key-
stone of both these arches. When standing, the arch
is represented by the sacrum, the sacro-iliac synchon-
droses, 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 synchon-
droses, 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

chap, xvin i The Pelvis and Perineum. 373

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 ; 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 spina?, 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 becomes 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 3| 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.

Fractures of the pelvis. — From what has

* Henry Morris on "The Joints," p. 116, where a most valu-
able account of the mechanism of the pelvis will be found

374 Surgical Applied Anatomy. [Chap, xviii.

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 circum-
stance 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 cause 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
at about the twenty-fourth year. In one case the
anterior 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

Chap, xvni.] The Pelvis and Perineum. 375

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 fully 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 bone 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 the 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 symphysis pubis
in cases of contracted pelvis, with the idea of obtaining
more room during labour, and of so avoiding Caesarian
section. The union consists of fibro-cartilage and trans-
verse peripheral fibrous bands. It varies in depth from
1^ to 1} inches, and may be divided subcutaneously
when the bones gape quite \ an inch. It has been shown,
however, that to gain \ an inch in the antero-posterior
diameter the bones must be separated to the extent
of 2 inches. Such a separation involves laceration of
the sacro-iliac ligaments, and more or less damage to
the attachments of the pelvic viscera.

The sacro-iliac synchondrosis 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

376 Surgical Applied Anatomy. [Chap. xvm.

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 and when sitting. When
abscess forms it tends to come forwards, owing to the
anterior ligaments being 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 the 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 connected
with the articulation. It will be understood from these
relations that in the 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 (lumbo-sacral cord and connection with
great sciatic nerve). Dislocation of the sacrum at this
joint is prevented by the remarkable double-wedge-
shaped outline of the bone, and by the very dense liga-
ments 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 be-
coming rotated forwards on its transverse axis.

Trendelenburg 's operation. — In order to bring the
two pubic bones and the deficient soft parts together

Chap, xviii.] The Pelvis and Perineum. 377

in ectopia vesicae, Trendelenburg divide.-; the sacro-
iliac synchondroses on either side. The knife is made
to cut the posterior sacro-iliac ligaments, the inter-
osseous and superior ligaments, and the interarticular
cartilage. The operation, which has been very
successful, is Limited to children between the ages of
two and five. The distances between the anterior
superior iliac spines has — in a child aged two and a-half
years — been lessened 2 inches by this operation.

Spina bifida. — This term refers to certain con-
genital malformations of the vertebral canal associated
with the protrusion of some of its contents in the form
of a fluid tumour. The malformation usually consists
in an absence of the neural arches and spines of certain
of the vertebrae, and the tumour therefore projects
posteriorly. Spina bifida is most common in the lumbo-
sacral region, the neural arches of the last lumbar and
of all the sacral vertebrae being absent. The neural
arches close first in the dorsal and last in the lumbo-
sacral region. Next in frequency it is found limited
to the sacral region. It is rare elsewhere. (1) The
membranes may protrude alone (spinal meningocele).
(•2) The membranes may protrude together with the
spinal cord and its nerves (meningo-myelocele). (3) The
membranes may protrude with the cord, the central
canal of which is dilated, so as to form a sac cavity
(syringo-myelocele.) (See Fig. 80, p. 546.)

The meningo-myelocele is the most common form.
The first-named variety is rare, the last-named very rare.
When the cord occupies the sac it usually adheres to
its posterior wall, the nerves running transversely
across the sac to reach the intervertebral foramina.
When compressed, the cerebro-spinal fluid is forced
into the subarachnoid spaces at the base of the brain,
which is forced upwards against the anterior fontanelle,
where its impact may be felt. The tumour becomes
enlarged and tense when the child cries. The distension
of the cerebral and spinal veins forces the fluid in the
direction of least resistance.

As might be expected, spina bifida is very commonly

378 Surgical Applied Anatomy. [Chap, xv hi.

associated with some evidence of injury to the nerves
arising from the lower part of the spinal cord. In the
majority of instances certain of these nerves would
appear to have become atrophied through pressure.
In some cases the nerve affection takes the form of club-
foot of a severe grade. In other instances there is more
or less complete paralysis of the lower limbs, bladder,
and rectum.

" The anatomy of the spina bifida assumes a primary
defect of development of the mesoblast, from which
the structures closing in the vertebral furrow are de-
veloped. After the closure of the neural furrow it
would appear that the processes of mesoblast, which
subsequently insinuate themselves between the primi-
tive spinal cord and its overlying epiblast, are formed
in an insufficient degree to meet and combine " (Com-
mittee of the Clinical Society, London, 1885).

Sacro-coccygeal tumours* — The sacro-coccy-
geal region is very often the seat of cod genital 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
" tripodism."

Parasitic foetuses are also frequently found attached
to this segment of the spine. In many of the instances
of attached foetuses the two individuals have been
joined together at this part of the column. Some of
the sacro-coccygeal tumours contain epithelial cysts
and fragments of skin, muscle, nerve, bone, cartilage,
and mucous membrane. These strange masses spring
from the anterior part of the coccyx, between it and
the rectum. By some they are supposed to arise from
Luschka's gland, by others (Sutton) from the structures
known to embryologists as the post-anal gut and the
neurenteric passage.

The sacro-coccyg-eal 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 maximns, coccygeus,
levator ani, and sphincter). In the luxation the bone

chap . x v 1 1 1 . ] The Pel vis a nd Per ine um. 379

may project into the rectum, and thus give trouble.
The joint and the parts about it may be the seat of such
severe neuralgia (" coccygodynia ") 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. In old age the coccyx becomes ossified
to the sacrum.

The tliioiiiest pints of the os iimoiiiiiiaftiiii
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.

The fl»or 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 for-
wards : 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 Avails 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 ] elvis,
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 interims 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 corresponds 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

380 Surgical Applied Anatomy, chap, xviii.

ani, and attaches itself to all the pelvic viscera with
which it comes in contact, forming fibrous expansions
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 subperitoneal 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 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. Suppuration, 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 excluded

Chap, xviii.] The Pelvis and Perineum. 381

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 %\ or 3 inches of the rectum. On
the side of the rectum the fascia reaches the level of a
line drawn from the top of the seminal vesicles to the
middle of the fifth piece of the sacrum. In the middle
line it reaches a point some little way below the recto-
vesical cul-de-sac of the peritoneum. 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 connective 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 sup-
posed, 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, or in the supra-
pubic region, having spread along the obliterated hypo-
gastric artery. 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 suppuration, twenty-
four burst externally, and for the most part in the
inguinal region (McClintock).

* Clinically the term pelvic cellulitis includes also pelvic
peritonitis, and often inflammation of one or other of the viscera.
Indeed, many so-called cases of pelvic cellulitis are examples of
localised pelvic peritonitis with or without suppuration.

382 Surgical Applied Anatomy. [Chap, xviii.

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, there-
fore, that leave the pelvis, escape by piercing that
membrane. The obturator artery is an exception to
this rule, since it passes over the upper border of the
parietal pelvic fascia (Cunningham). The nerves in
the pelvis lie behind or outside the fascia, and, therefore,
the pelvic vessels and the 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 the ischia, the ischial tuberosities,
the great sacro-sciatic ligaments, the edges of the two
great gluteal muscles, and the coccyx. A transverse
lLie 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 3j 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 3 J
inches from side to side, and about 4 inches from before
backwards in the middle line. The average antero-
posterior diameter of the pelvic outlet in the male aver-
ages 2>\ inches. This measurement in the undissected
subject is increased to 4 inches by the curving of the
surface. The average transverse diameter of the male
pelvic outlet is 3^ inches, and corresponds to the measure-
ment 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 l|-
inches from the tip of the coccyx. The raphe, a central
mark or ridge in the skin, can be followed from the anus
along the middle line of the perineum, scrotum, and

chap, xviii.] The Pelvis and Perineum.

33;

penis. No vessels cross this line, and, therefore, in
making incisions into the perineum this line is always
chosen when possible. In the middle line, midway

Fig. 51.— The Male Perineum. (After Riidir-ger.)

a, Gluteus niaxinms ; b, senii-tendinosus and biceps; c, adductor magnus: d,
gracilis; t, piriformis: f\, obturator interims; </, quadratus femoris; /(, leva-
tor ani ; i, external sphincter; j, accelerator urinse; A\ erector penis; /,
transversus perinei ; l. great sciatic nerve ; '2, external bsemorrboidal vessels
and nerve; 3, superficial perineal vessels and nerves; 4, pudic nerve (.can
and pudic artery ; 5, pudendal branch of small sciatic nerve.

between the centre of the anus and the spot where the
scrotum joins the perineum, is the central point of the
perineum. The two transverse perineal muscles, the
accelerator urinse and the sphincter ani meet at this

384 Surgical Applied Anatomy. [Chap, xviii.

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 litho-
tomy, 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 con-
siderably in different parts, measuring from 2 to 3 inches
in the hinder and outer parts of the perineum, and less
than 1 inch in the anterior parts of the space.

The iscliio-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 2 inches from before
back, 1 inch from side to side, and is between 2 and 3
inches in depth. Its boundaries are : on the outer side,
the obturator internus 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 transversus 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 1\ 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
lateral wall is exposed for a distance of nearly 3 inches,
its posterior wall for about 1 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

Ch^p. xviii.] The Pelvis and Perineum. 385

abscess). These abscesses are hemmed 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 fistidce in ano the opening into the
rectum is nearly always within \ 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 haemorrhoidal 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 haemorrhoidal
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 haemor-
rhoidal vessels.

Anus. — {See paragraph on the Kectum.)

The urethral triangle. — The skin of the peri-
neum between the anus and the scrotum is thin, and
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 aponeurotic space, containing the bulb with

386 Surgical Applied Anatomy-. [ChaP. xvm.

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 the
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. 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 aponeu-
rotic 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 (the three long
scrotal nerves) are included within the space.

The triangular iigainciat. has a depth of about
\\ 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
1 inch below the symphysis, and about f of an inch
above the central point of the perineum. The artery
to the bulb passes inwards between the two layers about
\ an inch above the base of the ligament and 1^ inches 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 \ an inch below the sym-
physis. In uncomplicated rupture of the membranous
urethra, the urine extravasated would be limited to
the space between the layers of the ligament, until

chap, xviii.] The Pelvis and Perineum. 387

subsequent suppuration had made a way for it to escape.
When extravasation occurs behind the triangular
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 prostate,
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 urethral muscle ; (5) tri-
angular ligament (post, layer) ; (6) levator ani muscle ;
(7) capsule of prostate.

Stone in the bladder. — Stones of the bladder
which were formerly removed by a perineal incision
are now commonly crushed and washed out through
the urethra by the operation of litholapaxy. This
operation is carried out readily even in male children.
If too large for crushing, the supra-pubic operation
is performed to give sufficient room for extraction.
Although the perineal operations are now but very
rarely performed, a description of the parts involved
helps to give a proper conception of their important
anatomical relationships.

Lateral lithotomy. — The first incision, 2 or
3 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 \\ 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 super-
ficial fascia ; (2) transverse perineal muscle, artery and
nerve ; (3) the lower edge of the anterior layer of the

388 Surgical Applied Anatomy. [Chap. xvm.

triangular ligament ; (4) the external hsemorrhoidal
vessel and nerves. (Figs. 51 and 52.)

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 : (l) Membranous
and prostatic portions of urethra ; (2) posterior layer
of triangular ligament ; (3) compressor urethrae ; (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 of 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 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 will be under-
stood 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 superior 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.

Chap, xviii.] The Pelv.-s and Perineum. 389

The left ejaculatory duct would be cut if the prostatic
incision were 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
finger 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. In
children also the peritoneum descends lower on the
posterior surface of the bladder, and may be wounded
by a careless operator.

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
a wound made in the median raphe of about 1^ inches
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 lie wounded if the bladder be entered by

39° Surgical Applied Anatomy. [Chap. xvm.

dilation 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 possible,
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 the 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
2^ to 3 inches from the surface when the body is in
lithotomy position. (Fig. 52.)

Suprapubic lithotomy. — This operation has
been revived of late years, and in cases in which litho-
lapaxy is contraindicated has practically supplanted
the two forms of lithotomy just described. In order
to bring the summit of the bladder well above the sym-
physis, both bladder and rectum may be dilated. Into
the former viscus, tepid water or boracic lotion is
injected. It is found that in the adult 8 to 10 ounces is
sufficient to ensure the desired distension. The rectum
is dilated by some operators by means of a soft rubber
bag. The gut, when thus distended, pushes forward
the bladder, and gives it a firm basis upon which to
rest. In the adult from 10 to 14 ounces are usually
introduced into the bag. Distension of the rectum
alone will elevate the bladder, but it will usually have
no effect upon the reflection of peritoneum. In operating
upon children the rectal bag is very seldom required,
and many surgeons do not employ it in any case. In
the case of a male child, aged five, the injection of 3
ounces of water into the bladder caused the reflection
of peritoneum to mount to more than 1 inch above

chap, xvi n.] The Pelvis and Perineum. 391

the symphysis. An incision, some 3 inches in length, is
made immediately above the symphysis in the median
line. The bladder is exposed below the peritoneum,
is drawn forwards by a hook, and opened.

The Madder. — When empty the bladder is
flattened and of triangular outline, and lies against
the anterior wall of the pelvis. The empty bladder
may be found in one of two conditions (as demonstrated
by Dr. Hart in the adult female bladder). It may
be small, oval, and firm, with its upper wall convex
towards the abdomen. In vertical antero-posterior
section the urethra forms with the cavity of the bladder
a curved slit (the systolic empty bladder). It may
be larger, and soft, with its upper surface concave to-
wards the abdomen, and fitting into the concavity
of the lower wall or surface. In the section named,
the urethra forms, with the bladder cavity, a Y-shaped
figure, the two diverging limbs of the Y corresponding
to the concavity named (the diastolic empty bladder).
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 abdominal 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, and in suprapubic lithotomy.
When greatly distended it may reach the umbilicus,
and may even touch the diaphragm. The usual capacity
of the organ is about one pint, out when fully occupied
it may hold some quarts. When both bladder and
rectum are quite empty the apex of the bladder and
the pre-vesical reflection of the peritoneum are a little
below the upper margin of the symphysis pubis. 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

392

Surgical Applied Anatomy. [Chap, xvm

Pig. 52. —A Vertical Anteroposterior Section of the Male Pelvis
(Braune).

bladder and the parietes. When the apex of the bladder
is 2 inches above the pubes the peritoneal reflection
is probably not more than £ of an inch above the same

Chap, xvm.] The Pelvis and Perineum. 393

point of bone. When the apex of the bladder is midway
between the umbilicus and the pubes there may be
2 inches (vertical) of the anterior abdominal wall in
the middle line and immediately above the symphysis
devoid of peritoneal lining. Thus it happens that the
distended viscus may be readily tapped above the pubes
without the peritoneum being wTounded. As the bladder
becomes distended, not only does it rise into the abdomen,
but it extends also towards the perineum, diminishing
the length of the prostatic and membranous urethra.
In suprapubic lithotomy that tendency to extend down-
wards is prevented by the rectal bag (page 390).

Between the anterior surface of the bladder 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 connections
of the organ. In injuries to the pelvis and to the front
of the bladder a diffuse inflammation may be set up
in this tissue and assume serious proportions. I have
reported a case wrhere an extensive suppuration in this
area followed upon aspiration of the bladder above
the pubes, and led to death. Like suppuration has
followed suprapubic lithotomy. In rupture of the
anterior wrall of the viscus the urine 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 hernias. 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
\\ 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

394 Surgical Applied Anatomy. [Chap; XWti.

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 peritoneum. This
recto-vesical pouch of peritoneum in the adult extends
to within about 3 inches of the anus, and does not reach
below a line 1 inch above the base of the prostate.
Harrison Cripps gives the distance of the pouch from
the anus as 2| inches when the bladder and rectum
are both empty, and as 2>\ inches when those viscera
are distended. (See Bladder in the Child, page 398.)

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 equilateral,
and in the dissected specimen measures about 1^ 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 prostate, that the bladder
is tapped when the operation 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.

liupture of bladder. — The bladder may be
ruptured by violence applied to the anterior abdominal
wall apart from pelvic fracture or external evidence
of injury. Such a rupture can, however, hardly happen
to the empty bladder, which should 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 stitched up the rent in the viscus with perfect
success. 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

Chap, xviii.] The Pelvis and Perineum. 395

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 con-
sequence of neglected retention of urine." In neglected
cases of stricture in the male the urethra gives way
rather than the bladder, and an extravasation 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 contraction 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 pro-
lapsed 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 lh 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 structure. 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.

396 Surgical Applied Anatomy. [Chap. xvm.

The sensory nerves for the bladder are derived
mainly from the third sacral segment, to a less degree
from the second and fourth, and pass to the bladder from
the third and sometimes fourth sacral nerve through the
nervi errigentes. The skin of the scrotum, penis, and
mucous membrane of the urethra are supplied from
the same segments. Hence, in diseases of the bladder,
especially of the trigone, pain is referred along the dis-
tribution of the perineal nerves. The motor nerves of
the bladder come from the eleventh and twelfth dorsal
and first lumbar segments, and pass to the bladder by the
hypogastric and pelvic plexuses. Both the sensory
and motor centres are concerned in the reflex act
of micturition. Being situated at different levels
of the cord one centre may be affected without the
other.

In the muscular coat of the bladder the fibres
are collected into bundles which interlace in all direc-
tions. When the viscue 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 obstruc-
tion to the escape of urine, increases in size, as do other
much exercised muscles, and that increase serves to
demonstrate the arrangement of the individual bundles.
In a fasciculated bladder the muscular bundles present
much the appearance of some of the columnae earner
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

chap, xviii.] The Pelvis and Perixeum. 397

as tlio bladder itself, and give rise to the erroneous

description of " double bladder,-' etc.

The anterior wall of the bladder is thicker and
stronger than the posterior, and in cases of hypertrophy
the increase appears to mainly involve the anterior
wall. The difference between the two parts is well
shown in frozen sections (Symington).

The ureters run for f 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 overflow 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 hori-
zontal 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 con-
nection 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
I of an inch have been removed. Through the dilated
urethra the orifices of the ureters can be seen and ex-
amined. 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
fistula?. Strange foreign bodies have been introduced
into the female bladder, such as hair-pins, crochet hooks,
sealing-wax, penholders, and the like.

The orifice of the ureter is 3 cm. from the cervix
uteri, and 4 cm. from the vesical opening of the urethra.
Its close relation to the cervix renders it liable to injury
in supravaginal amputation of that part, and in certain
operations on the uterus.

398 Surgical Applied Anatomy; [Chap. xvm.

The bladder in the child is egg-shaped, and
its vertical axis is relatively much greater than it is
in the adult. The larger end of the egg-shaped cavity
is directed downwards and backwards. 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. At birth the
orifice of the urethra is on a level with the upper edge
of the symphysis. Although the bladder projects so
freely into the abdomen, its anterior wall is still entirely
uncovered by peritoneum. On the posterior wall the
serous membrane extends lower down than in the adult,
reaching the level of the urethral orifice at the time of
birth, and the level of the prostate in young male children.
The prostate is exceedingly small in children. Thompson
states that at the age of seven years it only weighs thirty
grains, whereas in subjects between eighteen and twenty
it weighs two hundred and fifty grains. The bladder
wall in the child 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
£ 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 l£ to 2 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 prostatic ducts.

The prostate is enveloped in a firm capsule derived
from the pelvic fascia, and it is to this fascia that we look
for an explanation of the course of prostatic abscess.

The prostatic abscess usually bursts into the
urethra, that being the direction in which least resistance
is encountered. If it does not enter the urethra, it will
probably open into the rectum, there being only one
layer of thejpelvic fascia, and that layer not a thick one,

chap, xviii.] The Pelvis and Perineum. 399

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 membrane
will serve to in part explain the severe pain felt in acute
prostatic abscess. In acute prostatitis pains are referred
over the tip of the last rib (tenth dorsal nerve), over the
posterior iliac spine (eleventh dorsal nerve), or even to the
soles of the feet (third sacral nerve). It derives its nerve
supply from the lower three dorsal and upper three
sacral segments ; hence the widely distributed character
of the referred pains (Head).

Hypertrophy of tlie prostate. — The average
measurements of the normal prostate are \\ inches
across at its widest part, and 1 \ inches from before back-
wards, 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
2 inches from side to side, or wrhen it weighs 1 ounce.
The usual weight of the prostate is 6 drachms. If the
enlargement mainly affect the lateral lobes, it will be
understood that the hypertrophy may attain consider-
able dimensions without retention of urine being pro-
duced. On the other hand, a comparatively trifling
enlargement of the middle lobe may almost entirely
block 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 particularly

4-oo Surgical Applied Anatomy. [Chap, xviii.

affects the middle lobe, the prostatic urethra, which is
normally almost straight, becomes considerably 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.

The severity of the symptoms in a case of hyper-
trophy of the prostate bears little or no relation to the
apparent size of the gland as felt per rectum. A portion
of the enlarged body may project into the bladder.
This usually takes the form of a projecting middle lobe
which, when viewed from the interior of the bladder,
may appear as a distinct well-rounded pedunculated
or sessile growth.

In the operation of prostatectomy this projecting
and most troublesome mass is removed through a supra-
pubic incision. The prostate is a sexual organ, and
its size and development depend on the presence and
activity of the testes. Castration prevents its develop-
ment or causes atrophy if already developed. Removal
of one testicle causes a partial atrophy, and section of
the vasa differentia has usually a similar effect. These
two facts show that the atrophy is not due to the removal
of any internal secretion which the testicle may impart
to the blood. The effect is probably produced through
the nervous system. The prostate and testicle derive
their nerves mainly from the tenth dorsal spinal segment.
Between the prostate and its capsule is an extensive
plexus of veins, the prostatic plexus, into which enters
the dorsal vein of the penis. This plexus is cut in lateral
lithotomy, and it is through its vessels that septic matter
is probably absorbed in cases of pyaemia following that
operation. Its lymphatics, which are numerous, pass
to a group of glands on the wall of the pelvis, between
the external and internal iliac arteries.

The male urethra, is about 8£ inches in length
(21 cm.),lj inches being devoted to the prostatic urethra,
| of an inch to the membranous, and 6^ inches to the
penile or spongy portion. Between the ages of four
and six years its length is 8 to 9 cm., and between ten
and thirteen years 10 to 11 cm. The canal may be

Chap. xviii.] The Pelvis and Perineum. 401

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 articulation. The curve is formed
around this line, its summit corresponding to a pro-
longation of the vertical axis of the symphysis, and to
about the centre of the membranous urethra. This
part of the tube lies about 1 inch below the pubic arch.
The movable portion of the urethra forms, when the
penis is dependent, a second curve in the opposite direc-
tion, so that the whole canal follows somewhat the
outline of the letter S.

The prostatic portion of the urethra will be nearly
vertical. It is surrounded by circular muscular fibres
which may give rise to a spasmodic stricture. This
part of the canal corresponds to the posterior ventral
part of the urogenital sinus of the cloaca, which receives
the Wolffian and Miillerian ducts. The sinus pocularis
or uterus masculinus, in the floor of this part of the
urethra, represents the united ends of the rudimentary
Miillerian ducts.

That part of the urethral canal which lies beyond
the prostate is of different origin, and is a portion of
the anterior segment of the cloaca, which has been
formed into a canal by a superficial union of the tegu-
mentary folds in the median line.

The penile or spongy portion of the urethra is sur-
rounded by the erectile tissue of the corpus spongiosum
urethra?, which is thickest on the under side of the
canal. A very thin layer of erectile tissue surrounds
the membranous urethra lying beneath the fibres of
the compressor urethras.

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

402 Surgical Applied Anatomy. [Chap. xvm.

traversing the fixed segment the instrument must
accommodate itself to the unyielding canal. In intro-
ducing 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 tri-
angular ligament. At this spot the tube abruptly*
becomes 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.

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
£ an inch ; at the bladder end its diameter is about

Chap; XVIII.] Tf/E PELVIS AND PERINEUM. 403

\ of an inch, while at the anterior extremity of this
part of the urethra the measurement is a little less
than \ 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 le kept well
along the roof 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 ^ 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 urethrse often offers 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 membiunous
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 I to \ 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,

404 Surgical Applied Anatomy. tchaP. xvin.

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.

Keegan has shown that the urethra of a male child
two or three years of age will take a No. 9 catheter.
In boys between eight and ten years a No. 11 lithotrite
may be passed.

It will be obvious, therefore, that the operation of
lithotrity may be performed upon quite young male
children, and that fragments of crushed calculus of no
small dimensions may be removed from the bladders
of such patients by washing.

The mucous membrane presents, in addition
to many mucous glands, several lacunas, the orifices of
which for the most part open towards the meatus.
These lacunas 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 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 instru-
ments 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, therefore, 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

Chap, xviii.] The Pelvis and Perineum. 405

Struck, the greater is the length of penile urethra that
may be crushed against the pubes.

The female urethra is about 1^ inches in length,
and has a diameter of from \ to \ of an inch. It is
capable, however, of great distension. In the erect
position the canal is nearly vertical, and in the recum-
bent 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 sub-
cutaneous tissue permits the organ to become enormously
swollen when cedematous, or when extravasated 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 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 in-
duration 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 In-
securing it by tapes around the penis. The blood spaces
in the corpus spongiosum may be rendered indistensible
from gonorrheal inflammation while those of the corpora
cavernosa remain free. The corpus spongiosum then
acta like the string of a bow during the erection of the

406 Surgical Applied Anatomy. [Chap. xvm.

psnis. Through the superficial lymphatics disease may
spread from the skin and meatal region of the penis to
the inner of the inguinal glands. Deeper vessels pass
with the prostatic veins to the internal iliac group of
glands on the lateral wall of the pelvis. Some vessels
pass directly to the external iliac glands through the
crural ring. 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. The raphe along the penis, scrotum, and
perineum marks the union of the genital folds in the
foetus. These folds correspond to the labia minora
and majora of the female. The male urethra from the
sinus pocularis to the meatus is thus formed.

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 hernias 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
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 rugse are a sign of health, since they depend
upon the vigorous contraction of the muscle fibres in

chap, xviii.] The Pelvis and Perineum. 407

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 cedematous in dropsy,
and is apt to show that oedema in a marked degree.
The scrotum also is the part most frequently the seat of
elephantiasis, which is due essentially to a distension
of the lymphatic vessels and spaces of the connective
tissue. The vitality of the scrotum is not considerable,
and it therefore not unfrequently sloughs in parts when
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 integu-
ment of the scrotum can be subjected to considerable
pressure when the strapping 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

408 Surgical Applied Anatomy. [Chap, xviii.

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 abdominal
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 aboutTthe
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 epididymis,
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 lie more or less loosely
in the serous cavity as lies the small intestine in the
abdomen. This condition occasionally occurs, and in
such cases the testicle is liable to strangulation from
twisting on its mesentery. 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 inflamed. 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 j the swelling, and yet so
extensively is^the^organ surrounded by[that*membrane

chap, xviii.] The Pelvis and Perineum. 409

that the position of the gland in the larger hydroceles
is often difficult to determine. 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 hydrocele, 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
inflammation 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 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 at 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 testicle is developed in front
of the tenth dorsal vertebra, and receives its nerve
supply from the tenth dorsal segment. Its nerves pass

4i o Surgical Applied Anatomy. [Chap, xviii.

by the small splanchnics, solar and aortic plexuses, to
the spermatic artery, on which they reach the gland.
The epididymis receives its nerve supply from the pelvic
plexus, along the vas deferens. In 10 per cent, of cases
where castration of both testicles has been performed in
adults, the operation was followed by acute mania.

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 pampiniform
plexus of veins, (7) the genito-crural nerve, (8) sym-
pathetic nerve fibres, and (9) lymphatics. The vas

yd DA

\ /

Vfov/dftftifik s A

&v%2w CA

■CM

pr til.

1

Fig. 53. — Section of the Left Spermatic Cord of an Adult, at the level*
of the External Abdominal Ring, viewed from above. (From a
specimen prepared by Mr. W. G. Spencer.)
vc, Vas deferens: da, deferential artery; dv, deferential veins; .sa
sparmatic artery ; ca, cremasteric artery; cm, cremaster musc.c ; pp, para
piaiform plexus.

deferens lies along the posterior aspect of the cord (Fig.
53), and can be 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 approaches
the ureter. The injury is followed, as may be supposed,
by atrophy of the corresponding testicle. Resection
of part of the vas has been practised to bring about
atrophy of enlarged prostate. The size of the cre-
master muscle depends mainly upon the weight it has to

chap, xvin.] The Pelvis and Perineum. 411

suspend. In atrophy of the testicle 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 below Pou part'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
cremaster 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. Of the arteries, the spermatic comes from
the aorta and lies in front of the vas, the cremasteric
arises from the deep epigastric and lies among the super-
ficial layers of the cord in its outer segment, while the
deferential artery from the superior or inferior vesical
lies by the side of the vas (Fig. 53). The first-named
vessel is the size of the posterior auricular, and the two
latter the size of the supraorbital. The three arteries of
the cord are divided in castration, and may all require
ligature. It is advisable to secure the vessels in sections,
rather than adopt the clumsy plan of involving the whole
cord in one common ligature. The veins are divided
roughly into two sets. The anterior is by far the larger
set, runs with the spermatic artery, and forms the
pampiniform plexus. The posterior set is small and
surrounds the vas, running with the deferential artery.
The veins of the spermatic and pampiniform plexus
are very frequently varicose, and then constitute the
affection known as varicocele. 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 corre-
sponding artery, and so the vis a tergo must be reduced
to a minimum ; they occupy a loose tissue, and are lack-
ing in support and in the aid afforded to other veins
(as jn the limbs) by muscular contraction : they are

412 Surgical Applied A na to my. [Cbap. xvni.

very tortuous, form many anastomoses, and have few
and imperfect valves ; they are exposed to pressure
in their passage through the inguinal canal. The left
veins are more frequently affected than the right. Mr.
Spencer has shown that the veins in the left cord are
always much larger than those of the right. It may
also be pointed out that the left testicle hangs lower than
the right ; that the left spermatic vein enters the left
renal at a right angle, while the right spermatic vein
passes obliquely into the vena cava ; and that the left
vein passes beneath the sigmoid flexure, and is thus
exposed to pressure from the contents of that bowel.
The congenital origin of varicocele is now very generally
allowed.

When the varicose veins are exposed by operation it
is impossible to isolate or even recognise the arteries.

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 oedematous, 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.

" On everting one of the labia minora and pressing
the hymen inwards, a small red depression may gener-
ally be seen on the vulva, somewhat posteriorly. It leads
to the orifice of Cowpers duct " (Doran). Cowper's
gland, an oval body about ^ an inch in length, lies
against the posterior part of the vaginal orifice, under
the superficial perineal fascia, and covered by the fibres
of the sphincter vaginae. It wastes after thirty.
Abscess of the gland and cystic dilatation of its duct are
not uncommon.

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,

chap, xviii. i The Pelvis and Perineum. 413

the rectum, or the small intestines_rnay~protrude into
the vagina by a yielding of some parts of its walls and
thus produce a vaginal cystocele, rectocele, or enterocele.
The anterior wall of the vagina measures a little
over 2 inches, the posterior wall about 3 inches. The
long axis of the canal forms an angle of 60° with the
horizon, and is therefore almost parallel to the pelvic
brim. The loose areolar tissue at the base of the broad
ligament lies on each side of the upper extremity of the
vagina. The ureter terminates in the bladder, on the
upper part of its roof.

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 fistulas
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 uterus weighs about one ounce. The uterine
cavity and the cervical canal together measure about
2 1 inches. This must be borne in mind when passing
a uterine sound. The blood-vessels run transversely
to the length of the uterus, so that a ligature may be
placed completely around the organ without affecting
the circulation above or below. Ligature of the uterine
artery has been practised to arrest the growth of uterine
tumours. The artery rises from the internal iliac
£ an inch below the pelvic brim and passes to the neck
of the uterus in the broad ligament. It is 2| inches
long and loops over the ureter midway. It is reached
by incising the broad ligament between the Fallopian
tube behind and the round ligament in front. It is
found in the loose areolar tissue under the wound.

414 Surgical Applied Anatomy. [Chap. xvm.

The lymphatics from the fundus of the uterus and
appendages pass to the lumbar glands, a few also pass
along the round ligament to the inguinal glands. The
lymphatics of the cervix, which is frequently the seat
of cancer, pass to the internal iliac glands on the lateral
wall of the pelvis.

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.

The ovary is so placed that the outer part of the
Fallopian tube turns downwards external to it. " Both
ovaries lie in a sagittal plane against the side walls of
the pelvis, with their long axes nearly vertical; so
that their surfaces are internal and external, borders
anterior and posterior, and extremities upper and lower "
(Symington). It lies in the angle between the external
and internal iliac arteries and may be indistinctly palpated
through the vagina. Its nerves come from the tenth
dorsal segment of the cord. The sensory nerves for
the cervix are derived from the lower sacral segments.
The lymphatics of the ovary pass to the lumbar glands.
The ovaries exert atrophic influence on the breast.
By their removal it was hoped that cancer of the breast
might be arrested, but the procedure has not been
followed by much success. The main ovarian vessels
lie close to the outer part of the organ, after passing
along a short fold of peritoneum, which runs from the
brim of the pelvis to the ovary, and is termed the
infundibulo-pelvic ligament. This ligament forms "the
outer part of the pedicle in ovariotomy.

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 (see page 342). 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, together with the fact that the sacrum is straight,
the prostate small, and the connections of the bowel

Chap, xviii.] The Pelvis and Perineum. 415

loose, prolapsus ani is much more common in children
than in adults. Children are, besides, especially liable to
such exciting causes of prolapse as worms and rectal polypi.

The rectum is about 8 inches in length. Its upper
part, for some 3 inches, is entirely invested by peritoneum.
The serous membrane gradually leaves its posterior
surface, then its sides, and lastly its anterior surface.
Anteriorly, the peritoneum, in the form of the recto-
vesical pouch, extends in the male to within 3 inches
of the anus, while on the posterior aspect of the gut
there is no peritoneum below a spot 5 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
carcinomatous and other spreading ulcers are more
apt to invade the peritoneal cavity when they are situated
in the anterior wall of the intestine. The internal
sphincter surrounds the lower part of the rectum,
an inch above the anus, and extends over about i an
inch of the intestine. Mr. Cripps has shown that the
posterior edge of the levator ani forms a distinctly felt
free border, which crosses the rectum, nearly at a right
angle at a point from H to 2 inches from the anus.
The third stage of the rectum (anal canal) is firmly
fixed by the levator ani and is seldom involved in prolapse
of the rectum.

By inserting the finger into the rectum the prostate
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 39 [).

It will be understood that the prostate, when
enlarged, 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 defalcation they may be pressed
upon by the rectal contents, and so in part emptied,
producing a kind of spermatorrhoea. Defamation also
often causes much pain in inflammatory affections of
the prostate and adjacent parts.

The anterior surface of the rectum in the female

416 Surgical Applied Anatomy. [Chap. xviii.

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 faecal accumulations it may be
distended 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 dis-
tended 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. The rectum is artificially
distended in suprapubic lithotomy, in order to bring
the bladder into better position (page 390).

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 8 inches. By a semi-rotary
movement, and by alternately flexing and extending
the fingers, the hand can be insinuated into the com-
mencement of the sigmoid flexure. Owing 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 cpine, 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).

Owing to the constrained position of the hand and
the cramping of the fingers, this method of examination
has proved to be of but limited service.

chap, xvin.] The Pelvis and Perineum. 417

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
been used in arresting hemorrhage during amputation
through the hip joint. The instrument, however, is of
little practical value.

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.

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 ^ 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 commencement of
the bowel on the right side. These folds, especially
when the gut is empty, may offer considerable resistance
to the introduction of a bougie or 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 fasces 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 connection with the
portal trunk causes the rectum to participate in the many
forms of congestion incident to that vein. The veins of the
rectum, also, can be affected by violent expiratory efforts.
For the last 4 inches, moreover, of the bowel, the
- u

4i 8 Surgical Applied Anatomy. [Chap, xviil

arrangement 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 considerable
size " (Quain). The veins form a plexus with a precisely
similar arrangement. The veins beneath the mucous
membrane of the anal canal perforate the muscular
coat of the rectum about 1 inch above the rectum.
At the point of perforation they are liable to be
compressed.

The lymphatics of the second and third stages of the
rectum pass to the internal iliac group of lymphatic
glands on the lateral wall of the pelvis. Hence in cancer
of the lower part of the rectum these glands and the
vessels leading to them are the earliest seats of secondary
infections. The lymphatics of the first stage pass to
the glands in front of the sacrum and between the layers
of the meso-rectum.

The second and third stages of the rectum may be
most freely exposed from behind (Fig. 51, p. 383). In
Kraskes operation for the extirpation of cancer of the
rectum an incision is made along the sacrum in the
middle line, from the level of the posterior inferior iliac
spines to the anus. A flap is turned out on the left side
including the skin and origin of the gluteus maximus.
The attachments of the left sacro-sciatic ligaments, coc-
cygeus, and levator ani, to the sacrum and coccyx are
divided and turned outwards. The lateral and median
sacral arteries and a plexus of veins are raised with
the fibrous tissue from the anterior surface of the
sacrum by a periosteal elevator. The left halves
of the fourth and fifth sacral vertebras, with
the left half of the coccyx, are removed. The fourth,
fifth sacral and coccygeal nerves are necessarily cut,
but an attempt should be made to save the third sacral
nerve, owing to the importance of its function. The

Chap, xvi u.] The Pelvis and Perineum. 419

second and third stages of the rectum are then exposed,
with the hemorrhoidal vessels and reflection of peri-
toneum. By opening the peritoneal cavity the greater
part of the first stage of the rectum may be brought
into the wound. After the diseased part is removed,
with the presacral and internal iliac lymphatic glands,
the upper end of the rectum is brought down and sutured
to the anal part. An attempt should be made to save
the levator ani and third sacral nerve, in order that the
integrity of the pelvic diaphragm be maintained. The
rectum is supplied with sensory and motor nerves from
the second, third, and fourth sacral segments through
the corresponding nerves. Some motor nerves are
also derived from the lower two dorsal and upper lumbar
segments. These nerves reach the rectum through the
hypogastric and pelvic plexuses. The stimulus which
maintains the reflex act of defecation passes from the
mucous membrane of the anal canal.

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. When the anus is closed the vertical
columns of Morgagni meet. At their upper ends they
are united by small valvular folds of membrane, which
prevent the escape of liquid contents. These valves
may be torn by the passing scybalous masses, and from the
rent thus caused a fissure of the anus may be produced
(Ball). The extreme painfulness 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. Belief 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
junction of the skin and mucous membrane, indicates
the interval between the external and internal sphincters
(Hilton).

The anus may be torn during defecation, when
the stools are hard. A case is reported of a woman
who, during violent efforts at defecation, felt something

420 Surgical Applied Anatomy. [Chap, xviii.

give way, and discovered faeces in her vagina. The
recto-vaginal wall had ruptured 2 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 ©f 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 the origin of the sensory nerves for those organs
from the same segments of the spinal cord. The upper
part of the rectum is provided with but little sensation,
as illustrated by the passage of instruments, 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 with hardened faeces.
From this apathy it has probably happened that, in the
self-administration of enemata, patients have thrust
the tube through the rectum into the peritoneal cavity.
The last 2 inches of the bowel, on the other hand, are
extremely sensitive.

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

Chap, xviii.] The Pelvis and Perineum. 421

(the sphincter and levator) and the integument 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, from the
second, third, and fourth sacral segments, 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 produce 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 pro-
voke great irritability of the organ, and it is well
known that painful affections of the perineum and
anus may be associated with priapism. The distribution
of the third sacral segment in the perineum by means
of the long pudendal nerve 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 neuralgia
of the same parts has been met with in cases of inflam-
mation involving that structure.

The testicle is supplied mainly from the tenth dorsal
segment by the spermatic plexus. The kidney is also
partly supplied from the same segment. This is illus-
trated 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, which
receives some of the terminal fibres of the vagus. This
communication serves to explain the great collapse often
noticed in sudden injuries to the testicle, and especially

422 Surgical Applied Anatomy. [Chap, xviii.

the marked tendency to vomit, so often observed in such
lesions. So far as its nerves are 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 woiild 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.

4^3

prt V.

The Lower Extremity.

CHAPTER XIX.

THE REGION OF 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 ilium 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 articulation.
The great trochanter is a conspicuous landmark. It
is covered by the fascial insertion of the gluteal maxi-
mus. 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 com-
paratively slight prominence of the trochanter 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 fills up
the hollow between the trochanter and the ilium. When
these muscles are atrophied the process becomes very
conspicuous. In fat individuals its position is indicated
by a slight but distinct depression over the hip.

If a line be drawn from the anterior superior spine
to the most prominent part of the tuber ischii, it will

424 Surgical Applied Anatomy. [Chap. xix.

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 backwards 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 is considerably above the
level of the lower border of the gluteus maximus, with
which it therefore does not correspond. When the
hip is fully extended, as in the erect posture, the but-
tocks are round and prominent, the gluteal fold is trans-
verse and very distinct. When the hip is a little flexed,
the buttocks become flattened, the gluteal fold becomes
oblique and to a large extent disappears. Among
the early symptoms of hip disease are flattening of
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

Chap, xix.] The Region oe the Hip. 425

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 trochanter 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 2 inches
and the latter about 4 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.

The subcutaneous fascia is lax, and 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 super-
ficial fascia permits large effusions both of blood and
pus to take'place in the gluteal region, and ecchymoses

426 Surgical Applied Anatomy. [Chap. xix.

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. De-
scending 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 fora-
mina. Extra vacations 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 extravasa-
tions may be long pent up, and, as they would fluctuate,
may be mistaken for abscess.

Deep inflammations beneath this fascia, and especi-
ally 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 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

chap, xix.] The Region of the Hip. 427

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 " 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 gluteus maxiiiius is
oblique, and is some way below the transverse line of
the fold of the buttock.

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.

At least three I>ufi*sae 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 " lighter-
nun's bottom." When enlarged this bursa may press
upon the inferior pudendal nerve.

428 Surgical Applied Anatomy, tchap. xix.

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 haemorrhage.
Wounds of the gluteal vessels 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 without much effect. Aneurism of
the commencement 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 continued 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 faeces within the rectum, may all

Chap, xix.j The Region of the Hip. 429

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 under-
stood 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 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 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 great sciatic nerve
may be stretched by flexing the extended lower extremity
on the belly. This measure has served to cure certain
cases of sciatica.

The skin of the buttock is well supplied with nerves,

43° Surgical Applied Anatomy. [Chap. xix.

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 sensorium through some or all 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. These
nerves are derived from four spinal segments — the
twelfth dorsal, first lumbar, second and third sacral
(Fig. 78, p. 534). The second and third sacral also
supply the sexual organs, hence the physiological
effects which may follow application of punishment to
this part, as in the celebrated case of J. J. .Rousseau.

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.
It is by this route that Kraske's operation for resection
of the rectum is performed.

2. The region of Scarpa's triangle. —
Surface anatomy. — The most important landmarks
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

Chap. xix. j The Region of the Hip. 431

has already been made (page 423). Poupart's ligament
follows a curved line, with its convexity downwards,
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 individuals its
position is indicated by a slight furrow. Owing to its
attachment to the fascia lata 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 : " When the thigh is even
slightly bent, there appears a second furrow in the
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
ilium. It runs right across the front of the capsule
of the hip-joint. For this reason it is a valuable land-
mark 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
make a fulness when contrasted with the opposite groin."
It must be confessed that this line is not always so dis-
tinct as Mr. Holden'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 rin£ lies on a horizontal line drawn from

432 Surgical Applied Anatomy. [Chap. xix.

the pubic spine to the top of the great trochanter, at
about 1 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 \ 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 opening is
sometimes indicated by a slight depression in the integu-
ments. It lies just below Poupart's ligament, and its
centre is about 1 \ inches below and external to the pubic
spine. In thin subjects the long saphenous vein can
be often made out, passing to the saphenous opening.

If a line be drawn from a point just to the inner
side of the middle of Poupart's ligament to the tubercle
for the adductor magnus, on the inner condyle of the
femur, when the thigh is slightly flexed and abducted,
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 of the artery, while the anterior crural nerve runs
about \ of an inch to its outer side. The profunda
femoris arises about \\ inches below Poupart's ligament,
and the internal and external circumflex vessels come
off about 2 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 ab-
domen, and, forcible extension being applied to relieve
the deformity, the skin gave way just below the groin,

Chap, xix.] The Region of the Hip. 433

and separated to the extent of some 2^ inches. Con-
tracting scars in the region of the groin may produce
a permanent flexing of the hip, and this result is not
uncommon after deep and severe burns this neigh-
bourhood. 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. (See page 178.) 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 direc-
tion 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 tri-
angle 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
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.
The fascia lata completely invests the limb,
being, so far as the front of the thigh is concerned

434 Surgical Applied Anatomy. [Chap. xix.

attached above to Poupart's ligament, to the body and
ramus 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 deep origins of the ilio-
psoas lie behind the caecum and kidney, and may elicit
symptoms from those organs when contracted. 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 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

Chap, xix.j The Region of the Hip. 435

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 attach-
ments. 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 \ an inch, 2 inches,
and even 3 inches long.

Blood-vessels. — The femoral artery occupies so
superficial a position in Scarpa's triangle that it is not
unfrequently wounded. The vessel also has been
opened up by cancerous and phagedaenic 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 parts 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. Aneur-
ism is frequent in the common femoral, and many
reasons can be given why that vessel should be attacked.
It i3 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 coat
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 bag even followed

436 Surgical Applied Anatomy. [Chap. xix.

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 that may probably be due to this cause ;
but the evidence is not sufficient to sanction the opera-
tion proposed for such cases, viz., an enlargement of
the saphenous opening itself. That varicose veins are,
in the majority of cases, of congenital origin is now
very generally allowed.

The anterior crural nerve lies on the ilio-psoas
muscle, and it is said that neuralgia, and even paralysis
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. Irritation 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
retractation of the testicle. The same result is often
S3en in adults, also, on more severe stimulation. In
this manner the condition of the second lumbar
segment of the cord may be tested.

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
afferent vessels. They are divided into a superficial
and deep set. The superficial set, averaging from ten
to fifteen glands, are arranged in two clusters, 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 reach
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.

chap, xix.] The Region of the Hip. 437

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 enlarged glands, like strings
of a violin over its bridge, so that violent pain and con-
vulsive movements were set up in the limb.

The efferent vessels from the inguinal glands pass
through a chain of lymphatic glands stretching along
the course of the external and common iliac vessels.
Three of these glands lie immediately above Poupart's
ligament. The efferent vessels of the internal iliac
group of glands into which the pelvic lymphatics drain,
join the chain along the common iliac vessels. The
lumbar glands are continuous with these.

Elephantiasis Arabum is more common in the lower
limb than in any other part, and leads to an enormous
increase in the size of the extremity (Cochin or Bar-
badoes leg). Its pathology is intimately concerned
with the crural lymphatics. The lymphatics are ob-
structed by a small thread worm, filaria sanguinis
hominis. The lymph vessels and lymph spaces in the

43 8 Surgical Applied Anatomy. [Chap. xix.

connective tissue become greatly distended, and the
elements of the connective tissue hypertrophied.

The hip joint. — The hip joint is an articulation
of considerable strength (Fig. 59, p. 455). 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 be brought to bear upon the femur, and the
numerous strains and injuries to which the joint is
subjected, as the sole connecting link between the trunk
and the lower limb.

The acetabulum is divided into an articular and a
non-articular part. The former is of horse-shoe shape,
and varies from 1 inch to \ an inch in width. The
bone immediately above the articular area is very dense,
and through it is transmitted the superincumbent
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 may 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.

chap, xix.] The Region of the Hip. 439

Flexion, when the knee is bent, is limited by the contact
of the soft parts of the groin, and by some part of the
ischio-femoral ligament ; when the knee is extended
the movement is limited by the hamstring muscles.
Extension is limited by the ilio-femoral or Y-ligament.
Abduction by the pubo-femoral ligament. Adduction
of the flexed limb is limited by the ligamentum 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 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 distinctly
chronic character. It follows also, from the deep position
of the articulation, that pus, when it is formed in con-
nection 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 pos-
terior 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 cor-
respond also to the regions where tenderness is most
marked and is earliest detected.

In chronic hip disease, certain false positions are

440 Surgical Applied Anatomy. [chap, xix.

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 adducted and inverted, and incident to this there is
(5) apparent shortening of the limb ; (6) there is real
shortening of the limb.

1. The first position is simply the posture of
greatest ease. It depends mainly 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 liga-
ment, 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 upper
part of the capsule. Eversion slightly relaxes the inner
limb of the Y ligament and the ischio-femoral ligament.
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 ligament. Any but a moderate
degree of abduction would be limited by the pubo-
femoral ligament, especially as that band is rendered
most tense when abduction is combined with flexion
and rotation outwards. The attachments of the psoas
muscle are approximated and its pressure over the joint
relaxed.

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

chap, xix.] The Region oe the Hip.

441

the limbs, the pelvis has to be tilted down on the affected
side. Thus, an apparent lengthening is produced,
which is seen when the patient lies upon a bed and the
abduction is made to disappear. Real lengthening of
the limb can scarcely be produced by the effusion into
the joint. By forcible injection into the joint Braune
could only separate the
articulating surfaces
about |th 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 position,
or at least to minimise
its inconveniences (Fig.
54). When the thigh
is flexed at the hip by
disease, the lower limb
can be made to appear
straight by simply
bending the spine for-
wards in the dorso-

1 1 • -j. i, t. a Femur flexed at hip. pelvis (represented 1>>

lumbar region Without A' *ffi ! dotted line) straight, and spine
pffpptino- tViP lpiqf normal, b, Tue flexion concealed or

eneciing Hie least overepme by lordosis of the spine; the

movement at the dis- pelvis rendered oblique.

ordered joint. Indeed,

the movement proper to the hip is in this case transferred
to the spine. A patient with a flexed hip as the result of
disease can lie on his back in bed, with both limbs ap-
parently 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,

L

B

54.— Diagram to show the Mode of
Production of Lordosis in Hip Disease.

Fig

442 Surgical Applied Anatomy. [Chap. xix.

and after the limb has become more or less fixed in
the false positions by contraction of the surrounding
muscles.

4. Sooner or later, in hip disease, the thigh
becomes adducted and inverted, while it still remains
flexed. The head of the femur then rests on the upper
and posterior part of the acetabulum, quite half of it
being outside the socket. 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 horizontal
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 unsatis-
factory ; 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

Chap, xix.] The Region of the Hit.

443

relation to adduction that apparent 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 55). It thus happens

a-

\

*l B

C d

fig 5p4 — a, Parts in Normal Position, b, Femur adducted. c, The
Adduction corrected by tilting up the Pelvis.

ac, I.mc of pelvis; oh, limb on diseased side; cd, limb on sound side; e, the
suine. It will be found that in Pigs. B and c the angle at a is the samein
the two eases.

that a patient with his femur 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 by the tilting of the pelvis.

444 Surgical Applied Anatomy. [Chap. xix.

In some cases of simultaneous disease in both hip-joints
that has been indifferently treated, both thighs may
remain adducted. The limbs are unable, of course,
to remedy their position 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 upon 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 position
of flexion and abduction with eversion 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 the hospital 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 from the same segments of the spinal cord.
In the hip, branches from (1) the anterior crural enter
at the front of the capsule ; (2) branches from the
obturator at the lower and inner part of the capsule ;

Chap, xix] The Region oe the Hip. 445

and (3) brandies from the sacral plexus and sciatic
nerve at the posterior part of the joint. In the knee,
branches from (1) the 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 referred
along the anterior crural curve, and pain at the back
of the joint along the obturator or sciatic nerves.

In hysterical individuals joint disease may be imi-
tated by certain local nervous phenomena, the articula-
tion 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 filaments 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. The common
origin of the joint and 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 unsatisfactory,
since the uterus receives many of its nerves from the
ovarian plexus, and the theory is founded upon the
unwarranted supposition that all hysterical disorders
are associated with some affection of the uterus or its
appendages. __ More recently Head has revived a modified

446 Surgical Applied Anatomy. [Chap. xix.

form of Hilton's theory. He explains the connection
not through an anatomical association of nerves, but
through an association of the centres from which nerves
arise in the spinal cord. The spinal segments from which
the obturator nerve arises, the second, third, and fourth,
contain no visceral nerves, and, therefore, cannot be
associated with visceral conditions. On the other hand,
the sacral segments from which the great sciatic nerve
arises are those which supply the pelvic viscera.

Fractures of the upper end of the femur
may be divided into (l) 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) separa-
tions of epiphyses. It can 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 supplied indirectly to
the bone, as by a fall upon the feet or great trochanter,
or by a sudden wrench of the lower limb.

M. Kodet, 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 intra-
capsular 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
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
js explained upon the following grounds. The angle

chap, xix.] The Region of the Hip. 447

between the neck and shaft of the femur, which will
be about 130° in a child, tends to diminish as age ad-
vances, 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 degenera-
tion of the cancellous 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 main-
tains 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 com-
pact neck, is driven into the larger and more cancellous
fragment made up of the head of the bone. The frac-
ture 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 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

448 Surgical Applied Anatomy. [Chap. xix.

neck, it must be remembered that a wholly extracapsular
fracture of the neck of the femur is an anatomical im-
possibility. 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 about \ 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 \ of an inch in thickness, that a fracture involv-
ing 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 trochanter 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 this splintering.

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 projection 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 outwards 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.

chap. xix. j The Region of the Hi p. 449

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 rotator 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 arc separated 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 violence, but
the accident is, I believe, illustrated by no actual speci-
mens. 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.

In the condition known as coxa vara the neck of
the femur sinks under the weight of the body, coming
to form an angle of 90° or less with the shaft of the
femur. It occurs in adolescents. Owing to the
prominence of the trochanter and shortening of the
limb which necessarily result, the condition may be
mistaken for a fracture of the neck of the femur or a
congenital dislocation of the hip-joint.

Dislocations ol 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,

2D

4 5° Surgical Applied Anatomy. [Chap. xix.

as shown in a few rare cases, or may be the result of
disease of the articulation. Congenital dislocation of
the hip joint is due in most instances to a failure in
the development of the acetabulum. In such cases
the acetabulum retains the shallow character seen
during the second month of foetal life. The outgrowth
of the acetabular rim fails, especially the iliac part. The
head of the femur is flat and the neck short, and the
bone slips backwards on the dorsum ilii when the child
learns to walk. The weight of the body is supported
by the muscles and ligaments round the hip- joint.
If replaced the head again slips from the shallow cavity.
In time osteophytic outgrowths from the ilium lead
to the formation of a new cavity.

In dislocations due to violence 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 vertic-
ally through the acetabulum, and in the other two
it is found anterior to that line.

(1) Backwards and upwards. Head rests upon
ilium, just above and behind acetabulum. The " dis-
location upon the dorsum 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.

General facts. — In all these dislocations of the
hip, (a) the luxation occurs when the limb is in the
position of abduction ; (b) 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) t he Y ligament is untorn, while the
iigamentum teres is ruptured.

chap, xix.] The Region of the Hip. 45 1

(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 dis-
location 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 abduc-
tion 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.

(6) 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 acetabulum,
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).

(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 valuable. The head having
left the acetabulum, its ultimate destination will depend

45 2

Surgical Applied Anatomy. [Chap.xix.

upon the character of the dislocating force. " If the
limb be flexed on the pelvis, and rotated inwards, or
the pelvis be correspondingly 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 fol-
lowed by rotation or
fixed flexion or ex-
tension, the head of
the femur will remain
below the acetabu-
lum, and will occupy
the foramen ovale if
it takes a slightly for-
ward direction in its
descent, or some
position near the
tuberosity of the
ischium if it leaves
its socket in a back-
ward 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 the Y liga-
ment, and in the forward displacements in front of it.

-Dislocation upon the Dorsum ilii
(Bigelow).

Chap, xix.] The Region of '/he Hip.

453

The anatomy of cacli 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 adductor muscles. The bone having
taken a general direction backwards, the height to
which it ascends depends mainly upon the nature of
the dislocating force, and also upon the extent of the
rupture in the capsule
and the laceration of
the obturator interims
tendon and other
small external rota-
tors. The dorsal dis-
location 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 dis-
location to be sciatic.
More moderate flexion
and inward rotation
will produce a luxa-
tion upon the dorsum.
In the dorsal luxation
the head is above the Fig.
obturator interims
tendon, while in the

sciatic form it is below it (Bigelow). 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.

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

-Obturator or Thyroid Disloca-
tion (Bigelow),

454

Surgical Applied Anatomy. [Chap. xix.

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 luxations there
is shortening, due to the
circumstance that the
Une between the anterior
superior spine and the
femoral condyles is les-
sened by the displacement
backwards of the bone,
with the additional
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
the tension of the Y ligament and of the ilio-psoas muscle.
Nos. 3 and 4. The dislocation fomvards. If the
head after leaving the acetabulum simply moves a little
forwards along the inner edge of the socket, the thyroid
luxation is produced. If it goes farther and moves
upwards, the pubic displacement will result. The latter
dislocation is therefore but an advanced form of the

Fig. 58.-Dislocation upon the Pubes
(Bigelow).

Chap, xi x.j The Region of the Hip.

455

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

Fig. 5.'.— Vertical section of the Upper Third of the Thigh showing the
structures in relationship with the hip-joint. (Ajter Braune.)

Muscles.— 1, psoas; 2, iliacus; 3, gluteus niedius; 4, gluteus minimus; 5, ob-
turator internus; 6, obturator extcrnus ; 7, iliopsoas; 8, pectineus; 9, ad-
ductor maKnus ; 10, adductor brevis; LI, gracilis; 12, adductor longus ;
13, vastus internus; l-l, vastus externus; a, anterior crural nerve; b, external
iliac artery ; c, external iliac vein ; </, obturator nerve ; e, obturator artery ;
/branches of obturator vessels to hip joint ; </, internal circumflex vessels:
ft, deep femoral vessels; /, branch of external circumflex: j, bursa over
great trochanter ; ic, reflections of capsule to neck of femur ; m, asc. ramus
of pubes ; n, peritoneum ; <\ iliac fascia.

the displacement. 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.

456 Surgical Applied Anatomy. [Chap. xix.

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 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 acetabular 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
and 2. i To relax the

Flex the thigh in the abducted , Y ligament,
position in luxations Nos. 3
and 4. /

Secondly. — Circumduct out in\ To bring back the head
Nos. 1 and 2. ! to the rent in the cap-
Circumduct in in I sule by the same route
Nos. 3 and 4 J 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 condyle of the femur faces in nearly
the same direction as the head of the bone.

In amputation of the thigh at the hip-
joint many methods may be employed. A common
procedure consists of a circular incision which divides
the soft parts to the bone at the junction of the upper
with the middle thirds of the thigh, and is combined
with a vertical incision over the great trochanter,
through which the upper extremity of the femur is

Chap. xix. The Region of the Hip. 457

exposed and the joint disarticulated. (See section,
Fig. 59.) Haemorrhage from the femoral, gluteal,
and sciatic vessels is prevented either by compressing
the termination of the abdominal aorta a little below
and to the left of the umbilicus, or by encircling the
junction of the thigh and body with a loop of elastic
bandage. The bandage must pass inside the ischial
tuberosity to compress the contents of the sacro-sciatic
foramen, over the groin to compress the femoral vessels,
and above the iliac crest to prevent it from slipping
downwards. In the circular incision the vessels divided
are : the superficial and deep femoral, the second per-
forating artery, descending branches of the external
circumflex and sciatic vessels, and long saphenous vein ;
the nerves divided are : the external, middle and
internal cutaneous, the internal saphenous, the deep
muscular branches of the anterior crural, the obturator,
the great and small sciatic ; the muscles divided are :
the sartorius, quadriceps extensor cruris, adductors
magnus and longus, gracilis, and hamstrings. In the
vertical incision (Fig- 59) the ilio-tibial band and the
insertions of all the gluteal muscles are divided to the
bone. Communicating branches between the ascending
and transverse branches of the external circumflex
artery in front with the gluteal sciatic and first per-
forating behind are cut. The capsule of the joint is
divided, the head of the femur thrust from its socket,
and the ligamentum teres cut. The attachments of
the following structures to the upper third of the
femur have to be separated : the gluteus maximus,
medius, minimus, pyriformis, gemelli, obturator in-
ternus and externus, quadratus femoris, adductor
magnus, brevis, pectineus, psoas and iliacus, with the
capsular ligament.

By the method of disarticulation at the hip-joint
known as the anterior racket, no elastic tourniquet
and no compression of the iliac vessels are needed.

The vertical part of the racket-shaped incision is
placed over the femoral vessels, and those vessels are
secured by two ligatures each and are then severed

458 Surgical Applied Anatomy. [Chap. xx.

between the ligatures. The circumflex arteries are in
the same way secured before division.

If carefully performed, very little blood is lost in
the anterior racket amputation.

CHAPTER XX.

THE THIGH.

Undee 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 mus-
cularly 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
internus. 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, how-
ever, more conspicuous below.

Running down the anterior and inner aspect of
the thigh, from the apex of Scarpa's triangle, is a depres-
sion which indicates the interval between the quadriceps
muscle and the adductors. Along this groove the
sartorius lies. Over the surface of the vastus internus
a longitudinal depression is often to be observed, formed
by the pressure exercised by the superimposed ilio-tibial
band of the fascia lata. The hamstring muscles cannot
usually be distinguished the one from the other above
the popliteal space, nor is their separation from the
adductors indicated. The separation, however, between
them and the vastus externus is distinct, and corre-

Chap, xx.] The Thigh. 459

spends to t lie 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 432) 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 fine, 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 perform-
ance 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 intermusciuar septum. The laxity of the sub-
cutaneous tissue favours extensive extravasations be-
neath the skin, and permits of large 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

460 Surgical Applied Anatomy. [Chap. xx.

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 rup-
tured 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 " hernial " 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 interims 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 quadri-
ceps 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 apo-
neurotic expansion from its anterior border to the capsule
of the knee-joint. In the case alluded to (Lancet, 1873),

chap, xx.] The Thigh. 461

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 waggon, when his companion tripped
over him and fell across his bent knees. Something
was felt to have given way near the ham, and on examina-
tion 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. In the middle third of the thigh it lies beneath
the sartorius in Hunter's canal. 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 sub
cutaneous rupture of the external circumflex artery.
Unfortunately the extravasation was cut into, and the
patient, after being subjected to many modes of treat-
ment, died from the effects of repeated haemorrhage.
Dr. Butcher (Dub. Jour 11. 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 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,

462 Surgical Applied Anatomy. [Chap. xx.

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 mus-
cular 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 examina-
tion. 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 direc-
tion is more commonly downwards and forwards, with
a slight lateral inclination that is sometimes inwards
and sometimes outwards. 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 displacements of the fragments depend
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, gracilis,
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 pro-
jection 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 eversion 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

Chap. XX.]

The Thigh.

463

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

,a /i

Fig. 60. —Trjnsverse Sectiou through the Middle of the Thigh
(Braune).

c Rectus feraoris ; b, vastus extenraa ; c, crureus; d, vastus interims } e, snort
' bead of biceps; f, long bead of biceps ; a, semitendinosus : fc,6emimenibra<
nosus: i, adductor magnus; 3, gracilis; k, adductor longus; I, sartonus : 1,
femoral artery; 2, great sciatic nerve; 3, great saphenous vein; 4, middle
cutaneous nen e : 5. external cutaneous nerve ; 6, perforating branches from
profunda: 7, small sciatic nerve.

reversed, can be produced by carrying the limb outwards
and then rotating it inwards.

Shortening of the limb after fraeture.—

It is doubtful if a fracture of the shaft of the femur
can, after any treatment, become united without some
shortening resulting, save in a few exceptional cases.
It is important, in connection with this subject, to
remember that the lower limbs may be normally of

464 Surgical Applied Ana to my. [Chap. xx.

unequal length. Dr. Wight, of Brooklyn, has fully in-
vestigated this matter, and has arrived at the following
conclusions : (1) The greater number of normal lower
limbs are of unequal length ; (2) the left limb is often
longer than the right ; (3) the average inequality of
normal lower limbs is probably about \ of an inch ;
(4) the average amount of shortening after a fracture
of the femur that has been well treated is about § 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 10 per cent, of all cases.
He also found that the femur was more frequently
the seat of variation than the tibia.

Amputation oi the thigh. — In a circular
amputation of the thigh about its middle the following
parts would be divided (Fig. 60) : the quadriceps, sar-
torius, gracilis, long and great adductors, and the three
hamstring 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.
Owing to the unequal manner in which the divided
muscles retract, a simple circular amputation is not
well adapted for the thigh. A more convenient method
of amputation is represented by the elliptical method,
the lower extremity of the ellipse being on that side
of the limb on which muscular retraction is the more
marked, i.e. on the posterior side of the thigh. "/

465

CHAPTER XX!.

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 hollow between the tibia ami
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 com-
pletely filled up with fat in the obese.

When the limb lies in the extended posture the
ligamentum patellaf 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

466 Surgical Applied Anatomy, tchap. xxi.

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
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 down-
wards. 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 ther femur
a little below its point of entry into the popliteal space.
The upper articular arteries run transversely inwards

Chap, xx i.] The Region of the Knee. 467

and outwards just above the femoral condyles. The
lower articular arteries are also placed transversely,
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 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 conspicuous than is the long
saphenous vein, and is, indeed, not often to be seen
unless varicose.

The internal popliteal nerve descends in the middle
line, 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 bursa? 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 wTith bluntish instruments,
and in any injury Avhere the gliding movement of the
skin may direct the violence away from the articulation.
The comparative looseness of the integument is some-
times utilised 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 complete, the surface wound
and that in the knee capsule no longer correspond.

468 Surgical Applied Anatomy. [Chap. xxi.

In flexion, the skin is drawn tightly over the patella,
and, as is the case elsewhere, where integument lies
more or less directly upon the 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 was burst
across the front of the knee, and a wound was produced
that was 7 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 amputations
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-irritant,
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 nerves 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 ar-
ticular 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, there-
fore, 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 skin over the front of the knee is supplied by nerves
from the third lumbar segment (Head). Through the
obturator nerve the joint is also partly supplied from
this segment.

The superficial lymphatics in the region of the knee

Chap, xxi.] The Region of the Knee. 469

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 of the joint
than when placed in front or to the outer side of it.

The bursa? 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 frequently divided
by septa into superficial and deep compartments. 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. 61, 62, and 65).

(2) There is a small bursa between the patellar ligament
and the tubercle of the tibia (Fig. 62). When inflamed,
it causes more pain than is observed in affections of the
previous bursa, since it is firmly compressed between
two rigid structures, 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 tibial tubercle,
which often protrudes a little at either side of the former
structure, and lias 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 resulting
cicatrix may lead to a rigidly bent knee. The skin in

47° Surgical Applied Anatomy. [ChaP. xxi.

this place has also been ruptured by forcible extension
applied to the limb in cases of contracted 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 production 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. Velpeau has seen a case where a litre
(1 pint, 15 oz.) 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
popliteal 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 nmscEes 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. Irritation from disease of the knee-
joint may lead to contracture of the hamstring muscles.
These muscles are supplied through the great sciatic
nerve from the fifth lumbar segment, from which
the knee-joint derives in part its nerve supply. Muscles
on the flexor aspect of a bent joint undergo a permanent
shortening if the position be maintained for a consider-
able space of time.

Contraction of these muscles in knee-joint disease
tends not only to flex the knee but also to draw the

chap, xxi.] The Region of the Knee. 471

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
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, collected

47 2 Surgical Applied Anatomy. [Chap. xxi.

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
diminished 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 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.

Chap, xxi.] The Region of the Knee. 473

From the relations of the artery to the vein and
nerve it will be understood that a popliteal aneurism
may soon lead to cedema 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 the 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. 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-

474 Surgical Applied Anatomy. [Chap. xxi.

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.— {I) 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 connected
with the articulation. (4) A bursa between the biceps
tendon and the external lateral ligament. The peroneal
nerve runs across this sac, a circumstance 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.

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 fasciae 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 powerful,
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

chap, xxi.] The Region of the Knee.

475

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 ligamentum patella?
and anterior part of the capsule, in addition to the crucial

HH

fi a

\~~f

Fig. 61.— Vertical Section of Normal Knee-joint (Braune).

a, (Quadriceps; 6, semimembranosus ; c, gastrocnemius; d, posterior crucial
ligament ; e, ligamentum patella,' ; /, bursa between quadriceps and femur.

ligaments. Rotation is possible only in the flexed
position. The thinnest part of the posterior ligament
is the portion below the oblique fibres derived from the
semimembranosus. 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

476 Surgical Applied Anatomy. [Chap. xxi.

the lateral ligaments, and in the fibrous and fatty tissue
between the former ligament and the posterior crucial
band.

The synovial 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
distinct when the joint is distended with fluid (Fig.
62). 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 synovial
pouch is a bursa that separates the quadriceps tendon
from the femur, and is usually over an inch in its vertical
measurement (Fig. 62). From the examination of
two hundred and sixty knee-joints in both infants
and adults Schwartz found that this bursa 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 2 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, and divide the
cavity behind into an outer and inner condylar recess.
The posterior ligament is continuous with the posterior
part of the capsule.

The upper third of the patellar ligament is in relation
to the synovial membrane, from which, however, it is
separated by a pad of fat. The lower two-thirds of the
ligament are in relation to the bursa and fatty tissue

chap, xxi.] The Region of the Knee.

All

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. 61). If, however, there be any

Fig. 62. —Vertical Section of Knea-joint distended with Fluid
(Braune).

a, Vastus extenms ; b, crureus : c, short head, and rf. lone head, of biceps ; e. plnn-
taria :/, gastrocnemius ; g, popliteus ; >>. soleus; »', tibialis posticus ; jt bursa
natcllsa; Jr, ligamentum patellar ; l, ligamentiim luueosum ; m anterior crucial

lipament: n, external semilunar cartilage; l, external popliteal nervt;

2. popliteal artery.

effusion in the joint, or the limb be a little flexed, a knife
so introduced would pass between the two [ bones
(Fig. 62).

Joint disease. — Owing to its superficial position
thejmee-joint is the articulation that is most frequently

478 Surgical Applied Anatomy. [Chap. xxi.

the seat of inflammation 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.
Fluctuation is soon to be detected, and the patella,
being pushed away from the femur, is said to " float "
upon the distending fluid (Fig. 62).

The inflamed knee-joint, if left to itself, almost in-
variably 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 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 instinctively 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 capacity
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 minimum of the
capacity of the synovial cavity coincides with the maxi-
mum 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

chap, xxi.] The Region of the Knee. 479

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 a flexed position. The accident is usually
brought about by a twist given to the leg when the
knee-joint is more or less bent. In 200 cases of internal
derangement of the knee-joint, Bennett found that the
internal cartilage was affected in 155 cases and the
external in only 45. The left knee was the seat of de-
rangement nearly three times as often as the right,
and the lesion occurred nine times more frequently
in men than in women. In every one of twelve cases
operated on by Marsh, the anterior extremity of the
internal semilunar cartilage was found bruised and torn
from its tibial attachment. It may be noted in connec-
tion 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 one or other disc is fixed and the tibia rotates beneath
them. Dr. Scott Lang has pointed out that displace-
ment of the internal disc occurs through violence applied
when the leg is rotated outwards, while displacement
of the external cartilage can only occur when the leg
is rotated inwards. " Rotation outwards is performed
chiefly by the biceps ; consequently, when this move-
ment is taking place, the tibia will be found to be held
closely to the external condyle of the femur, and the
outer cartilage is thus held firmly in its place between
the two bones. But the gap between the internal con-
dyle and the tibia will be increased, and the movable
cartilage is apt to slip between the internal condyle
and the corresponding part of the tibia. When the
tibia is rotated inwards the internal cartilage is held in
like manner between the bones by the internal rotators,
while the gap between the external condyle and the tibia
is increased " (Scott Lang). The external cartilage is

480 Surgical Applied Anatomy. [Chap. xxi.

smaller than the internal, is rounder, is more movable,
and possibly on these accounts is less likely to be
" nipped " between the bones. It is attached in part to
the femur through the posterior crucial ligament, and
is grooved by the tendon of the popliteus, two factors
which add to its security.

Oeiiiwvsiigum, or knock-knee. — The appearances
produced by this affection are familiar. When a person
stands erect, 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 width of the pelvis.
In 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
stands upright and when he is not concealing any of
the deformity by rotating the limb.

The progress of the 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 prob-
able 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 liga-
ment, 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
boc bs the greater part of the weight of the body will

chap. xxi. j The Region of the Knee.

481

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 in-
terval 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 contact with the
tibia. Mikulicz lias pointed out that '* the alteration

Fig. 63.— a, Normal femur ; B, femur in au advanced case of knock-knee,
sliowiug the enlargement of the internal condyle. The dotted line
in each case represents the liue of the epiphysis.

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 is shown in the diagram
(Fig. 63), where it will be seen that the enlargement
of the internal condyle is due almost entirely to increased
growth in the diaphysis. The increased growth does
not affect the anteroposterior diameter of the condyles.
Hence, when the knee is flexed, all trace of the deformity
disappears.

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
by both muscular and direct violence, it would appear
that the former is the agent that most often produces

482

Surgical Applied Anatomy. [Chap, xxi

the lesion. Thus, in 127 cases of simple transverse
fracture collected by Hamilton, he considers that
muscular action was the cause of the injury in 106
instances. 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 fracture by muscular
action is that of flexion. When
the knee is bent, the patella
rests upon the femoral condyles
along its transverse axis only.
Nearly the whole of its 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. 64). As the
fracture usually causes the patient to fall, it has been
supposed that the contact with the ground, rather than
any previous muscular action, may have caused the
lesion. But, as Hamilton has pointed out, if a person
falls upon the bent knee when the limb also is flexed
upon the trunk, the 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

Tig. 64. —Diagram to show
Mechanism of Fracture of
the Patella hy rnusculai?
action.

a, Line of action of quadriceps
muscle ; 6. femur ; c, tibia.

Chap, xxi.i The Region of THE Knee. 483

patellar bursa opened up. Tims 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 the separation of 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). Jn all
cases where there is much separation of the fragments,
the fibrous expansion attached to either side of the
patella must be torn through. Indeed, none but a
slight separation of the parts is possible until that ex-
pansion is ruptured. Braune has demonstrated this
by experiment, by sawing through the patella without
damage to the lateral ligamentous 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
permitted 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 patella?. In the flexed position it will be seen
(Fig. 64) that the bone is placed at a considerable
disadvantage when compared with the two other
structures. Richet 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.

The patella may be congenitally absent. It is
developed in the tendon of the quadriceps, remaining
cartilaginous until the end of the second year. Its
sesamoid nature is seen in the tendency to unite by
fibrous rather than by bony union after fracture. It
receives its blood supply from nearly all the arteries
round the knee-joint.

Dislocation of the patella. — This bone may
be dislocated outwards or inwards, or turned upon its

4§4

Surgical Applied Anatomy. [Chap. xxi.

c-#

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
a. passes to the outer

side of the angle
formed by the
femur with the leg
at the knee-joint.
Muscular contrac-
tion, therefore,
tends to draw the
knee-cap outwards,
a tendency that is
in all normal cir-
cumstances cor-
rected by the in-
creased 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 muscular
action, and are most
apt to occur in the
extended position
of the limb, the position in which the patella is not fixed
and its ligament and the anterior part of the joint cap-
sule attached to the bone are the most lax. The lateral
luxations are usually incomplete, but may be complete.
In the former case the anterior part of the capsule need
not be torn, but in the latter form it can scarcely escape
extensive rupture.

In the dislocation of the patella upon its edge, the

Fig. 65. —Transverse Section of left Knee-
joint through the centre of the Patella
(Braune).

a, Bursa patel las; &, internal lateral ligament and
iDner condyle; c. external lateral ligament
and outer condyle; d, biceps: e, semimem-
branosus; /. semltendinosus ; gr, gracilis
tendon; h. sartoiius; 1, internal popliteal
nerve; 2, external popliteal nerve ; 3, inter-
nal saphenous vein.

Chap, xxi.] The Region of the Knee. 485

inner border of the bone usually projects forwards,
while the outer is placed between the condyles. But
little is known as to the mechanism of this dislocation.

In dislocations oi" 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
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 arc 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 eompressed,
and appear to be more severely injured by the femur
in the forward dislocation than by the tibia in the back-
ward displacement.

The lower end ct the femur. — The condylar
part of the femur is composed almost wholly of can-
cellous bone, but with 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

486 Surgical Applied Anatomy. [Chap. xxi.

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 violence.
Fractures Nos. 1 and 4 may be produced by indirect
violence, as by a fall upon the feet from a height. Henry
Morris states that lateral flexion, or force applied in a
lateral direction, is best calculated to produce 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 un-
dressing 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 2 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 462), and its sharp upper end is very
apt to be pulled forcibly into the popliteal space by the
gastrocnemius muscle. This latter displacement is
difficult to remedy. If the limb be extended, the frag-
ment 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 several 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 position of the fragments was in each case very good
{Brit. Med. Jour., 1883). The lower fragment of the
femur may be replaced by completely flexing the leg
on the thigh. (Hutchinson and Barnard.)

Chap, xxi.) The Region of the Knee. 487

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 tuberosities. Such
accidents are the result, in nearly every instance, of
great direct violence. Dr. Hutton reports a case, prob-
ably unique, in which the spine of the 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
to 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 these.

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 exeising the knee-joint through an incision
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 mem-
brane, lateral and crucial ligaments, the superior and
interior articular arteries, the anastomotica magna,
and the anterior tibial recurrent vessels.

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

488

Surgical Applied Anatomy. [Chap. xxi.

rule, therefore, is that the saw be applied parallel to
the articular surface and perpendicular to the shaft.

In young subjects care must be taken that the
saw-cuts do not pass beyond the epiphyseal line. The
upper limit of the femoral epiphysis will be represented
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 ex-
cision 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 twen-
tieth year. The limits
to the tibial epiphysis
are represented behind
and at the sides by a
horizontal line that just
marks off the tuberosi-
ties. It includes, there-
fore, the depression for
the insertion of the
semimembranosus, 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 enclose the whole of the tubercle of the tibia.
The centre joins the main bone at the twenty-first
or twenty-second year. The popliteal artery runs
some risk of being wounded in excision of the
joint. The vessel is separated by some little distance
from the popliteal surface of the femur (Fig. 66), but
is in very close relation to the tibia, the posterior liga-
ment alone intervening at the upper level of the bone.

Fig. 66. —Disarticulation at the Knee-
joint by' single Anterior Flap
lAgatz).

a, Int. condyle ; b, ext. condyle ; c, inter-
condyloid fossa ; d, lig. patellae ; e, sar-
torius;/, gracilis; y, semitendinosus;
h, ext. lat. ligament; i, popliteus ; j,
plantaris ; k, semimembranosus ; I and
in, inner head of gastrocnemius ; n, outer
head of gastrocnemius; o, biceps; p,
popliteal vessels; q, int. pop. nerve.

Chap, xxi.] The Region of the Knee. 489

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.

Excision of the knee is, to a large extent, replaced
by arthrectonry. Indeed, excision of this joint carried
out in the complete manner just described must be
classed as a quite rare operation.

Amputation throug-li the knee-joint. — To
illustrate the anatomy of the part an amputation by
a single anterior flap may be selected. 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 capsule
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 popiiteus, plantaris, and biceps. The popliteal
vessels, the sural arteries, the short saphenous vein,
(lie internal and external popliteal nerves, the external
saphenous and the small sciatic nerves will also be found
divided in the same incision.

The most convenient amputation at the knee-joint
is by equal lateral flaps (Stephen Smith's operation).
This operation has been attended by excellent results,
and in actual practice the method of amputation by a
single anterior flap is but very rarely employed.

CHAPTER XXII.

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

49° Surgical Applied Anatomy. [Chap. xxii.

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 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.
The fibula is situated so far behind the line of the tibia
that a knife thrust transversely through the leg from
the inner side behind the tibia will appear in front
of the fibula on the outer side (Fig. 68). 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 and 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

Chap. XXII.] l^HE LEG. 49 1

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 3 inches below
the knee, follows the posterior surface of the fibula,
and ends behind the outer 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 integu-
ment 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 integu-
ment. 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
tightly-drawn buskin, being lacking only over the
subcutaneous surfaces of the bones. It is attached
to the head and the anterior and inner borders of the

492 Surgical Applied Anatomy, tchap. xxit.

tibia, 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 anterior 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 between
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 ligature
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 unfrequently torn across, producing a sudden
sharps 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 close^proximity with the bones, are apt to be injured

chap. xxn. i TtiE Le& 493

by sharp fragments in fractures of the limb. This
especially applies to the peroneal artery, which runs
along the fibula in a fibrous canal, 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
unfrequently follows the occurrence. Billroth states
that in all the cases of gangrene of the leg due to
embolism that he has met with, the plug 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, perhaps,
in the hamiorrhoidal 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 com-
pressed, and upon the fact that the superficial veins,
being outside the fascia, lose that assistance to the
circulation derived from muscular contraction. From
a physical point of view the vascular system must be
regarded as a vertical column of fluid. The lower the
level the greater is the pressure on the containing walls.
The saphenous veins are thin-walled, distensible tubes
situated outside the rigid-walled cylinder formed by
the deep fascia of the leg and thigh, low in the body,
where the pressure from gravity is great* st (Hill). The
use of garters especially affects the long saphenous vein,

494 Surgical Applied AnaTomV. [Chap.XXtl.

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 Verneuil 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 ex-
plain the " aching legs " complained of by those who stand
a great deal. The intramuscular veins are very large.
Callender showed that the six chief veins which pass
from the soleus muscle alone to enter into the posterior
tibial and peroneal trunks have a united diameter of
not less than 1 inch. Varix would appear to commence
most often at points where the deep veins join the super-
ficial vessels. There is good reason for this,
for at these points three forces meet, the
general directions of which are shown in
» 1 the annexed diagram (Fig. 67). There is

the weight of the superincumbent column
of blocd (a) acting from above, the resistance
a r 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

'Fig. 67. 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). Un-
fortunately 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
remembered 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
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

Chap, x x 1 1 . i The Leg. a o

r;j

lumbar spine, which had evidently compressed the
left great sciatic nerve.

There would appear to be little connection between
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 kncc-joiiil 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."

Dr. Ralfe mentions cases of renal calculus attended
by severe pain in the sole of the foot, and I have met
with many instances of this association, the pain being-
most commonly in the heel.

Fractures of the 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 malleolus
and at its upper extremity. Its great length and the
in inner 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, 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
lower third. According to Dr. Leriche, the average
transverse diameter of the adult tibia just below the
tubarosities 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 1 inch. This narrow part is at the

496 Surgical Applied Anatomy, ichap. xxii.

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 accord-
ing 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 depending 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
fracturing force and the bone, it comes to pass that
fractures of the leg are more often compound and com-
minuted than are those of any other bones of the ex-
tremities. If the fracture be oblique, as is commonly
the case when the violence is indirectly applied, the line
of breakage usually extends from behind, downwards,
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 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.

Chap. XXII.]

The Leg.

497

2. The fibula alone. Fractures of this bone in
its loAver fourth are usually due to indirect violence,
and will be dealt with in connection with the ankle-
joint. When it is broken in any other'part the fractur-

Fig. 68. — Amputation of Leg at junction of Upper with Middle Third
l>y single Posterior Flap (Agatz).

o, Tibia; b, fibula; r, tibialis anticus : <>, ext. com. rlii-'it ; <•, peron. long.;/, tib.
post. ; a, BOleus with flow Iohk. digit; ft, gastrocnemius : ?'. antenoi tibial
vessels; ./, post. tii>ial and peroneal vessels; fc, int. saphen. vein; /, post
tibial nerve.

ing 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

G

498

Surgical Applied Anatomy. [Chap. xxii.

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.
Whsn transverse there may bs no visible displacement,

Fig. 69.— Transverse Section through the Lower Third of the Leg
(Braune).

a, Tibialis an ticus ; 6, extensor longus pollicis; c, extensor communis digitorum;
dx peroneus brevis ; e, peroneus longus ; /, tibialis posticus : g, flexor longus
digitorum ; h, flexor longus pollicis; i, gastrocnemius and soleus ; j, short
saphenous nerve and vein ; fc, anterior tibial vessels and nerve; I, peroneal
vessels; m, posterior tibial vessels and nerve ; n, musculo-cutaneous nerve.

the fibula acting as a splint.. Thus Mr. H. Morris men-
tions the case of a woman who walked into and out of a
hospital with a transverse fracture of the tibia that was
not detected on examination, and was not indeed dis-
covered 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
displacement being resisted and limited by the inferior
tibio-fibular ligaments.

Chap, xxn.] The Leg. 499

In rickets the tibia is, of all the bones of the
extremities, the one that most frequently becomes
bent. Jt yields at its weakest part (the lower third),
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 by unequal antero-posterior
flaps may be taken as an example. This is not the best
method of amputation, but it serves best to illustrate
the anatomy of the part. In the anterior flap the follow-
ing structures would be cut : Skin, cutaneous nerves,
fascia, tibialis anticus, extensor communis digit orum,
and a little of the extensor proprius pollicis, the pero-
neus 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, gastrocnemius, 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. 68 shows the stump left after the amputation
through the lower part of the 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. 69 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 amputa-
tions through that part.

An excellent method of amputation at the upper
part of the leg is by a single external flap containing the
anterior tibial artery in its entire length.

5°°
CHAPTER XXIII.

THE ANKLE AND FOOT.

Surface anatomy. — Bony points. — The outlines
of the two malleoli 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 |- 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 astrag-
alus 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 1 inch vertically below the inner malleolus,
is the projection of the sustentaculum tali. About
l\ inches in front of the malleolus the tubercle of the
scaphoid can be distinctly made out. In the interval
between it and the last-named process lies the inferior
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 meta-
tarsal 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 sesa-
moid bones that lie on the plantar aspect of the meta-
tarsal 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 1 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 2|- inches from the outer malleolus the projection
of the base of the fifth metatarsal bone is very evident,

Chap. xxiii.] The Ankle and Foot. 501

and extending for an inch or so behind it lies the cuboid
bone.

Joint lines. — The ankle-joint lies about on a level
of a point \ 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 trans-
versely across the dorsum of the foot, just behind the
process, very fairly corresponds to the mid-tarsal joint
(the joint compounded of the astragalo-scaphoid and
calcaneo-cuboid articulations).

PIf the latter articulation be approached from the
outer side it will he 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 meta-
tarso-phalangeal articulations are situated about 1 inch
behind the webs of the corresponding toes. The proximal
phalanx and part of the middle are buried in the web.

Tendons. — The tendo Achillis stands out very con-
spicuously 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
ton dons of the extensor muscles are readily to be dis-
tinguished, especially when the joint is flexed. From
within outwards they are : the tendons of the tibialis
anticus, extensor longus pollicis, extensor longus digit-
orum, and peroneals 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.

502 Surgical Applied Ana tomy. [Chap. xxin.

f^- 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
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 obliqiiely 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 slim 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

Chap, xxiii.] The Ankle and Foot. 503

that would cause but little trouble in other parts. Over
the sole the integument is dense and thick in all those
parts thai conic in contact with the ground. In the
normal loot, the heel, the outer margin of the foot,
and thelineof metatarsophalangeal joints arc in contact
with the ground when the sole is placed Hat 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 substances) have often to be of
greater dimensions than would be needed elsewhere.

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 subcut-
aneous tissue is most developed where most pressure
is received. Thus, beneath the heel it is often £ 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 musl
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 con-
ditions 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

504 Surgical Applied Anatomy. [Chap. xxm.

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 with
nerves, being furnished with branches from no less than
six nerve trunks, the museulo-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 of the 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 cethesiometer, is not acute, the dorsum of the
foot • showing, in regard to this matter, no more
sensitiveness 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 fasciae of the foot and the tendons
about the ankle. — The fasciae 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

Chap, xxiii.] The Ankle and Foot. 505

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
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 mem-
brane is at a spot about 1 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 expansion. 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
it'ii dons to the region of the ankle. There are certain
1 '< .lamina 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 abc<s 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

506 Surgical Applied A na to m y. [Chap, xxiii.

which pass the tendons, vessels, and nerves bound for
the digits. Two intermuscular septa connected with
the membrane 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 synovial
sheath, that for the tibialis anticus ; beneath the latter
are three sheaths : one for the peroneus tertius and
extensor communis, 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 digi-
torum 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
synovial sheaths for the tendons of the tibialis posticus,
flexor longus digitorum, and flexor longus pollicis.
Inflammation involving the sheath for the tibialis pos-
ticus may spread to the ankle joint, with which the
tendon is in close relation. Beneath the outer annular
ligament is the single synovial sheath for the long and
short peroneal tendons.

In severe sprains of the ankle not only are the liga-
ments 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 foursae of any magnitude about the
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
\ an inch above the os calcis, and bulges out on either

Chap, xxiii.] The Ankle and Foot. 507

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 constitutes a bunion. It lies in the
subcutaneous tissue between the internal sesamoid
and the skin, and is not present at birth. This con*
dition 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 cartilage over the inner part of
the head of the metatarsal bone disappears, and a com-
munication between the bursa and joint may be set up.
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 joint, and a dis-
placement outwards of the tendon of the extensor pro-
prius pollicis. Bursao are often developed over the
malleoli in tailors, and especially over the external pro-
cess, the part most pressed upon when sitting cross-
legged. In club-foot, bursa? are found over any points
that are exposed to undue pressure.

The tendons about the ankle are not unfrequently
ruptured by violence. Those that most often are
so injured are the tendo Achillis and the tendons
of the tibialis posticus, and long and short peroneal
muscles. The tendo Achillis usually breaks at a point
about l| inches above its insertion, where it becomes
narrowed and its fibres are collected 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 may be allowed to become displaced. This has hap-
pened to the tibialis posticus and peroneal muscles. In
each instance the dislocated structure comes forwards
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

508 Surgical Applied Anatomy. [Chap, xxiii.

by operation. The tendo Achillis is usually cut about
1 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. On section of a tendon a gap is felt,
owing to retraction by the muscle. The cut ends are
still united by the fibrous tissue in which they lie, and
from which they derive their blood supply. If cut
within a sheath the synovial membrane forms a loose
binding between the cut ends. A fibrous band between
the cut ends is ultimately formed from the effusion
which fills the gap. The new band is firmly adherent
to the sheath in which it lies, and at first will limit the
movements of the tendon.

Part of the tendon of a sound muscle may be yoked
to that of one which has become paralysed, thus restoring
certain movements to the foot.

BBood-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 con-
tinuation of the anterior tibial vessel. In cases, how-
ever, 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
indirectly to the arch by means of the peroneal artery.
By its anterior peroneal branch this vessel communicates
with the external malleolar branch of the anterior tibial
artery, and with the tarsal branch of the dorsalis pedis.

Chap, xxiii.] The Ankle and Foot. 509

By its terminal branch it communicates with the two
last-named vessels, and also with the internal calcaneal
branches of the external plantar artery. As a matter
of practice, however, elevation of the limb, together
with pressure upon the wounded point and com-
pression of the main artery, are sufficient to check most^
haemorrhages 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
t lie 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 posi-
tion 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 phlebitis than are like lesions when
situated upon the sole. Venesection is sometimes per-
formed in the foot, the vein opened being either one of
those forming the dorsal plexus, or more usually the

510 Surgical Applied Anatomy. [Chap xxm.

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 con-
cerned, 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.

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 insignifi-
cant, although thejatter is supported by the tendon

chap, xxiii.] The Ankle and Foot. 511

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 ligament 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
fluctuation 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 move-
ment 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 posterior part of the external liga-
ment, l'\ the posterior 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 external
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
circumstances that the flexor and extensor muscles
about balance one another, and it does not seem that

5*2 Surgical Applied Anatomy, [Chap, xxi i.

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-fibular articu-
lation.

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 the lumbar segments of the spinal cord through
the internal saphenous, and the sacral segments
through 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 ahvays
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 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 con-
siderable. 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 eversion of the foot, the
luxation inwards to violent inversion.

It is of interest, in the first place, to note the relation
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 3 or 4 inches of the fibula may

Chap, xxiii.] The Ankle and Poor.

5i3

be considered to form a lever of the first kind (Fig. 70, 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 2 or 3 inches of the shaft of the bone. Xow

Pig. 70. —Diagrams to illustrate the Mechanism involved in Fractures
of the Lower End of the Fihula.

A, Parts in normal position; a, tibio-fibular ligaments; 6, external lateral liga-
ment; c, internal lateral ligament; b, fracture of fibula clue to eversiou of
foot ; 0, fracture of tllmia due to inversion of foot.

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 particularly insist
that in no ordinary lesion about the ankle, whether
fracture or dislocation, do these ligaments give way.
If they should yield, then an anomalous form of fracture

-h

5'i 4 Surgical Applied Anatomy. [Chap, xxiii.

or luxation will be produced. 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 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 2 or 3 inches above the
end of the bone (Fig. 70, b). In forcible inversion of
the foot, the astragalus undergoes a little lateral rotation
in the opposite direction ; the external lateral ligament
is greatly stretched, and tends to drag the end of the
outer malleolus inwards. If the ligament 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 (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. 70, 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 fracture 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 external
lateral ligament remains entire.

In the outward luxation, better known as Pott's
fracture, 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
2 or 3 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

chap, xxiii.] The Ankle and Foot. 515

much everted, its outer edge is raised, while its inner
edge rests upon the ground. The inferior tibiofibular
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 Dupuytrens fracture (a rare injury) the fibula
is fractured from 1 to 3 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
fragments of the fibula. The foot is dislocated
horizontally outwards, and is drawn upwards, the
extent of the upward displacement depending upon
the height at which the fibula breaks.

In the imvard luxation the external lateral ligament
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 dislocation, 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 scaph-
oid and cuneiform bones. The anterior and posterior

5«6

Surgical Applied Anatomy. [Chap. xxm.

ligaments are entirely torn, and a great part also of the
two lateral bands. The fibula is broken some 2 or
3 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.
R. W. Smith believes that the dislocation is never
complete.

3. The dislocation upwards. In this rare accident

3

FiEr.,71.

-Antero- Posterior Section of the Foot (Eudinger).

1, Tibia ; 2, astragalus : 3, ns cnlcis : 4, scaphoid ; 5, int. cuneiform ; 6, first
metatarsal bone ; 7 and 8, phalanges of great toe.

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 ruptured, but the
lateral ligaments usually escape with but some slight
laceration. 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.

Chap, xxiii.] The Ankle and Foot. 517

1. The anteroposterior arch has its summit at the
astragalus. It may be considered as composed of two
piers. The hinder pier consists of the os calcis, the
anterior pier of the scaphoid, cuneiform and metatarsal
bones. The astragalus forms the keystone of the arch,
the head of the bone especially performing that function
(Fig. 71).

The foot rests upon the heel, the heads of the
metatarsal bones, and the outer margin of the foot
(Fig. 72). The hinder pier is solid, is made up of a
strong bone, 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 and muscles of the sole. The peroneals 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 antcro-posterior arch.

The chief joints of the foot. — The articulation
between the os calcis and astragalus forms a double
joint. The posterior joint, that behind 1 he interosseous
ligament, has a separate synovial sac, while the anterior

518 Surgical Applied Anatomy. [Chap, xxiii.

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 sup-
ported also by the external 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 in the movement of inversion,
and abduction with some turning of them outwards
in eversion of the foot.

Dislocation 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,
the next in frequency being a luxation outwards and
forwards. The backward displacement is extremely
rare. The dislocations are usually complete, 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 the 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 in-
stances the malleoli are brought nearer to the sole. In
the antero-posterior 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,

chap, xxiii.] The Ankle and Toot. 519

and is torn away from its attachments to the astragalus
and cuboid, or from the former bone alone.

Suhastragaloid 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 astragal o-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 displacements the foot is dislocated
outwards or inwards, and is at the same time carried
backwards. Thes° 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 ligament 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
literal 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
forms a projection at the outer aspect of the foot, while
below them a deep hollow exists. The inner border of
the 03 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. Tn the outward luxa-
tion the foot is abducted, its outer border is raised, and
the deformity produced is not unlike that of talipes
\ ilgus. The outer malleolus is lost in the hollow caused
by the eversion of the foot, while the tibial malleolus

520 Surgical Applied Anatomy. [Chap. xxin.

and head of the astragalus form a projection on the
inner aspect of the limb.

The inedio-tarsal joint is composed of two
articulations, the astragaio-scaphoid and calcaneo-
cuboid. The ligaments supporting the former joint
are the external and inferior calcaneo-scaphoid and
the astragaio-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 movements
permitted in the articulation as a whole consist of
flexion and extension, with some rotation around an
antero-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 de-
formities 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. (l) 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
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

Chap, xxiii.] The Ankle and Foot. 521

the os calcis. The ligaments of the sole are usually
much contracted.

•1. Talipes calcaneus. 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 ren-
dered 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.
Certain features of the foetal foot are retained in an
exaggerated degree. In a well-marked congenital case
there is a fourfold 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 neck of the astragalus is elon-
gated and deflected downwards and inwards to a greater
extent than in the normal foot. In the adult the neck of
the astragalus is deflected inwards to the axis of its body
at an angle of 10° ; in the newly born at an angle of 25° ;
and in talipes varus at an angle of 50°. The scaphoid is
displaced upwards and backwards, until its inner border
often touches the internal malleolus. The three cunei-
form bones follow the scaphoid, and the cuboid becomes
the lowest bone in the tarsus. The outer border of the
cuboid forms an angle with the os calcis, and the tendons
of the peroneus longus slip backwards from the groove in
the cuboid to lie on the os calcis. The anterior border
of the internal lateral ligament is contracted and unduly
prominent.

4. In talipes valgus the foot is abducted and its
outer border drawn upwards. The contracting muscles
are the two peronci. In a well-marked congenital

522 Surgical Applied Anatomy. [Chap. xxm.

case the os calcis is found a little raised and the astrag-
alus 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, and 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 mem-
ber 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 calcaneus upon the heel. In
cases of extreme and obstinate club-foot wedges of bone
are sometimes removed by the operation known as
Tarsectomy. Thus in talipes equino-varus the base of
the wedge will be on the outer side of the foot and will
be mainly represented by the cuboid ; the apex will be
at the scaphoid.

FSat-foot and 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 and plantar
muscles from long-continued pressure. When the
weight of the body is brought to bear on the foot placed

Chap, xxiii.] The Ankle and Foot.

523

flat upon the ground, it will be transmitted in an oblique
direction from above downwards and inwards (Fig. 72, b').
The foot, therefore tends to become abducted, a tendency
resisted by such powerful ligaments as the internal

Fi£

72 — Showing some of the Alterations which take place in the Arch
in Fiat-Foot.

I. The skeleton of the normal foot
.seen from above.

v b c, Line of the inner arch formed
by the <>s calcis, astragalus, sca-
phoid, internal cuneiform, and first
metatarsal bone; 4 u'c. the line of
the arch in flat-foot ; x, a point on
the astragalus indicating where
the centre of the weight of the
body is transferred to the arch ;
x', corresponding point in flat-
foot; the position of the inferior
calcaneo Bcaphoid ligament is in-
dicated (i. c.s. I.).

II. The shaded part represents the
impress of a normal foot. The
stippled area represents the
additional part uf the arch which
rests on the ground in flat-foot

The lines a b 0 and a b' c as in I.

lateral of the tinkle and those connecting the os calcis
with the astragalus. In flat-foot these ligaments yield,
and the toes consequently are turned out or abducted.
The ligament, however, that is mainly affected in this
deformity is the inferior caicaneo-scaphoid. This strong
baud of fibres supports the head of the astragalus and

524 Surgical Applied Anatomy. [Chap, xxiii.

holds up the keystone 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 turned out. The os calcis slants inwards,
and its anterior end is depressed. The sustentaculum
tali, the head of the astragalus, and the scaphoid tubercle
form prominences on the inner side of the foot, and
may rest on the ground (Fig. 72). The long and short
plantar ligaments also, which contribute so much to the
maintenance of the arch of the foot, in time yield, and
allow of a still greater degree of deformity. There is a
stretching also of the deltoid ligament. 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, shortened, and 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. The calf muscles waste,
owing to the arch of the foot having lost its rigidity
and being no longer able to support the weight of the
body.

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.

The tarsal bones, owing to their spongy
character, are readily broken by direct violence, as in
severe crushes. The soft parts that cover these bones
being scanty upon the dorsal aspect of the foot, it follows
that these accidents are often compound and associated
with much laceration 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

chap, xxiii.] The Ankle and Foot.

525

recorded of fracture of the calcaneum by muscular
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 2 \ 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
produced by falls upon the
sole or by extreme supina-
tion (rotation outwards) of
the foot, whereby the as-
tragalus is forced violently
against the process.

The astragalus alone
may be broken by a fall
upon the feet, and such
accidents are often associ-
ated with fractures of both
that bone and the os calcic
It must be noted, however,
that in a fall, when the
patient alights upon the
feet, the tibia and fibula
arc 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

Fig. 73.—Oblique Autero-Posterior
Section of the Foot (Rudiuger).

1, Tibia ; 2, fibula ; 3, astragalus ; 4, os

caii-is; r>, external lateral ligament :
6, internal lateral ligament ; 7, inter-
osseous I ii-'aim'iit i»'t ween astragalus
and os calcis ; 8, liead of astragalus ;
9. scaphoid; 10, 11, and 13, the three
cuneiform bones; 13, cuboid.

526 Surgical Applied Anatomy. [Chap, xxiii.

up when passing through the foot with its many
bones and joints.

The metatarsal bones and phalanges are nearly
always broken by direct violence. 1 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 alone. 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 luxated
alone is the internal. The attachments 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 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.

Ossification of the tarsus.— At birth the
tarsus is mainly cartilaginous. Ossification begins
in the os calcis in the sixth month and in the
astragalus in the seventh month of foetal life. The
centre for the cuboid appears at birth, and in the
scaphoid, the last to ossify, in the third year. It is

chap, xxiii.] The Ankle and Foot. 527

not until puberty that the cartilage of the tarsal bone
is completely ossified.

Dislocation of the proximal phalanx of the great toe
is often very difficult to reduce, as is also the case in
the corresponding luxation of 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). A partial dislocation of the
proximal phalanx outwards on the head of the meta-
tarsal bone of the great toe constitutes the condition
known as hallux valgus. The inner lateral ligament
of the joint is elongated, while the outer is contracted.
In hallux rigidus this joint is slightly flexed and rigid,
due probably to a reflex contraction of the flexor brevis
hallucis. The second toe is commonly longer than the
others and is more liable to assume the form known as
" hammer toe." The proximal phalanx in such a form
is extended, while the middle is strongly flexed. The
condition is commonly inherited and is due to a con-
traction of the glenoid and lateral ligaments of the
proximal phalangeal joint. The extensor tendon is
also contracted.

There are six synovial cavities in the foot,
excluding that of the ankle-joint, viz., one for the pos-
terior calcaneo-astragaloid joint, a second for the anterior
calcaneo-astragaloid and astragaloid-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

528

Surgical Applied A na to m y. [Chap, xxiii.

metatarsal bones, and a sixth for the remaining articu-
lations (Fig. 73). These synovial cavities tend greatly

to diffuse disease among
the various bones of
the foot when once one
bone has become in-
flamed. The best
position, therefore, for
bone disease, with re-
ference to the question
of extension, would be
in the hinder parts of
either the os calcis or
astragalus, and one of
the worst positions
would be assumed by
disease involving the
scaphoid bone.

Syme's ampu-
tation at the ankle.
— In the heel-flap are
cut the integuments,
the external saphenous
nerve and vein, the
peroneus longus, pe-
roneus brevis, tibialis
posticus, flexor longus
digitorum, flexor
longus pollicis, tendo
Achillis, points of
origin of the flexor
brevis digitorum and
of the two abductor
muscles, and the in-
ternal and external
plantar arteries and
nerves.
In the dorsal flap are cut the integuments, tibialis
anticus, extensor communis digitorum, extensor pro-
prius pollicis, peroneus tertius, anterior tibial vessels

Same's Amputation (Agatz).

a, Tibia; b, fibula: c, tibialis anticus: d,
extensor proprius pollicis; e, extensor
communis digitorum ; f, peroneus tertius ;
if, flexor longus pollicis ; h, tibialis posti-
cus : i, flexor loncrus digitorum ;j, peroneus
brevis: k, peroneus longus; I, tendo
Acliillis; in, some muscles of the sole that
are not usually left in this operation ; n,
anterior tibial vessels; o, posterior tibial
vessels ; p, posterior tibial nerve.

Chap, xxiii.] The Ankle and Foot.

529

and nerve, musculocutaneous nerve, and internal
saphenous nerve and vein. The position of the principal
structures divided is shown in Fig. 74. 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 poste-
rior peroneal artery,
and the internal
calcaneal from the
external plantar.

If the heel in-
cision is carried suf-
ficiently far back to
divide the trunk of
t he posterior tibial
artery, the heel flap
is deprived of the
last-named source of
blood supply. The
I x tsterior tibial artery
bifurcates upon a
line drawn from the
tip of the inner mal-
leolus to the centre
of the convexity of
the heel.

The nerves sup-
plying the integu-
ments of the heel
arc the calcaneal
branch of the ex-
ternal saphenous and the calcaneal and plantar cutaneous
twigs from the posterior tibial.

In Pirogoff's amputation the parts divided
in the anterior flap are the same as in Syme's operation,
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

Fig. 7">.~Cliopart's Operation (Agatz).

7, Astragalus; '>. r>s calcis; c, extensor propriue
pnllicis: <'. tibialis antious ; e, extensor com-
munis digitorum ; f. peroneus loneus ; ^.alulur-
tor minimi digiti : n, flexor brevis digitorum ;
f, flexor longusdigitoruin : /, abductor pollicis ;
k, flexor longus pollicis; l,dorsalis pedis artery :
m, internal plantar artery; n, external ?lautar
artery.

53°

Surgical Applied Anatomy. [Chap, xxiii.

flextfr brevis digitorum, abductor pollicis, abductor
minimi digiti, and flexor accessorius are divided more
extensively, and the plantar vessels are cut farther
from the bifurcation.

€ho part's operation is an amputation at the

medio-tarsal joint. In
the dorsal flap are cut
the integuments, the
extensor communis and
brevis digitorum, ex-
tensor proprius pollicis,
tibialis anticus, pero-
neus 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 dis-
sected up from the
bones, parts of the
short flexors of the
great and little toes,
the abductor pollicis,
and transversus 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. 75).

Nj Lisfranc's operation, or amputation through
the tarso-metatarsal line of joints. In the dorsal flap

Tig. 76.— Lisfranc's Operation (Agatz).

a, b, c, Inner, middle, and outer cuneiform
hones ; d. cuboid : e,f, the metatarsal bones ;
g, tibialis anticus; h, extensor proprius
pollicis; i, extensor c minimis digitorum ;
i, extensor brevis digitorum ; k, extensor
tendons; I, dorsalis pedis artery.

Chap, xxiii.] The Ankle and Foot. 531

the same structures are divided as are cut in the
corresponding flap in Chopart's amputation. In the
plantar flap also the parts divided are the same as in
that procedure, with the exception that the flexor
accessorius and the tendon of the tibialis posticus escape
section. In opening the line of joints it should be noted
that the articulations between the three outer meta-
tarsals 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.

a

Fig. 77. -Amputation of Great Toe, with its Metatarsal Bone (Agatz).

a, Internal cuneiform hone ; b, adductor pollicis : c, extensor longus pollicis;
■1. flexor longus poldcis ; e, plantar branch of dorsalie pedis artery.

The joint also between the first metatarsal and
internal cuneiform bones is in a straight hue and readily
opened. The most difficult part of the disarticulation
concerns the separation of the second 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 interosseous ligament
that passes between it and the internal cuneiform.
In Fig. 76 the knife is placed in the position required
to divide that ligament.

In the subastragaloid amputations a dis-
articulation is effected at the astragalo-scaphoid - and

\2!

2

\ 4

5 \

vll

/ 7

6\ i

": 8

10

nVte-

Fig. 78. --Cutaneous Nerve-Supply of Lower Limb.
A. iterior Aspect.— I, Ilio-inguinal ; 2, genito-crural ; 3, external cutaneous ; 4, middle
cutaneous ; 5, internal cutaneous; 6, patellar plexus ; 7, branches of external
,, popliteal ; 8, internal saphenous; 9, musculo- cutaneous; 10, external saphe-
"* nous ; 11, anterior tibial.

Posterior Aspect.-^, 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.

Chap, xxiii.] The Ankle and Foot. 533

astragalo-calcaneal joints. The astragalus is the only
bone of the foot left behind, and forms the summit of
the stump.

Fig. 77 shows the position of the more important
structures that are divided in amputation of the great
toe together with its metatarsal bone.

The nerve supply of the lower limb. — In
Fig. 78 is shown the cutaneous nerve-supply of the
inferior extremities on both the anterior and the posterior
aspect, and in Fig. 79 are seen the cord segments from
which they are derived. Paralyses of the lower 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 erural nerve
has been caused by injuries to the lower part of the
vertebral column implicating the cauda equina, by
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 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.

Para lysis 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 lie
brought about by the pressure exercised upon the nerve
in cases of obturator hernia and by the foetal head
dining delivery. The muscles implicated are the
adductors, gracilis, pectineus, and external obturator.
The patient is unable to press the knees together, or
to cross the legs. Rotation outwards is difficult, and
sensation is affected in the skin supplied.

Paralysis of the internal popliteal nerve.

Fig.179 -Showing the Skin Areas in the Lower Extremity supplied bv the
Lumbar and Sacral Segments of the Spinal Cord. &S?Head )

°n?h?n^^SKSS^^tSCOrd *™**tf***i For

chap, xxiii.] The Ankle and Foot. 535

— There is inability to extend the ankle and to flex the
toes (flexor longus digitorum, flexor propriua pollicis,
tibialis posticus, gastrocnemius, and soleusj. 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 movement
in the toes is lost owing to paralysis of all the small
muscles of the sole. Sensation is impaired over the
plantar aspect of the toes, the sole, 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 proprius
pollicis, peroneal muscles). Adduction is imperfect,
owing to paralysis of the tibialis anticus. Extension
of the toes is only possible to the slight extent effected
by the interossei. The arch of the foot becomes flattened
owing to loss of the support furnished by the peroneus
longus. Sensation 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 peronei.

When the great seiatie nerve is paralysed
there will be, in addition to the loss of function in the
two preceding nerves, an inability 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 interims.

A knowledge of the segments of the eord from
Avliieli the nerves of the lower limb arise often
assists the surgeon in localising certain lesions. Section
of a nerve root, as may happen in fracture of the spine,
or destruction of its centre in the spinal cord, gives rise
to paralysis in a definite group of muscles and anaesthesia
of a certain area of skin. The skin areas supplied by
the lumbar and sacral segments are shown in Fig. 79,
and these segments, according to Kocher, innervate

536 Surgical Applied A n atomy. [Chap. xxm.

the following groups of muscles : Third lumbar, the
psoas, iliacus, pectineus, sartorius and adductors ;
fourth lumbar, quadriceps extensor cruris ; fifth
lumbar, gluteus medius and minimus, tensor vaginae
femoris and hamstrings ; first sacral, gluteus maximus,
short external rotators of hip-joint, peronei, extensors
of toes and flexors of ankle ; second sacral gastro-
cnemius soleus, long flexors of toes and extensors of
the ankle-joint and muscles of the sole.

537

Part Vh

CHAPTER XXIV.

THE SriNE.

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 miti-
gating 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. Of the four curves, two, the dorsal and sacral,
are primary, are due to the formation of the thoracic
and pelvic cavities, and depend mainly upon the shape
of the bones. The other two, the cervical and lumbar,
are compensatory curves, and depend mainly upon
the shape of the intervertebral discs. The dorsal and
sacral curves appear in fcetal life ; the lumbar and
cervical curves appear after birth, and depend on the
assumption of the erect position. The infant's spine
appears straight. The only marked curve seen in the
back of the young child is a general curving of the
column backwards, a kyphosis. 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. The discs are twenty-three

538 Surgical Applied Anatomy. [Chap. xxiv.

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 con-
cavity 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 for-
ward 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.

Scoliosis.— In very few people do the spines of. the
vertebrae lie in a perfectly straight line down the back.
There is commonly a slight degree of lateral curvature.
If the pelvis be tilted laterally, as when the limbs are
unequal in length, a compensatory lateral curve is pro-
duced. In scoliosis, lateral curvature is combined with
a rotation of the vertebrae, the spinous processes turning
to one side of the median line and the bodies to the

chap, xxiv.j The Spine. 539

opposite. It is a disease of adolescents, due to a weakness
of the spinal muscles, which are unable to maintain
the vertebrae in the position necessary for the erect
posture. Each vertebra is provided with three levers,
a posterior (the spinous process) and two lateral (the
transverse processes and attached rib). The erector
spinas acts on the lateral levers ; the multifidus spinas
and muscles for the upper extremity on the posterior.
It is through training these muscles by suitable
exercises that the vertebras can be restored to, and
maintained in, their normal positions.

Sprains of the vertebral column. — The many
joints and ligaments of the part, and the varied and
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 vertebra? articulated, that
any force severe enough to produce other than slight
tearing of the ligaments will tend to cause a fracture
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 ten-
dency 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 expansions
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 hematuria (page 362).

.~54° Surgical Applied Anatomy. [Chap. xxiv.

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 ;
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 articulating 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 compressing power.

The parts of the spine most liable to injury are (l)
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

chap, xx rv.] The Spine. 541

to be concentrated rather than diffused. The sternum
and .ribs act as a splint to the dorsal part of the column.
The mechanism is in a way illustrated by the circum-
stance that a fishing-rod when it snaps commonly breaks
near a joint, that is to say, at a spot where a flexible
segment of the rod meets a less elastic portion. In the
dorso-lumbar region, moreover, the vertebras, 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 dislocations 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 vertebra?, and their
relation to one another, are of a character to afford much
protection to the cord, even in cases where they them-
selves are extensively 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 wThen 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 condition. When the spine is examined, it will
be found that its anterior part, composed of the large

542 Surgical Applied Anatomy. [Chap. xxiv.

cancellous bodies, is excellently adapted to resist the
effects of compression, while its posterior parts, com-
posed 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 the 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 vertebras 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 vertebras, 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 forwards
and downwards. Luxations in other directions have
been noted, but they are extremely uncommon. The
possibility of luxation in the cervical region without
dislocation is explained by the small size of the vertebral
bodies, the obliquity of their articular processes, 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 forwards and down-
wards. 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 extension, although the
circumstances under which such a procedure is advisable
are neither frequent nor very distinctly marked.

Chap, xxiv.] The Sp/ae. 543

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 vertebrae
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 the sliding of the
centrum above downwards and forwards upon the
centrum below. Complete displacement of any two
vertebra? 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 lamina?
and spines may be fractured, while the articulating
processes, being broad and nearly horizontal, usually
escape, even when there is much displacement of the
parts. In the dorsal spine the lamina? 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-

544 Surgical Applied Anatomy. [Chap. xxiv.

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 vertebrae 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 result
of well-localised blows. The prominent spines in 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 com-
paratively 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

Chap, xx i\. The Spine. 545

portions of the Laminae and spinous processes have
been resected {laminectomy). By this means the
spinal canal has been freely opened up, effused blood
has been allowed to escape, and the cord has been freed
from pressure. The laminae are divided as near the
transverse process as possible, and the tough ligamenta
subflava require careful division. Dr. White, of Phila-
delphia, has collected (1889) thirteen recent examples
of operation for fracture with only one death.

The column is reached through a median incision,
and the great muscular masses are cleared from the
spinous processes and lamina? on either side. The
wound being nearly median, the bleeding is not excessive.
The dorsal spinal plexus of veins lies, along the spines
and over the lamina?. On the deep surface of these
veins lie the posterior longitudinal spinal veins.'

This operation has also been carried out with success
in cases of paralysis due to the pressure upon the cord
by displaced bone or inflammatory exudations in caries
of the spine (Pott's disease). It has to be noted, how-
ever, in the last-named class of case, that the condition
exhibits a tendency to spontaneous cure.

The spinal cord is in the adult about IS 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 little raised. When the body is bent
and the arms stretched out the lumbar part is raised
LO mm. In the earlier 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 cord
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

;46

Surgical Applied Anatomy, rchap. xxiv.

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.

A..Div.

t.Art.

Fig. SO.— Section through Spinal Cord, Membranes, and Spinal Canal.

a.r., at origin of anterior root; p.b., at origin of posterior root; s.p., septum
posticum ; p.m., pia mater ; l.d., ligamentum denticulatuin ; the arachnoid
(arach.), dura mater (dura m.i, and sub-arachnoid space are shown.

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 vertebrae, 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-

Chap, xxiv.] The Spine. 547

tebral canal a considerable space exists occupied by
loose areolar tissue and a plexus of veins (Fig. 80). It
is tough, and may remain undamaged when the cord
is completely severed by a crushing force. 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 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 medulla spinalis.

Over the arches at the posterior aspect of the ver-
tebra? is situate a plexus of vessels (the dorsal spinal
veins) that receives blood from the muscles and integu-
ments 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. The
arachnoid is closely applied to the dura mater, the
subdural being merely a potential space, while the
subarachnoid is extensive and occupied by cerebro-
spinal fluid, which surrounds the cord and is continuous
with the great subarachnoid spaces at the base of the
brain (Fig. SO). By means of this open communication
inflammatory affections may readily spread from the

548 Surgical Applied Anatomy. [Chap. xxiv.

cord to the brain. Into these spaces blood may be
extravasated 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 fluid normally contains "05 per cent, of albumen,
but if the membranes are inflamed the percentage is
double that amount. In certain conditions the pressure
of the fluid may rise to such an extent as to cause death.
In normal conditions the fluid is absorbed at any pressure
above that of the surrounding veins (Hill). In the
recumbent posture the pressure should support a column
of water 2 inches high. In disease it may rise to ten
times that amount. The pressure may be relieved
by a lumbar puncture, made by thrusting a needle
8-10 cm. long into the subarachnoid space in the
lumbar region of the spine. A point is selected between
the third and fourth lumbar spines, \ an inch from
the middle line. The needle perforates the ligamentum
subflavum between the laminse. Convulsions follow if
the pressure be reduced much below the normal. At
this level the cord cannot be injured, but the needle
may pierce one of the lower nerve roots, giving rise
to twitching in some of the muscles of the lower
extremity.

The position of the cord is such that it is not readily
reached in incised and punctured ivounds. 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 the
medulla spinalis may be 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 vertebra?, 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.

The pia mater forms a strengthening sheath for the

Chap, xxiv.] The Spine. 549

co?d. On it the arteries ramify before entering to
supply its substance. The vertebral, intercostal lumbar,
ilio -lumbar, and lateral sacral arteries send twigs along
the nerve roots to the cord.

< aissiou of the cord. — After certain injuries

to the back a train of symptoms, usually of a severe
and complicated character, has been described, which
has 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, although
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 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
82), and it would appear that the most violent move-
ments possible of the brain within the skull could be

55° Surgical Applied Anatomy. [Char. xxiv.

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 diincult to understand, therefore, how a structure
so protected can be so violently disturbed by a shock
received upon the body as to undergo a grave and pro-
gressive loss of function. The cord is, indeed, somewhat
in the position of a caterpillar suspended by a thread
in a phial of water. It would probably be difficult
to permanently disturb the internal economy of such
an insect (even if it had a structure as elaborate as the
cord) by other than violence that would be comparatively
excessive.

Contusion and crushing: of the cord. — As
has already been 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 vertebras
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 perceptibly
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 corre-
sponding pia mater being in any way lacerated. 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 displace-
ment 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,

Chap, xxiv.] The Spine. 55 r

and arc associated with much displacement, hi 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 displace-
ment 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 cord as extends into
the lumbar region is protected by the many cords of
the cauda equina, which, by their looseness and com-
parative 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 examinations
] x irtions 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 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 \ 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 upon the situation and extent of the lesion.
The diagnosis of the situation and the lesion is compli-
cated by the relation the nerves bear to the various

552 Surgical Applied Anatomy. [Chap. xxiv.

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 intervertebral 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 verte-
brae, and so on.

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 vertebrae respectively.
The first four dorsal nerves arise from the cord opposite the discs

helow the seventh cervical and the first, second, and third

dorsal vertebra? respectivel}-.
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 coccj-geal

nerves, arise from the cord opposite the first lumbar vertebra.

It will be seen, therefore, that in taking note of

chap, xxiv.] The Spine. 553

the symptoms due to crushing the entire nerve con-
tents of the vertebral canal at a certain spot, considera-
tion 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 arc 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 forward, 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 vertebras below the seat of lesion.

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 intercostals. A
fracture associated with injury to the cord, when above
the fourth cervical vertebra, is, as a rule, instantan-
eously fatal. The phrenic nerve comes off mainly
from the fourth cervical nerve, receiving contributions
also from the third and fifth. The fourth nerve issues

554 Surgical Applied Anatomy. [Chap. xxiv.

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 contribu-
tion to the phrenic, respiration 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 enlargement.
The irritation of the vesical walls, produced by the
increasing distension of the bladder, provides the needful
sensory impulse. This impulse is reflected to the nerves
controlling the bladder muscles, and especially to the
detrusor urinse, and by their contraction the organ is
emptied (page 396). The action, however, 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, inhibition can have no effect. Imme-
diately 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 sacral.

The act of defaecatioh 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.

chap, x x i v. ] The Spine. 555

When the centre itself is damaged, or the connection
severed that unites it with the viscus, the patient will
suffer from incontinence of fa?ces 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 defaecation will be performed at regular intervals,
without either the 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 disturbance
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. Some details concerning
the position of centres in the spinal cord, connected with
areas of skin, groups of muscles and viscera, have been
given already when dealing with the nerve supplies
of the extremities and abdomen (see pages 533 and 368).

Operations upon the cord. — Mr. Victor
Horsley and others have cut down upon the spine and
removed a tumour from the spinal cord with perfect
success, and with relief to the symptoms from which
the patient was suffering. The spinal canal has also
been exposed in certain cases where callus in an old
fracture of the spine was pressing upon the cord, or where
a small osseous growth was encroaching on the canal.

INDEX.

Abdomen, blood vessels of, 284, 292,

370
,, blows on the, 387

,, congenital deformities

of the, 29S
,, fascia of, 286, 311

,, lymphatics of the, 292
,, nerves of, 293, 368
,, parietes of, 282, 2S5, 2S6,

291, 311
,, skin of the, 285
,, surface anatomy of the,

282
,, wounds of the, 292

" Abdominal belt," 286

,, ,, connective tis-

sue and abs-
cesses, 291
Abdominal viscera, nerve supply
Abscess, alveolar, 1 It J [of, 368

,, axillary, 204
,, cervical, 143, 144
,, gluteal, 426
,, hepatic, 352
„ iliac, 312
,, in antrum, 95
,, mastoid cells, 76

,, testis, 409

,, the abdominal parietes,

292, 315
,, the scalp, 6

,, the temporal fossa, S

,, intercostal, 174
,, ischio-rectal, 384
,, lumbar, 312, 315
,, mammary, 177
,, mediastinal, 144, 184
,, orbital, 44
,, palmar, 263
,, parotid, 103

pelvic, 381, 43S
,, perinephric, 362
,, perityphlitis 338
,, plantar, 505
,, popliteal, 470
,, post- pharyngeal, 131
,, prostatic, 398

Abscess, psoas, 313, 43 1
,, renal, 363
,, retro-peritoneal, 313
,, thecal, 265
Acetabulum, 438

,, fractures of, 375

Aeromio-clavicular joint, 197

,, ,, disloca-

tions of, 199
Acromio-thoracic artery, 190
Acromion process, fracture of, 200
Addison's disease, 369
Adductor longus muscle, 431, 435
Air in veins, 163, 207
" Alderman's nerve," 73
Alexis St. Martin's case, 330
Alveolar abscess, 116
Amputation (see Ann, Leg, etc..

amputation of, etc.)
Anal triangle, 383
Anastomotica magna, 468
Aneurism, aortic, 160, 370
,, axillary, 207

,, in the neck, 160, 162

,, of the posterior tibial

artery, 493
,, popliteal, 472

Ankle, 500, 510

,, fascia; of, 504
,, joint, 500, 510
,, ,, amputation at, 528
,, ,, disease of, 511
,, ,, dislocations at, 512

,, ,, fractures about, 512
,, surface anatomy of, 500
,, tendons of, 504, 507
Annular ligaments of ankle, 506
fingers, 263
,, ,, wrist, 263, 266

Anterior crural nerve, 436, 445, 533
Antrum of Higlnnore, 93

,, mastoid, 76

Anus, 385, 419

,, imperforate, 344
Aorta, abdominal, 284, 870

,, thoracic. 160, 182
Aortic orifice, 182

558

Surgical Applied Anatomy.

Aponeuroses (see Fascia?)
Appendicitis, 336 1
Appendix vermiformis, 336, 33S
Aqueous humour, 59
Arachnoid, 30, 547
Arcus senilis, 49 '
Arm, 223
,, amputation of, 220
,, fascia of, 224
,, nerves of, 275
,, skin of, 224
„ surface anatomy of, 223
Arnold's nerve, 72
Arteries (see Axillary, etc., and

Blood-vessels)
Arteriotomy, 12
Arterio-venous aneurisms, 45, 234.

435
Astragalus, dislocations of, 51S

,, fractures of, 525

Atlas, 131

Atlo-axial portion of spine, 540
Auditory meatus, external, 69

,, ,, its relations, 71

Auricle (see Ear)
Auricles, supernumerary, 68
Auriculo-ventricular orifices. 1S2
Axilla, 1S8, 202

,, suspensory ligament of, 204
Axillary abscess, 204

., artery, 187, 1SS, 207
,, fascia?, 203
,, glands, 177. 205
„ nerves, 20S
., vein, 206
Axis, 131
Azygos veins, 184

Barbadoes leg, 437

Base of skull, fractures of. 25

Basilic vein, 233

Bend of elbow, 230

Bent arm after venesection, 235

Biceps tendon in arm, 212

,, ,, ham, 471

Bile duct, rupture of the, 355
,, ,, relationships of, 254
Bladder, 391, 420

,, distension of, 391

„ double, 397

„ extroversion of, 293

,, fasciculated, 396

,, female, 397

,, foreign bodies in, 397

,, found in hernia?, 393

,, male, 391

., mucous membrane of the.
395
nerves of, 396

Bladder, of child, 398

., puncture of, above pubes,

393
,, ,, per rectum, 394

., relations to the peritoneum,

393
,, rupture of the, 394
,, sacculated, 396
,, stabbed through buttock,

430
,, stone in the, 387
Blood-vessels of abdomen, 284, 292,
370
., abdominal walls.

292
., auditor}' meatus.

,, brain, 38

,, breast, 17S

,, buttock, 425, 428

foot, 502, 50S
globe, 52
., hand, 25S, 266

,, heel, 529

,, knee, 471

leg, 492
,, naves, 90

,, neck, 137, 100

,, orbit, 45

., palate, 127

pelvis, 3S2
,, perineum, 336

., pinna, 72

., rectum, 417

,, retina, 54

,, scalp, 12

,, Scarpa's triangle.

432, 435
,, spermatic cord, 410

,, tympanum, 80

Brachial artery, 223, 231, 235

,, ., abnormalities of,

226
,, ,, in phlebotomy,

234
,, ,, ligature of, 226

,, fascia, 224
,, plexus, 139, 14S, 178, 278
Brachialis anticus, 225
Brain, 32, 38

,, and skull relations, 32
,, basal ganglia of, 37
,, blood-vessels of the, 3S
,, concussion of the, 38
,, convolutions of, 35
,, cortex of, 37
,, fissures of, 35
,, injuries t >, 32
,, membranes of, 2S

Index.

559

Brain, motor centres of, '■',
sulci i
., surface relationships of, 32

„ wounds of, 4u
Branchial fistula?, 68, 166

Brasdor's operation, 101
Breast (see Mamma), 170

,, abscess of, 177
Bregma, 15
Bronchi, 162, 154

,, foreign bodies in, 154
Bronchial lymphatic glands, 184
Bronchocele, 255
Brunner's glands in burns, 333
Bryant's method of dividing the
muscles of the palate,
129
,, triangle, 424
Buccal cavity, 118

,, ,, in embryo. 1-27

,, nerve, 101
Bunions, ">07

Bursa: about the elbow, 236
,, ,, four. 506

., ,, hum. 473

shoulder, 209, 211
over the great trochanter.
4ii7
,, „ ischial tuber-

osity. 427
,, ,, knee-joint, 469,

47a
,, patellar, 469
., subacromial, l'1 1
Buttocks, 423

., arteries and nerves sf
the, 425, 428
fascia of, 426
„ fold of, 424

,, surface anatomy of, 423

Caecum, 336, 348

,, foreign bodies in. 337

,, hernia of, 337

,, in intestinal obstruction,
339

,, opening of,

,, position of, 33(5
Caesarian section, 375
Calcaneo-astragaloid joint, 518

,, -cuboid articulation, 520

„ -scaphoid ligament, 524
Canal of Xuck, hernia in, 300
Cancrum oris. 96
Capsule of Tenon, 42
Cardiac orifice of stomach, 321
Carotid artery, 70, 132. 133, 137,
144, 101, 1S3
,, ,, aneurism of, 101

Carotid artery, destroyed by abs-
cess, 144
,, ,, ligature of, I'd

,, ,, wounds of, 140

,, tubercle, 130, 102
Castration, 411
Cataract, 58
Catheterism of Eustachian tube, 80

,, of urethra, 401

Centre of gravity of an adult body,

372
Cephallueinatomata, 7
Cephalic vein, 1S7, 230, 233
Cerebral circulation, 38

,, localisation, 37
Cerebrospinal fluid, 27, 547.
Cervical (see Xeck)

., sympathetic, paralysis of,
47
Cervico-dorsal part of spine, 540
Charbon, 97
Cheek, 96

Cholecystectomy, 355
Cholecystenterostomy . :; •". 5
Cholecystotomy, 355
Choparfs operation, 530
Chorda tympani, SI
Choroid, 50
Ciliary zone, 56
Circumcision, 405
Circumcorneal zone, 56
Circumflex artery, external, rap-
ture of, -At*. l
,, ., internal, wound

of, 401
,) :, posterior, 189,

200
,, nerve, ISO, 200

Cirsoid aneurism, 1::
Clavicle, 185, ISO, 190

,, dislocations of, 107, 199
,, excision of, 101
,, fractures of, 101
„ movements of, 19S
„ ossification of, 194
,, relations of, 100, 194

Clelt palate, 120
Clergyman's sore-throat, 150
Club-foot, 520
Coccygeus, 37S, 379
Coccygodynia, 370
Cochin leg, 437
Coeliac axis, 2S4, 370
Colectomy, 348
Colles' fascia, 385

,, fracture, 200, 270
Coloboma iridis, 52
Colon, 340

,, ascending, 341

$6o

Surgical Applied An atom V.

Colon, descending, 341

,, malformation of, 343, 345
,, operations on, 345
,, stricture of, 340
transverse, 340, 341
Colotomy, iliac, 347

,, lumbar, 345

Compression of brain, 29

,, cord, 550, 553

Concussion of brain, 38
,, cord, 549

Congenital club-foot, 520
,, exomphalos, 29S

,, fistula?, 68, 166

., hernia, 302, 304, 305

,, hydrocele, 303

„ malformations of anus

and rectum, 420
., malformations of blad-

der, 29S
,, malformations of colon,

343, 345
., malformations of penis,

406
,, tumour of sterno-mas-

toid, 140
Conjunctiva, 64
Contre-coup, fracture by, 25
Convolutions of brain, motor cen-
tres on, 37
,, of brain, relations of,

32
,, of brain, relations of,

to skull, 32
Coraco-acromial arch, 210
Coracoid process, 187

,, fracture of, 201

Cord, spinal, 545

,, concussion of, 549

,, contusion of, 550

,, injuries to the, symp-

toms of, 551
Cornea, 48
Coronal suture, 15
Coronoid process, 244
Corpus striatum, 37
Coryza, 85
Coup de fouet, 492
Cowper's duct, 412
Craniectomy, 28
Cranio-tabes, 16
Cranium, bony vault of, 15
Cremaster muscle, 410
Cremasteric artery, 410
Cretinism, 157
Cribriform plate, 84
Cricoid cartilage, 148, 149
Crico-thyroid space, 136, 154
Crutch paralysis, 227

Cuboid bone, 500
Cuneiform bone, inner, 500

,, ,, dislocation

of the, 526
,, ,, fracture of

the, 526
Curves of the vertebral column,

537
Cut throat, 146
Cyphosis, 538

Dartos, 386, 407
Deltoid muscle, 20S
,, region, 1S7, 20S
,, tubercle, 1S5
Descending palatine artery, 127
Diploic veins, 13
Dislocation (see the several bones

and joints)
Dorsal vein of penis, 386
Dorsalis pedis artery, 50S

,, scapula? artery, 1S9
Dorso-lumbar part of spine, 540
Drop-wrist, 278
Duodenal fossa, 332
Duodenum, 332

,, suspensory muscle of,

332
Dupuytren's contraction, 261

,, fracture, 515

Dura mater, 2S, 546

,, fungus of, 30

Dysphonia clericorum, 150

Ear, 6S

,, bleeding from, in fractures of
base of skull, 26

,, blood supply of, 72

,, coughing, 73

,, external, 68

, , frost bite of, 72

,, gangrene of, 72

,, haematomata of, 72

,, nerves of, 72

,, polypi of, 71

,, sneezing, 73

,, tophi in, 69

,, watery discharge from, 27

,, yawning, 73
Elbow, 230, 232

,, burs* about, 236

,, dislocations of the, 238

„ fold of the, 230

,, fractures about, 241

,, gland of, 235

„ joint, 236

,, „ disease of, 237

,, ,, sprains of, 237, 241

,, resection of the, 245| (JYy

Index.

56i

Elbow, surface anatomy of the, 230

,, veins about, 233
Elephantiasis arabnm, 437
Emissary veins of skull, 13
Emphysema, 179
Bncephalocele, IT
Encysted hydrocele of the cord,

304
Enterectomy, 335
Enteroraphy, 335
Enterotomy, 335
Epididymis, 409

Epiphysis, lower, of femur in ex-
cision of knee,
48S
,, ,, in knock-knee,

481
„ of acromion, separation

of, 200
,, of clavicle, separation

of, 194
,, of coracoid process, 201

,, of femur, separation of,

444, 449, 485

,, of humerus, separation

of, 220, 243

of olecranon, 244

,, of pelvis, separation of,

374
,, of radius, separation of,

244, 272
,, of tibia, separation of,

48S, 498
,, of third phalanx in
whitlow, 266
of upper limb, 2S1
Epipteric bone, 19
Epispadias, 406
Epistaxis, 90

Estlander's operation, 174
Eustachian catheter, to pass, 80

,, tube, 78
Excision (.see special parts)
External auditory meatus, OS

,, auditory meatus, blood

supply of, 72
,, auditory meatus, nerve

supply of, 72
„ carotid, bleeding from,
163
Extravasation of urine, 2S6, 380
Eye-ball, 48

,, blood supply of the, 52
,, dangerous area of, 50
,, nerves of tin . 5 1
Eyelids, 62

Face, 95
,, development of, 99

-K

Face, injuries to, 97
,, nerves of, 99
,, vessels of, 97
Facial artery, 27

,, nerve, 98, 106
Fascia, abdominal, 311, 386
,, axillary, 203
bicipital, 234
,, cervical, 141
,, clavi-pectoral, 204
,, iliac, 311
,, lata, 426, 433, 459
,, lumborum, 315
,, obturator, 379
,, of arm, 224
,, of buttock, 420
,, ofColles, 3S5
,, of deltoid region, 208
,, of foot, 504
,, of leg, 491
,, of palm, 20, 261
,, of scalp, 1, 6
,, of Scarpa's triangle, 433
„ of thigh, 426, 433, 459
,, orbital, 42
,, palmar, 261
parotid, 103
pectoral, 203
pelvic, 379
., perineal, 3S5
,, popliteal, 470
,, prevertebral, 143
,, recto- vesical, 3S0
temporal, 7
transversalis, 311
Fasciculated bladder, 396
Femoral hernia, 306

., vessels, 432, 435, 4(il
Femur, dislocations of, 44'.'

,, fractures of, 440, 401
Fenestra ovalis, 76

,, rotunda, 76
Ferguson's method of dividing the

muscles of the palate, 128
Fibula, 497

,, fractures of, 495, 497, 512
Filth nerve, 101

,, section of, 101
Finger "snap,'' 264

,, little, congenital contraction

of, 264
,, "mallet," 270
Fissure, of Rolando, 35
Sylvius, 35
Fissures of brain, relations of, 35

parietal, 19
Fistula ai the navel, 289

,, between the gall bladdei
and gut, 342

562

Surgical Applied Anatomy.

Fistula, congenital, 6S, 166
,, gastric, 324
,, in ano, 385
,, lachrymal, 67
,, salivary, 10S
., vesico- vaginal, 413
Flat-foot, 522
Fold, gluteal, 424
Fontanelle,. sagittal, 19

,, temporary occipital, 18

Fontanelles, 15
Foot, abscess of, 505
,, amputations of, 528
,, arches of, 517
,, blood-vessels of, 502, 508
,, chief .joints of, 517
,, dislocations of, 518, 527
,, fasciae of, 504
,, fractures of, 525
,, integuments of, 502
„ lymphatics of, 510
,, nerves of, 504
,, surface anatomy of, 500
,, synovial membranes of, 527
,, the, 500, 504, 517
Foramen caecum of tongue, 124
,, of Majendie, 32
,, Monro, 33

Fore-arm, 246

,, amputation of the, 252
,, bones of the, 248
,, fractures of the, 250
,, luxations of the, 238
,, surface anatomy of the.

246
,, vessels of the, 247
Fossa duodeno-jejunalis, 333
,, ischio-rectal, 3S2, 384
,, nasal, 84
,, of Rosenmuller, SO
,, subclavicular, 187
Fracture (see the several bones)
,, dislocation of the ver-
tebral column, 540
,, helicoide, 462, 496
Frsenum linguae, 120
Frontal sinus, 92

,, ,, infundibulum of, 93
Fungus of the dura mater, 30
,, testicle, 409

Gall bladder, 354

,, fundus of, 350

nerve supply of, 855
operations on, 355
rupture of the, 355
obstructed by mov-
able kidney, 364

Gall stones, 342, 354
Gangrene of nose, 82
,, pinna, 72

,, the leg and embolism.

493
Gasserian ganglion affected by abs-
cess spreading
from parotid,
105
,, ,, removal of, 102

Gastrectomy, 327
Gastrocnemius muscle, 490

,, ,, rupture of

the, 492
Gastroenterostomy, 328
Gastrostomy, 326
Gastrotomy, 326
Generative organs, female, 412

,, ,, male, 405

Genito-crural nerve, 410, 436
Genu- valgum, 480
Gladiolus, 171
Glaus penis, 405 (J
Glaucoma, 50, 60
Glottis, 149
Gluteal abscess, 426
,, aneurisms, 428
,, artery, 425, 42S
,, bursa?, 427
,, fascia, 426
„ fold, 424
,, region, 423
Gluteus maximus, 427

,, ,, rupture of, 427

Goitre, 155

Great occipital nerve/162
Groin, region of, 430
Gullet (see CKsophagus)
Gums, 120

Gustatory nerve, Moore's method
of dividing the, 119

Hyematomata of scalp, 7

,, on septum nasi, 90 A

,, the pinna, 72

Haemoptysis, 180

Haemorrhage from choroid, 50

,, ,, frsenum lingua?,

121
,, ,, intercostal ves-

sels, 174
,, s, tongue, 121

,, ,, tonsil, 134

,, in lithotomy, 3S2, 388

,, into vitreous, 54

,, in tracheotomy, 153

,, meningeal, 29

Index.

5^3

Haemorrhoids] vessels and nerves,

417

Hemothorax, 180
Hallux rigidus, 527

,, valgus. 527
Hamstring muscles, 460, 470

Hand, 250, 258

,, amputation of, 274
~ blood-vessels and lympha-
tics of, 258, 266

dislocations of, 27-2. 273
fasciae of, 260, 201
,, surface anatomy of. 2
,, synovial sheaths of, 264
Hanging, mode of death from, 550
Hard palate. 127
Hare-liy, 126
Heart, 182

,, its relation to the surface.

182
,, valves of, 182
,, wounds of, 183
Heel, blood-vessels of, 529
integuments of, 529
Helicoidal fractures of Leriche,

462, 40S
Hernia, congenital, 299, 304, 305
,, diaphragmatic, 310
,, direct, 300
,, encysted, 304
,, femoral, 306
,, infantile, 304
,, inguinal, 299, 305
,, into the funicular process.

305
,, ischio-rectal, 310
lumbar, 310
mesenteric, 333
obturator,
omental, 318
perineal, 210
pudendal, 310
,, rare forms of, 310

retro-peritoneal, 334
,, sciatic, 310

umbilical, 2SS, 310
,, vaginal, 413
Herniotomy, 306, 309
Hip, dislocations of, 449
,, joint, 43S

,, ,, amputation at the. 456
,, ,, congenital dislocations

of, 450
„ ,, disease, 439, 444

,, fractures about, 446
,, movements of, 439
,. region of the, 423
Hippocratic hand, 260
Holden's line, I'd

Hottentot Venus, 425

Human tails, 37S

Humerus, dislocations of, 214

iractures of, 219, 227, 241
,, non - union

after, 22S
Hydatid cyst in the liver, 354
Hvdrencephalocele. 17
Hydrocele, 303, 408

,, of the neck, 167
Hydrocephalus, 16, 32
Hyoid bone, 136, 148

,, ,, accessor^' glands about.

156
,, ,, fracture of, 14 S
Hypertrophy of the prostate, 399
Hypoglossal nerve, 162
Hypopyon, 60
Hypospadias, 406
Hypothenar eminence, 255
Hysterical hip, 445
,, knee, 445'

Ichthyosis linguae, 121
Ileo-cajcal intussusception, 339
,, region, 336
,, valve, 339
Ileo-colic intussusception, 339
Ileum (see Intestine, small)
Iliac abscess, 312
,, colotomy, 347
,, fascia, 311
Ilio-psoas muscle, 312, 434
Ilio-tibial band, 426, 459, 466
Indirect hernia, 300
Inequality of limbs in length, 464
Infantile hernia, 304
Inferior dental nerve, dividing the,
101
,, maxilla, deformities of, 115
,, ,, dislocations of. 112

,, excision of, 113
. , fracture of. Ill
,, subluxation of the.
113
thyroid veins, 136, 146
Infraorbital foramen, 100
,, artery, 100
,, nerve, 100

Inguinal caiial, 299, 305
,, colotomy. 347
„ hernia, 2*99, 305
Innominate artery, 154, 161, 162, 1S2

,, bone, 372

Intercostal artery, 174
,, spaces, 173

Intercosto-humeral nerve, 177
Internal mammary artery. 175
Interparietal bone, 19

564

Surgical Applied Anatomy.

Inter-scapulo-thoracic amputation,
202

Intersigmoid fossa, 343

Intervertebral discs, 537

Intestine, foreign bodies in, 338
large, 340
,, ,, operations on, 345,

,, ,, stricture of, 340

,, resection of, 34S
,, small, 328
., ., diverticula of, 331

,, „ injury of, 329, 330

„ ,, length of, 328

„ ,, operations on, 33-3

,, ,, position of, 329

Intestinal anastomoses, 348

Intussusception, 339

Inversion of the testicle, 409

Iridectomy, 52

Iris, 50

Iritis, 51

Ischio-rectal abscess, 384
„ fossa, 3S2, 384

,, hernia, 310

Isthmus of the thyroid, 153

,, ,, division of.

153, 150 '

Jacob's ulcer of the eyelid, 63
Jaws (see Inferior and Superior

maxilla)
Jejunum (see Intestine, small)
Joints, surgical classification of

the, 210
Jugular vein, 76, 132, 134, 138, 140

Keloid, its frequent seat. 170
Kidney, 360

,, abnormalities of, 364
,, abscess of, 362
., hilum of, 300
,, horse-shoe, 3»>4
,, its relations, 300
,, movable, 303
,, nerve supply of, 364
,, operations on, 366
,, pelvis of, 308
,, rupture of, 302
,, vessels, point of origin of,
285
Knee, blood supply of the, 471
, burste about, 409, 473
,, dislocations of the, 485
,, fractures about, 485
,, integuments of, 469
,, joint, 474
,, ,, amputation through,

489
,, ,, disease of, 477

Knee joint, excision of the, 487

,, region of, 465

,, surface anatomy of the, 405
Knock-knee, 480
Kraske's operation, 418

Labia majora, 412
Labyrinth of ear, 81

Lachrymal abscess, 00
,, apparatus, 65
,, gland, 05
,, sac, 00
Lacuna magna, urethral, 404
Lambda, 15
Lambdoid suture, 15
Lamina cribrosa, 50, 02
,, fusca, 50
,, suprachoroidea, 50
Laminectomy, 455
Laryngeal glands, 105
Laryngotomy, 151, 154
Larynx, 136, 148

,, excision of, 150
,, foreign bodies in, 154
,, fracture of, 149
,, lymphatics of, 151
,, mucous membrane of, 149
Lateral lithotomy, 387
Leg, 489
,, amputation of, 499
., fasciae of, 491
,, fractures of, 495
., rickets affecting bones of, 499
,, skin of, 491
,, surface anatomy of, 489
,, vessels of, 492
Lens, 57

., artery to the, 00
Levator ani, 379, 384

,, ,, relation to fistula in

ano, 385
,, palati. 128
,, palpebral, 03
Ligamentum patellae, 405, 470, 4S3
,, pectinatuin iridis. 59

Ligament, pterygo-maxillary, 119
Lighterman s bottom, 427
Linea alba, 283, 287

,, semilunaris, 283
Lingual artery, 121
,, tonsil. 123
Lipomata in deltoid region. 209
,, in neck, 139
,, in Scarpa's triangle, 133
,, on the buttock, 125
,, rare on face, 90
Lips, 117

Index.

-:'y.

Lisfranc's amputation, 530
Litholapaxy, 3S7
Lithotomy, lateral, 3S7

., ,, in children. 389

„ ,, parts divided

in, 38S
,, median, 3S9

,, ,, versus lateral,

3S9
,, suprapubic, 390

Little's operation, 343J .
Liver, 34$

,, abscesses of, 352
,, fixation of, 350
,, operations on, 352
,, in pyaemia, 352
,, protrusion of, 352
,, ptosis of, 350
,, relations of, 34S
., Riedel's lobe, 350
,, ruptures of, 351
,, wounds of, 351
Lockjaw, 115

Lordosis in hip disease. 441
Lower limb, length of, 4<:>4

,, lymphatics of, 43i>

,, nerve supply of, 533

Luksemic enlargement of the

spleen, 353
Lumbar colectomy, 348
,, colotomy, 345
,, fascia, 315
,, glands, 370
,, hernia, 310
,, puncture, 548
,, region, 314
,, spine, 538

,, ,, injuries to, 539, 546,

548, 553, 554
Lung 17S
,, and secondary deposits, ISO
,, cavities, drainage of, 181
,, hernia of, 14S, ISO
,, in neck, 148, 178
,, relations of to surface, 17S
,, rupture of, ISO
,, wounds of, 179, 180
Luschka's tonsil, SO, 131
Lymphangioma cavernosum, 124
Lymphatic glands and vessels (-••
each region)

Klacro-glossia, 193

Malar bone, 103

,, ,, fracture of. 1"3
Malleoli, .300

,, fractures of. in disloca-
tions of the foot, 513

Mamma, 175

,, arteries of, 17^
,, cancer of, 170
,, capsule of, 176
,, development of, 170
,, in groin, 433
,, lymphatics of. 176
,, nerves of, 177
Mammary abscess, 177
Manubrium, 171
Mastication, muscles of, 1 15
Mastoid antrum. 76
,, cells, 78

,, ,, perforation of, 7S

Maxillae (see Inferior and Superior)
Meatus, the auditory, 6S
Meatusesjof nose, S7
Meckel's diverticulum, 290, 331

,, ganglion, 100
Median lithotomy, 3S9

nerve, 220, 247, 280, 429
Mediastina, 1S4

,, abscess of, 144, 184
Medio-tarsal joint, 501, 520

,, amputation at, 530

Meibomian glands, 63
Melanotic growths of choroid. 51
Membrana tympani, 74
Membranous urethra, 403
Meningeal artery, 9, 29

,, haemorrhage, 29
Meninges of brain, 2S

,, spinal cord, 546

Meningitis from abscess in the ear,
71, 75, 77, 86
,, (spinal) from bed-sores,
547
Meningocele, 17, S3, 86
Mesenteric arteries, 2S4, 370
,, hernia, 333
,, holes, 320
Mesentery, 31S

,, length of, 319

,, prolapse of, 320

Meso-colic hernia, 334

,, -colon, 341
Metacarpo - phalangeal joint of

thumb, dislocations at, 273
Metatarsal bone of great toe, am-
putation of, 531
,, bones, fractures of the,
526
Metatarsophalangeal articulations,
501
,, ,, joint of great

toe, dislocation at. 326
Middle meningeal artery. 29
Miner's elbow. 286
Motor centres on the cortex, 37

566

Surgical Applied Anatomy.

Motor paralysis in injuries to cord,

553
' Month, 118

Mucous polyp of nose, 89
Mumps, 105
Muscse volitantes, 60
Musculo-spiral nerve, 227, 278
Myxcedema, 157

Nail, 260

Nares, anterior, 84

,, posterior, S4
Nasal bones, S3

,, ,, fracture of, 83

,, cavity, 84

,, cavities, lymphatics of, 92

,, ,, blood-vessels of, 90

,, ,, nerve supply of, 91

,, douche, 85

j, duct, 67

,, fossa?, 84

,, mucous membrane, SS

„ polypus, 89
Neck, 135

,, abscess of, 143, 144

,, fasciae of, 141

,, fistulse of, 166

,, great vessels of, 137. 160

,, hydrocele of, 167

... integuments of, 139

., lung in, 145, 177

„ lymphatic glands of, 163,
164, 165

,, middle line of, 136

,, nerves of, 13S

,, ribs in, 145

,, side of, 136

,, surface anatomy of, 135

,, wounds of, 146
Nelaton's line, 424
Nephrectomy, 366
Nephrolithotomy, 366
Nephroraphy, 366
Nephrotomy, 366
Nerve stretching, 429

,, supply of lower limb, 537

>) ,, upper limb, 275

Nerves (see the various regions)

,, division of (see the various
trunks).

,, of the spinal cord, their
points of exit, 552
Neuralgia, facial, 99

,, of scalp, 12

Nipple, 176

,, in groin, 433
Nipples, supernumerary, 178
Nose, 81

Nose, cartilaginous part of, 83
Notch of Rivini, 74

Obturator hernia, 309

,, nerve, 370, 442, 533
,, or thyroid dislocation,
449, 454
Occipital bone at birth, 17

,, ,, necrosis of, causing

■wasting of tongue.
122
,, glands, 163
(Edema of the glottis, 149
(Esophagostomy, 160
OEsophagotomy, 160
CEsophagus, 158

,, cancer of, 160

,, foreign bodies in, 159

,, nerve supply of, 160

,, operations on, 160

,, relations of. 159

Olecranon, 232

,, fractures of, 244

Omega loop of colon, 342
Omental hernia, 318

,, sac, 31S
Omentum, great, 317
Ophthalmia, sympathetic, 57
Optic disc, 5S
,, neuritis, 5S
,, thalamus, 37
Ora serrata, 58
Orbicularis-palpebrarum . G3
Orbit, 41
,, abscess of, 44
,, arteries of, 45
,, dimensions of, 41
,, fasciee of, 42
,, fracture of, 41
,, muscles of, 44
,, nerves of, 45
,, pidsating tumours of, 45
,, relations of, 41
Os calcis, dislocations of the, 518
,, ,, fractures of the, 524
,, epactal, 18

incisivum in hare-lip, 126
,, innominatum, 372, 375
,, magnum, dislocation of, 273
Ovary, 414

Pacinian bodies in the foot, 504

,, „ ,, hand, 259

Palate, 125

„ cleft, 12G

,, hard, 127

„ soft, 128
Palmar (see Hand)

IXDEX.

;67

Palmaris longus tendon, 523
Pancreas, 359
Pancreatic cysts, 359
Paracentesis of the pericardium,
1S4
,, thorax, 173

,, tympanum, 75

,, ventric les of

brain, 37
Paralysis in spinal injuries, 553

of anterior crural nerve,
533
,, cervical sympathetic,

47
,, external popliteal

nerve, 533
., fourth nerve. 4-'>

,, great sciatic nerve,

033
,, internal popliteal

nerve, 533
median nerve, 280
nmscuJo-spiral nerve,

270
obturator nerve, 533
orbital nerves, 4-3
sixth nerve, 46
ulnar nerve. 280
Parietal bone, relationships of, 36 .

,, fissures, 19

Parieto-oceipital fissure

Parathyroid bodies, 157

Parotid abscess, 103 ■

„ fascia, 103

,, gland, 107

nerve supply. 105
,, region, 103

structures, 106
,, tumour, 107
Patella, 413, 465, 473

., dislocation of, 4 S3
fractures of, 4:1
Patellar ligament, 465, t7"
Pelvic arch, 372

.. cellulitis, 313, 3S1

fascia, 379
,, symphysis, 373
Pelvis, 372

,, floor of, 37;'
,, fractures of, 373

mechanism of. 372
,, nerves of. 420
,, vessels of, 3S2
Penile urethra, 303
Penis, 405

,, malformations of, 400
Perforating ulcer, 504
Pericardium, tapping of. 184
Pericranium. 5

Perineal hernia, 310 '
Periuephritic abscess, 362
Perineum, depth of.

,, fascine of. 385
,, mali
,, nerves of. 420
,; vessels of,
Peritoneum, 310

fossa: of, 339
Perityphlitis, 33S
Peroneal artery, 4'.»1

,, tubercle, 500 ;
Peroneus tertius, 501
Petit's triangle, 284, 313
Petro-squamous suture, 77i
Phantom tumour, 290
Pharynx, 129

,, foreign bodies in, 130
,, mucous membrane of, 131
,, relations of, 132
Photophobia, 55
Phrenic nerve, 139, SOS
Pigeon breast. 106
Piles, 417
Pinna (see Ear), OS
Pirogoffs amputation, 529
Plantar (see Foot)
Plantaris tendon, rupture of. 492
Plaques des funieurs, 121
Platvsma myoides, 139
Pleura, 179

„ wounds of, 179, ISO
Pneumatocele, 7S
Pneumo-thorax, 179
Politzer's method of inflating the

middle ear, 79
Pollock's method of dividing the

muscles of the palate. 128
Polypus of nose.
Popliteal abscess, 470
,, bursas, 473
,, fascia, 470

glands, 468, 473
nerves, 429, 40s, 471, 333
,, space, 469

vessels. 471, 492
Post -nasal growth!
Pott's disease of spine, 543

,, ,, operations in, 168, " 15

,, fracture. 514
Profunda arteries in arm, 22

,, femoris, 432, 435
Prolapsus ani, 417
Pronation, movement of, 249
Pronator radii teres, 2
Prostate, 39S, 415
,, abscess of.
„ hypertrophy of, 399
Prostatectomv, 400

568

Surgical Applied Anatomy.

Prostatic plexus of veins, 400
Psoas abscess, 313

,, muscle, 311, 434
Pterion, 35
Ptosis, 45
Pubic spine, 283
Pudendal hernia, 310, 412
Pulmonary apoplexy, 180

,, artery, 1S2

Puncta lachrymalia, 67
Pylorus, 321, 326

,, resection of the, 327

Radial artery, 246, 268

,, nerve, strength of the, 429
Radius, dislocations of the, 239, 240
., fractures of the, 244, 250,
. 270
Ranula, 119
Rectocele, 413
Recto-vaginal fistula, 413
Rectum, 414

,, attachments of the, 417
, , effects of distension of, 41 6
,, foreign bodies in, 416
, , of infant, 414
,, introduction of hand into,

416
,, lymphatics of, 418
,, mucous membrane of, 417
,, nerves of, 419
,, serous membrane of, 415
,, vessels of, 417
Rectus abdominis muscle, 290
Referred pain, 296
Renal abscess, 363
Resections (see the various parts)
Respiration in fracture of the

spine, 553'
Retina, 58

Retro-peritoneal hernia, 334
Rhinolithes in the nose, SS
Rhinoplasty, 224
Rhinoscopy, 84
Ribs, 171
,, cervical, 145
,, excision of, 174
,, fractures of, 172
Rickets, effect of, on pelvis, 373
,, ,, the ribs, 173

,, „ skull, 16

„ ,, tibia, 499

Rider's bone, 435

,, sprains, 435
Riedel's lobe, 350
Rima glottidis, 136, 149
Rolando, fissure of, 35
Rosenmtiller, fossa of, SO
Rouge's operation, S4

Sacro-coccygeal joint, 37S
Sacro-iliac synchrondrosis, 375
Sacrum, 372

j, dislocation of the, 376
Sagittal fontanelle, 19
Salivary fistulse, 108
Saphenous opening, 432

veins, 436, 459, 467, 493
Sartorius muscle, 431
Scalene muscles, 137, 140
Scalp, abscess of, 6

,, dangerous area of, 3
,, fatty tissue in, 2
,, hsematoma of, 7
,, its mobility, 3
,, lymphatics of, 15, 165
,, nerves of 12, 14
,, neuralgia of, 14
,, sebaceous tumours of, 2
, , sutures in wounds of, 3
,, suppuration in the, 6
,, temporal region of, 7
, , A'ascularity of the, 4
,, vessels of, 12
,, wounds, 4
Scaphoid bone, dislocation of the,

526
Scapula, 186, 199

,, excision of, 202
,, fractures of, 200, 201
Scai'pa's triangle, 430

,, ,, fascia of, 433

,, ,, glands of, 436

,, ,, vessels of, 432,

435
Sciatic artery, 425, 42S
,, dislocation, 449
,, nerve, 'great, 425, 42S, 444,
• 535
Sciatica, 42S
Sclerotic, 50
Scoliosis, 538

Scrofula, sign of, in pinna, 09
Scrofulous pharyngitis, 131
Scrotum, 406

,, and elephantiasis, 407

,, ,, oedema, 407

,, application of leeches to

the, 407
,, subcutaneous tissue of
the, 407
Semilunar cartilages of knee, dis-
location of the, 479
Semimembranosus tendon, 466, 470
Sensori-motor areas of brain, 37
Septum of nose, 86
Shoulder, 185

,, bursa: about, 209, 211
,, dislocation of the, 214

IXDEX.

|69

Shoulder, fractures about the, 219
,, joint, 210

, ,, amputation at the,

222
, ,, disease of the, 212

,, surface anatomy of, ISO
,, tip pain from liver ail-
ments, 369
Sigaultean operation, 375
Sigmoid flexure, 342, 369
Sinus, cervical, 167
,, lateral, 12

,, superior longitudinal, 12
,, sphenoidal, 93
Sinuses of skull, 12, 30
,, (air) of skull, 92
Skull, 15
,, abnormalities of, 18
,, deformities of, 16, IS, 21
,, development of, 16
,, emissary veins of, 13
,, fractux-es of, 20
,, necrosis of, 5, 19
,, of infant, 1(3, 19, 20, 21, 22
,, soft parts covering, 1
,, sutures of, 15, 27
„ thickness of, 28
,, trephining the, S

venous tumours of. 14
Soft palate, 12S
Solar plexus, 36S
Soleus, 492
Spermatic artery, 410
„ cord, 410

,, plexus of veins, 411

Sphenoidal sinus, 94
Sphincter ani, 3S4, 419
Spina bifida, 377
Spinal accessory nerve, 14u
,, cord, 541, 545
,, ,, concussion of, 549
,, ,, contusion and crush-
ing of, 550
,, ,, loss of motion due to

injury of the, 553
,, ,, loss of sensation due
to injury of the, 553
,, ,, operations on, 555

,, wounds of, 54 S
,, injuries and defalcation, 554
,, ,, micturition,

55 l
,, ,, respiration, 553

n i) vomiting, 555

,, meninges, 547
,, meningitis, 547, 548

nerves, distribution, 296
1, ,, points of origin, 552
Spine, 537

Spine, curves of, 537

,, fractures and dislocations

of, 540
,, scoliosis of, 53S
,, sprains of, 530
,, trephining the, 545, 5">5
Spinous processes, fracture of, 544
Splay foot, 522
Spleen, 355

„ capsule of the, 357
,, dislocation of, 350
,, enlarged, 35S
,, extirpation of the, 3";8
,, injuries to the, 357
,, relations of, 355
,, rupture of, 357
St en son's duct, 107
Sterno-clavicular joint, 105

,, disease of, 196

,, dislocations of,

197
,, joint, movements

of, 195
.. -mastoid muscle, 130, 140,

143, 144
.. -xiphoid joint, 109
Sternum, 109

,, fractures of, 170

,, holes in, 171

, , separation of segment s of.

171
,, trephining the, 171
stomach, 321

,, displacement of. 323

fistula? of, 324
,, foreign bodies in, 324
hernia of. 323
lymphatics of, 326
,, operations on, 320, 32s
,, ptosis of, 323
„ relations of, 321. 323
,, vertical, 323
,, wounds of the, 323
Strabismus, 43, 45
Subacromial bursa, 211
Subarachnoid space, 30, 547
Subastragaloid amputation, 531

,, dislocations of the

foot, 519
Subclavian artery, 13S, 101

,, vein, 138, 190

Subclavicular fossa, 187
Subclavius muscle, 190
Subdural space, 30, 547
Sublingual bursa mucosa, 119
,, gland, 11^

,, papilla. 1 Is

Submaxillary glands, 10;;
Suboccipital nerve. 162

57°

Surgical Applied Anatomy.

Subserous connective tissue of the
abdomen, 291

Sulci of brain, relations of, 33

Superficial cervical glands, 163

Superior maxilla, 108

cleft of, 126
,, ,, excision of the,

109
,, ,, fractures of, 10S

,, ,, necrosis of, 109

,, thyroid artery, 137
,, vena cava, 182

Supination, movement of, 249

Supinator longus, 232

Supraclavicular nerves, 190

Supracondyloid process, 226

Suprahyoid glands, 163

Supraorbital foramen, 99

Suprapubic lithotomy, 390

Sustentaculum tali, 500

,, fracture of, 525

Sutures of skull, 15, 18, 27
,, ,, closure of, 22

,, ,, position of, 15

,, ,, relations of, to

brain, 32
,, ,, relations of, to

surface, 15
„ ,, separation of, 27

Sycosis, 64

Sylvius, fissure of, 35

Symblepharon, 65

Syme's amputation, 528

Sympathetic ophthalmia, 57

Symphysis of pelvis, 375

Synostosis of skull, 22

Synovial cavities of the foot, 527
,, ,, ,, hand, 273

,, sheaths in the hand, 264

Synovitis, acute, in the hip-joint,
439
,, „ in the knee, 477

Tabatiere anatomique, 258
Tagliacozzi's operation, 224
Talipes calcaneus, 521

,, cavus, 505

,, equinus, 520

,, and the plantar fascia, 505

,, mixed forms of, 522

,, valgus, 521

,, varus, 521
Tarsal bones, fractures and dis-
locations of, 525]

,, cartilage, 63

,, cyst, 64
Tarsectomy, 522
Tarsus (see Foot)
Taxis, 309

Teeth, 116

,, wisdom, 116
Temporal abscess, 8
,, fascia, 7
,, fossa, 7
Temporo - maxillary articulation.
112
,, -maxillary articulation,
dislocations at, 112
Tendo Achillis, 486, 503, 511

,, oculi, 66
Tenon's capsule, 42
Tenotomy and the peroneal nerve,
471
,, of hamstrings, 471
,, sterno-mastoid, 140

Tensor palati, 128
Testicle, 408, 421

,, descent of, 302
,, fungus of, 409
,, in the foetus, 302
,, inversion of, 409
,, investments of, 408
,, nerves of, 421
,, tunic of, 409
Thecal abscess, 265
Thenar eminence, 255
Thigh, 458

,, amputation of the, 464
,, fasciae of, 459
,, fractures of, 461
,, integuments of, 459
,, muscles of, 460
,, surface anatomy of, 458
Thoracic duct, 166, 184, 371 ^
Thoracoplasty, 174
Thorax, 168

,, deformities of, 169
,, paracentesis of, 173 ,
,, viscera of, 178

walls of, 168
,, wounds of, 183
Thumb, amputation of the, 275

„ dislocation of, 273
Thymus, 154
Thyroid body, 136, 137, 155

,, ,, accessory glands of,

124, 156
,, ,, development of, 156
,, ,, excision of, 157
,, ,, in tracheotomy, 153
,, cartilage, 136, 149
,, nerves of, 157
Thyroidea ima artery, 153, 158
Tibia and fibula, fractures of, 495
„ fractures of, 487, 497
,, in rickets, 499
,, shaft of, its strength, 495J
Tibial vessels, 492, 508

Index.

57i

Tibialis anticus muscle, 190
Tongue, L20

,, accessory glands about,

L24, 156
,, dermoid cyst of, 124
,, blood supply of, 121
,, epithelium of, 121
,, excision of, 124
,, lymphatics of, 123
,, mucous cysts of, 121
,, nerve supply of, 122
Tongue-tie. 121
Tonsil, 132

,, bleeding from, 134
,, foreign body in, 134
,, hypertrophy of, 133
., ,, an'd deaf-

ness. 133
„ lingual, 123
,, Luschka's, SO, 131
„ pharyngeal, 80, 131
Trachea, 130, 148, 152, 181

,, foreign bodies in, 1-34, 182
Tracheotomy, 151, 152
Transverse cervical artery, 138
„ colon, 340, 341

,, process of the atlas, 135
,, ., cervical ver-

tebne, 135
Trapezium, 258

Trendelenburg's operation, 376
Trephining, 8, 549

., for intracranial abscess,

10
Triangular ligament of the urethra,

379, 386
Trigone, 395
Trismus, 115
Tubera ischii, 372, 42 1
Tunica abdominalis, 286
,, albuginea, 40;>
,, vaginalis, 303, 40*
Tympanum, 75

Ulna, dislocation of the, 23S

,, fracture of the, 250
Ulnar artery, 247

,, nerve, 224, 235, 2S0, 429
,, vein in venesection, 233
Umbilical fistula, 289

,, hernia, 288, 310
Umbilicus, fibrous ring of, 288
,, position of, 2S3

,, vessels of. 293

Umbo of membrana tyrapani, 71
Urachus, 28S
Ureter, 307

,, and regurgitation or urine.
397/

Ureter, distension of. 367

,, resection of. 368
,, rupture of, 367
Urethra, female, 405. 42J
,, male, 400, 421
,, ,, curve of, 401

,, ,, membranous, 401

,, mucous membrane <»1. 404
,, narrowest parts of, 403
,, penile, 400
„ prostatic, 400
,, rupture of the, 404
( rethral triangle, 385, 380_
Uterus, 413

., lymphatics of. 414
Vagina, 412
Vaginal cystocele, 413
Valsalva's method of inflating tic

middle ear, 79
Varicocele, 411
Varicose veins, 411, 493
Vas deferens, 410
Veins (see various parts)
„ air in, 163, 207
,, emissary of skull, 13
,, of diploe, 13
Venesection at the elbow, 234
,. in the foot, 509

,, on the arm, 234

Venous tumours of skull, 14
Vermiform appendix, 338
Vertebra, caries of, 316

,, prominens, 135
Vertebral artery, 162

,, column, 537
Vesicovaginal fistula, 413
Vitello-intestinal duct, 2S9, 337
Vitreous humour, 59, 60
Volvulus of the sigmoid flexure,

343
Vulva, 412

Wardrop's operation, 161
"Weaver's bottom, 427
Wharton's duct, US
White line at anus, 419

,, in the pelvic fascia, 380
Whitlow, 265
Wormian bones, 19
Wrist, 253

,, joint, 255, 268

,, ,, amputations at, 274

,, ,, dislocations at, 272.

,, ,, fractures about, 270
,, movements at, 268
Burfa.ce anatomy of the. 253
Wry neck, 140

Zygoma, fracture of, 12

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