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APPLIED ANATOMY

DESIGNED FOR THE USE OF OSTEOPATHIC STUDENTS AND

PRACTITIONERS AS AN AID IN THE ANATOMICAL

EXPLANATION OF DISEASE FROM AN

OSTEOPATHIC VIEWPOINT.

-BY-

MARION EDWARD CLARK, D. O.,

Pro fessor of Applied Anatomy, Gynecology, Obstetrics and Diseases of Children,
in the American School of Osteopath}', Kirksville, Mo.

Illustrated With 175 Engravings, of Which Several are in
Color, and Many Halftones from Photos.

1 906

/I4U

U)S f/fd.JffO

Copyrighted 1906, by II. E. Clark.

iluurnal
printing (to..

Kirltiiliillr. iHu.

APPLIED ANATOMY.

PREFACE

Realizing the close relation existing between anatomy and osteo-
pathic therapeutics, that the science is built on anatomical and physio-
logical knowledge, I in 1901 outlined a course in a subject that I chose
to call, Applied Anatomy. This book is the outgrowth of that attempt
to anatomically explain the signs, cause and treatment of disease.

The object of this work is to place osteopathy on a scientific basis
by offering anatomical and physiological proof that our etiology of dis-
ease is correct; to demonstrate that disturbance of function is, as a rule,
due to structural changes, and to point out the significance of anatomical
changes; and to furnish the practitioner a ready reference for the explain-
ing of lesions and their effects. Anatomical details have been avoided
unless of importance in the explanation of the subject.

I am fully aware that many will differ with me in some of the state-
ments made, also that errors unintentional and unavoidable, have crept
into the text. Having no precedent, this being a practically new work
along its line, it was found hard to avoid repetition and present the sub-
ject in an interesting and at the same time, an instructive and correct
way.

In the arrangement of it I have followed my notes used in the pre-
sentation of the subject to my classes. The articulations of the body are
first studied, this being followed by a consideration of the regions of the
body, the nervous system and the viscera.

The scope of the work is not confined entirely to anatomy, but use
is made of physiology, pathology and physical diagnosis in the inter-
pretation of the signs of lesions and disease. In fact, it is almost as
much of a work on applied physiology as it is of applied anatomy.

The illustrations have been taken from various sources. Many
are from drawings of dissections, some adapted from the standard works,
some reproduced, and others from photographs of cases seen and treated
by the writer. Due credit is given when the illustration is not original.

10 APPLIED ANATOMY.

They are designed to elucidate the text and on this account have
been arranged so that they come at or near the part of the text that they
are intended to illustrate.

In the preparation of the work, I consulted many authorities, but
I especially used the following: Gray, Quain, Morris, Cunningham,
Gerrish, Eisendrath, Spalteholz, McClellan, Deaver, McLachlin, Taylor,
Eckley, Landois, Schafer, Howell, Brubaker, Mouillan, Lovett and Hare.
Credit has been attempted in all quotations from the above.

Much dissection has been done in order to ascertain course of nerves,
relations of viscera, pathological conditions and their causes, and to the
better understand lesions, their kinds and effects. The greater part of
the material has been taken from the writer's extensive experience in
the diagnosis and treatment of disease, having been a teacher and oper-
ator in the American School of Osteopathy since 1899. Many of the
conclusions drawn have been from actual cases treated, and we take it
that we have as much right to draw conclusions from clinical observa-
tions that are as accurate as those drawn from experiments on animals,
when cases are diagnosed, lesions found and on the removal of them the
patient recovers.

The majority of the illustrations were drawn by Dr. Wm. Most,
and I am glad to express my appreciation of his efficient work. I am
indebted to D. Appleton & Co., for electrotypes from Dr. Kelly's splen-
did work.

I am especially indebted to Messrs. Pratt and Sullivan, senior stu-
dents in the A. S. 0. for the preparation of the index.

I am also indebted to my co-laborers in the A. S. O. for many val-
uable suggestions.

It is the desire of the writer that this work will be of material aid
to the practitioner, in the understanding of the human body, that it will
stimulate the student to a closer study of the wonderful mechanism,
and it is his regret that it is so imperfect, that there are so many things
that he is unable to make entirely clear, since, as yet, many of the func-
tions of the body are mere speculations.

M. E. C.
402 Osteopathy Ave., Kirksville, Mo.

May, 1906.

APPLIED ANATOMY. 1 1

INTRODUCTION

Disease, in the average ease, is due to disturbance of structure.
Even in cases of disease resulting from abuse, there is often found some
structural change. In all diseases, whether from abuse or other causes,
there are to be found structural changes, peculiar to the disease. These
structural changes, are in a general way, called lesions. Lesions there-
fore, may be muscular, ligamentous, visceral or bony. A bony lesion
is one in which the function of the articulations of the bone are im-
paired. Anything that disturbs the function of a joint, causes a bony
lesion. The usual form is the result of displacement of the bone. This
displacement is very slight in the average case. A muscular contrac-
ture, a ligamentous shortening, an exostosis, or most important and com-
mon of all, an inflammatory deposit around the articulation, constitute
bony lesions. The function of a joint is movement. Ligaments and
muscles restrict this movement. If force is applied, this restriction is in
a measure, overcome and consequently the tissues around the joint are
injured. Nature sends out an exudate, which forms a splint, the lig-
aments become thickened, in short, we have a typical lesion. This con-
stitutes a sprain, the most common form of bony lesion. The contrac-
ture of these tissues injured by the excessive movement, holds the bone
in abnormal position, thus forming the slight displacement or sublux-
ation, so often spoken of in osteopathic literature. These conditions more
often follow trivial injuries than they do severe trauma. A person in
walking over an uneven sidewalk, may unexpectedly step in a depression
and twist the spine. There is a momentary pain and soon it is forgotten.
The injured place remains sore. The tissues become thickened. The
patient is not aware that it is tender until some osteopathic physician
presses directly on the spot. The movement of the joint is practically
lost, the foramina partly closed, and there is disturbance of function of
everything in relation. Physical culture is not a substitute for osteo-
pathic treatment since the movements of the spine take place in the
normal parts, while the place of injury is not moved at all. To reduce
such a lesion, passive movement must be directed to the injured joint.
By doing this, the function is temporarily restored, the circulation through
the part bettered and absorption of the deposits begins. This is followed

12 APLLIUU ANATOMT.

by restoration of function of the joint and the adjacent tissues. Such
conditions predispose to visceral disease. From this one can see that a
knowledge of anatomy is absolutely necessary in order to locate the lesion,
to explain the effects and to remove the cause.

Since disease is caused or characterized by structural derangement,
and these derangements "produce or maintain the functional disorder,"
the object of osteopathic examination and treatment is to locate
and correct these structural disturbances. Osteopathy, then, is the
science of locating and correcting by manipulation, structural disorders
that cause or maintain functional disturbances or disease, and the use
of common sense regarding the care of the body. Any one can become
an invalid by disobeying the laws of nature, consequently structural
disorders are not the primary causes of all diseases, yet in such cases
there are structural changes that maintain the disturbances which must
be corrected before normal function will be regained.

In lesions of the spinal column, there is, in practically all cases a
deposit around the joint and a thinning of the intervertebral discs. The
object to be attained in the treatment of the spine is to restore normal
function, that is movement, to the spinal articulations. This can be
accomplished by adjusting the articular surfaces and by stretching the
inflammatory tissues deposited around the injured joint.

The essential cause of bony lesions producing disease is pressure.
This pressure is exerted on nerves, vessels and other tissues, principally
at the intervertebral foramina. The pressure is from the displaced
bone or is the result of the inflammatory deposits around the injured
joint. On account of this, the nerve connections between the spinal
cord and the rest of the body are interrupted, the blood-vessels supply-
ing and draining the spinal cord compressed, the lymphatic vessels im-
paired and as a result of this, the nutrition of the cord disturbed, the
originating of impulses interfered with as well as the transmission of
them. Normal circulation to the spinal cord is essential to proper func-
tioning of it; the condition, that is, the mobility of the various vertebral
articulations, determines this.

The writer appreciates the fact that there are many exciting causes
of disease such as abuse of function, exposure, neuroses and inherited
weakness but the underlying cause of all disease is a structural derange-
ment of some part of the body and most important is a derangement of
the framework; the spinal column and the ribs in particular.

APPLIED ANATOMY. 13

TABLE OF CONTENTS

Page.

The atlas 17

The axis 53

The third cervical vertebra G7

The fourth cervical vertebra 76

The fifth cervical vertebra : 84

The sixth cervical vertebra 97

The seventh cervical vertebra 104

The region of the neck 11.5

The thoracic vertebr.e 127

The first thoracic vertebra 127

The second thoracic vertebra 138

The third thoracic vertebra 146

The fourth thoracic vertebra 156

The fifth thoracic vertebra ]67

The sixth thoracic vertebra 179

The seventh thoracic vertebra 192

The eighth thoracic vertebra 202

The ninth thoracic vertebra 211

The tenth thoracic vertebra 217

The eleventh thoracic vertebra 225

The twelfth thoracic vertebra 234

The first lumbar vertebra 241

The second lumbar vertebra 251

The third lumbar vertebra 261

The fourth lumbar vertebra 274

The fifth lumbar vertebra 287

14 applied anatomy.

The innominate 301

The sacrum 327

The back as a region 332

The spinal cord 367

The ribs 379

The first rib 384

The second rib 390

The third rib 395

The fourth rib 398

The fifth rib • 403

The sixth rib 405

The seventh rib 408

The eighth rib 410

The ninth rib 413

The tenth rib 414

The eleventh rib 415

The twelfth rib 418

The thorax 420

The abdomen 435

The temporo-maxillary articulation .• 448

The hyoid bone 451

The sterno-clavicular articulation 452

The acromioclavicular articulation 453

The shoulder-joint 454

The elbow-joint 459

The wrist-joint 459

The hand 461

The upper extremity as a region 461

The hip-joint 469

The knee-joint 477

The ankle-joint 483

The lower extremity as a region 486

applied anatomy. 15

The cranial nerves 494

The olfactory nerve 494

The optic nerve ■ 495

The third cranial nerve 496

The fourth cranial nerve 498

The fifth cranial nerve 498

The sixth cranial nerve 505

The seventh cranial nerve 506

The eighth cranial nerve 508

The ninth cranial nerve 510

The tenth cranial nerve 512

The eleventh cranial nerve 519

The twelfth cranial nerve 520

The brain 522

The medulla oblongata 527

The cerebellum 532

The eye 550

The ear 556

The nose 560

The mouth 563

The pharynx 569

The larynx 571

The thyroid gland 575

The trachea 579

The bronchi 580

The lungs 582

The heart 589

The stomach 598

The liver 60S

The pancreas 616

The spleen 620

The small intestine 622

16 applied anatomy.

The large intestine 628

The kidneys 639

The bladder 647

The supra-renal capsules 651

The ovaries 652

The testes 655

The spermatic cord 661

The vesicle seminales 663

The prostate gland 663

The uterus 669

The external genitalia 674

The mammae 674

Hpplied Hnatomy.

THE ATLAS.

The Atlas is the most peculiar of vertebra?. It is the uppermost
of the vertebrae forming the spinal column and supports the head. For
an object to be well supported, there must be little motion between the
part supporting and the part supported. This is true of the atlas and
occiput, the atlanto-occipital articulation being to all intents and pur-
poses immovable, very little motion at least, taking place at this
joint in movements of the head. On this account lesions of this artic-
ulation are rare as compared with other vertebral articulations, using
the term lesion in its usually accepted meaning. In the better use of
this term, that is including all affections of the articulation, especially

Fig. 1. — The atlas showing the superior aspect. Note the shape and depth of the

articular facets.

sprains of the ligaments, a lesion of this articulation is quite com-
mon.

The atlas is peculiar in that the body is absent, it being supposedly
usurped by the odontoid process of the axis. This is of interest since
complete dislocations result in pressure on the spinal cord by the odon-
toid process from breaking of the transverse ligament, and paralysis of

18 APPLIED ANATOMY.

all parts below follows. if pressure is constant and long"continued. The
absence of the body of the atlas makes it thinner, thus permitting of
freer motion of the head on the spinal column, in accordance with the
general rule that the smaller the vertebra the greater the arc of mobility.

The posterior spinous process, which is developed in all the other
vertebra?, is absent or, at least, poorly developed in the case of the atlas.
There is a rudimentary process or tubercle that takes its place, and to
which is attached the small posterior recti muscles. Ordinarily, it can-
not be palpated even though the neck be in extreme flexion, but in some
cases it is possible to distinctly palpate it. If it can be palpated it de-
notes either (1) an abnormal development of the tubercle; (2) an anterior
condition of the occiput on the atlas; or (3) a posterior condition of the
atlas, the atlas and occiput being displaced posteriorly on the spinal
column. The diagnosis is based on (1) tenderness over and around the
tubercle and (2) disturbance of function of the articulations involved.
If there is no tenderness in or around the articulations of the atlas and
the function is unimpaired, the prominence of this tubercle is not
pathological but only a peculiarity.

At the junction of the anterior arches is another tubercle. It is of
interest only in that the longus colli muscles and the anterior verte-
bral ligament are attached to it, hence in lesions of the atlas flexion of
the head and neck may be impaired indirectly, by affecting these muscles
through their nerve supply or attachment and directly, by derangement
of the articular facets. ,

The superior articular facets are peculiar on account of their shape,
size and the directions that they face. These facets are oval shaped,
deeply concave from before backward, converge in front and incline
obliquely inward. They are often indented, in which cases they are
divided into two unequal parts, thus lessening the mobility of the joint.
They receive the condyles of the occipital bone, thus forming a rather
secure articulation. On account of the depth of the concavity of the
superior facets of the atlas and the prominent convexity of the occipital
condyles, dislocation of this articulation either partial or complete, is
rare. Also the facets act as inclined planes, thus assisting spontaneous
reduction if the condyles were forced slightly upward on the facets.
By muscular contracture the occiput and atlas are approximated, this
of itself lessening the mobility of the occipito-atlantal articulation. If
in addition, an inflammatory exudate is present from meningitis, la-

APPLIED ANATOMY.

grippe or other causes, mobility of this articulation is still further less-
ened. The principal movement of this joint is an antero-posterior one,
thus permitting of a nodding movement of the head.

Another peculiarity is the fact that the articular facets of the atlas,
like those of the axis, are anterior to the place of exit op the spinal
nerves; the facets being posterior in the other vertebrae.

There is a circular facet on the posterior surface of the anterior arch
for articulation with the odontoid process of the axis. This indentation
or facet is called fovea dentalis. On account of this articulation a dis-
placement of the atlas directly backward is impossible unless it carries
the axis with it.

Fig. 2. — Inferior surface of the atlas. Compare with superior, Fig. 1.

The inferior facets are smaller and more nearly circular than the
superior, but like them, concave. They face inwards and downwards
and are more subject to abnormal movement than are the superior.
This is because of the freedom of movement and the leverage exerted
on it by the atlas and occiput.

The movements of the atlanto-occipital articulation are not very
well marked, they consisting principally of a rocking movement of the
occipital condyles on the superior facets of the atlas. This has been
described as of a ginglymoid character. Morris says: "There is also
a slight amount of gliding movement, either directly lateral, the outer
edge of one condyle sinking a little within the outer edge of the socket
of the atlas, and that of the opposite condyle projecting to a corres-

20 APPLIED ANATOMY.

ponding degree. The head is thus tilted to one side, and it is even
possible that the weight of the skull may be borne almost entirely on
one joint, the articular surfaces of the other being thrown out of
contact. Or the movement may be obliquely lateral, when the lower
side of the head will be a trifle in advance of the elevated side. "*

The head is so poised on the superior articular surfaces of the atlas
that it requires little muscular effort to keep it balanced. If the occiput
or atlas become changed in position as a result of a subluxation, the
balancing of the head becomes more difficult, that is, more muscular
effort is required to keep the head in a normal position. Since the cervi-
cal ligaments have little or nothing to do with the balancing of the head,
and since the muscles connecting the head with the spinal column are
the principal factors concerned in holding the head erect, it follows
that any disorder of these muscles or the joint itself, will interfere with
this function, that is the head is drawn too far to one side or else the
balance is lost so that it moves to and fro. Many of the cases charac-
terized by a constant nodding movement of the head are due to some
affection of either the joint itself or the mechanism moving the joint so
that the muscles are constantly drawing the head out of balance, that
is it is drawn too far forward or backward in the attempts of the cervi-
cal muscles to keep it poised. If the lesion exists for sometime, the
irritation is not overcome by assuming the prone posture but as a rule
the movement is decidedly lessened in the worst cases and is stopped
entirely in the mild cases. If the prone posture is assumed for several
hours as in sleep, the attempts of the muscles to balance the head cease.
The above is the principal cause of nodding of the head, the other ones
being of less importance.

The first cervical nerves making their exit in relation with the atlas,
pass along a groove over the posterior arch instead of through a foramen,
this groove being occasionally converted into a foramen. The vertebral
vessels also pass along with the first cervical nerve.

The transverse processes are unusually large and rough and extend
farther outward than those of the other vertebra?. They are perforated
by a foramen through which pass the vertebral vessels and vertebral
plexus of nerves. Numerous muscles are attached to the transverse
processes, in contractured conditions of which the position of the pro-
cesses is changed. These processes are quite superficial, hence tender

*Morris Human Anatomy, p. 204.

APPLIED ANATOMY. 21

on pressure. Use is occasionally made of this fact in treating hysterical
cases, pressure on the transverse processes producing such pain that the
patient forgets about the other trouble. The direction and position of
the processes vary in different individuals. Theoretically they should
point directly outward and be midway between the angle of the jaw and
the mastoid process. The position of the bone is partly determined by
the relation of the tip of the transverse process to the above named
landmarks, but it does not necessarily follow that a lesion exists if it is
nearer one than the other.

The position of the head is sometimes indicative, if not diagnostic,
of, a lesion of this articulation. If the chin is drawn in abnormally
far, the chances are that the head sets too far back on the spinal column,
that is on the atlas; if the chin protrudes unusually far, the opposite con-
dition exists. The sterno-mastoid muscles are put on a tension in the
first, and relaxed in the second condition.

The ligaments binding the atlas to the occiput are arbitrarily divided
into anterior occipito-atlantal, posterior occipito-atlantal, two capsular
and two anterior oblique. They are band-like, elastic and densely woven
ligaments and, if not diseased, hold the superior facets of the atlas and
the occipital condyles securely in apposition.

The anterior occipito-atlantal ligament is composed of very strong
dense fibers that radiate upward and slightly outward from the anterior
arch to the anterior border of the foramen magnum. It is in close re-
lation with the anterior common, the capsular and the atlanto-axoidean
ligaments.

The posterior occipito-atlantal is incomplete on both sides for the
passage of the vertebral vessels and the suboccipital nerve.

It extends from the upper part of the posterior arch of the atlas
to the posterior border of the foramen magnum. It is not very strong,
is not stretched very tightly and does not to a great extent limit motion.
Being weaker than the anterior, extreme flexion is more likely to pro-
duce a serious effect than is extreme extension. Because of the greater
strength of the anterior ligament the front part of the articulation is
held the more securely in place than is the posterior thus the latter
would respond to a force more quickly than would the former. The
capsular do not materially strengthen the joint since they are quite lax.
They entirely surround and enclose the occipito-atlantal articulation.
They are reinforced and strengthened by the anterior oblique ligaments.

22 APPLIED ANATOMY.

These ligaments are affected in various ways by bony and mus-
cular lesions of the neck. However, the principal effects are those of
relaxation and contraction or shortening. If the lesion is irritative the
ligaments are likely to become' thickened, less elastic and shorter, and
thus draw the head quite firmly down on the atlas. In the anemic and
malnourished, relaxation takes place with increased mobility.

The blood supply to these ligaments comes principally from the ver-
bral while a few twigs are given off by the ascending pharyngeal. The
innervation is from the anterior division of the first cervical nerve. In
subluxations of the occiput, these ligaments are injured, either torn or
badly stretched. This results in a thickening of the ligaments and de-
posits around the injured part. These conditions interfere with the
function of the joint, the blood-vessels, the nerves in relation, the mus-
cles attached and the intervertebral foramina that is the space between
the posterior arch of the atlas and the axis.

The brain has a pulsation in the direction where the resistance is
least. This is seen best in babies before the fontanelles close. The
diastole and systole of the brain are in part made possible in the un-
yielding box of the cranium by the ebb and flow of the cerebro-spinal
fluid. Hill says: "The occipito-atlantal and other vertebral ligaments
extend in cerebral diastole, and allow the fluid to escape from the cranial
cavity, while in systole, through the elasticity of these ligaments com-
ing into play, it is driven back. "* This then is an important factor in
the circulation of the brain. Lesions of the occipito-atlantal articula-
tion affect the ligaments and thus interfere with their elasticity.
Since in all vertebral lesions the ligaments in relation are always af-
ected, the direct relation of spinal lesions and especially cervical, to
brain disorders, becomes the better understood.

The ligaments uniting the atlas to the axis are the anterior and
posterior atlanto-axoidean, capsular and the atlanto-odontoirl.

The muscles attached to the atlas are the recti capiti minores and
laterales, longus colli, obliqui, splenitis colli, levator anguli scapulae and the
intertransversales. Most of these are attached to the transverse processes.
On account of the length of these processes, the number of muscles attached
and the mobility of the articulations, torsion of the atlas and occiput on
the axis from muscular contractions often occurs. These muscles con-
tract from thermic influences. This form of stimulation most often

*Schaffer's phys. p. 143.

APPLIED ANATOMY.

affects the neck. Nature provides against this by giving man hair
which, covering the neck, protects it against exposure. Fashion has
decreed that the hair should be worn closely cropped and as a result one
of nature's defenses is weakened. In the male the throat is protected
in a similar manner by hair from the face.

These muscles, on account of the thermic stimulation, fail to return

Fig. 3. — Showing the small deep muscles at the base of the occiput that are
always affected in lesions of the atlanto-occipital and atlanto-axoidean articulations.
In the average case of headache these muscles are tender and contractured.

to their normal length and thickness. Landois, in speaking of a con-
tracture says: "This is especially well marked in muscles that have been
previously subjected to strong, direct stimulation, or are greatly fatigued,
or more strongly acid, or approaching a condition of rigor or have been
obtained from animals poisoned with veratin. " In man, these con-

24 APPLIED ANATOMY.

tfactures come, in the neck, from thermic stimuli, as mentioned above;
toxemia, by which the cells are over stimulated; and from lesions of the
neck by which the nerve trunks are stimulated, the nerve cells irritated
and the muscles put on a stretch on account of change in position of the
origin or insertion. It seems that a muscle undergoes a change in struc-
ture as a result of prolonged stimulation of its nerve, which condition is
readily recognized on palpation and is called a muscular contracture.

When these muscles remain contraetured for any great length of
time the vertebrae are abnormally approximated, hence the interverte-
bral foramina are smaller, the circulation through the muscle impaired
and consequently the blood supply to the cervical spinal cord, medulla
and pons Varolii interfered with. The nerve filaments passing through
and in relation with, the contraetured muscle are also, affected. On
the other hand, lesions affecting the innervation of these muscles pro-
duce contracture., which in turn produces the above effects.

The upper two or, three segments of the cervical spinal cord are in
relation with the atlas but provision is made against pressure from move-
ments of the head and neck. This provision is a very large foramen in
the atlas portion of the spinal canal. If pressure is exerted on the
spinal cord in this region the lesion must necessarily be a complete dis-
location. Partial dislocations of vertebrae affect structures attached
to the bone and those in the spinal foramina more readily than those in
the canal.

The structures affected by vertebral lesions in order of frequency
are the ligaments, veins, arteries, nerves and muscles.

The veins in relation with the atlas are the vertebral and rami
spinales which collect the blood from the upper cervical segments of the
spinal cord and the spinal column. In lesions of t he atlantal articulation
there is pressure on these veins since they are in close relation with it.
The vertebral, at this level, drains the recti and obliqui muscles in rela-
tion, pericranium, and, through the lateral spinal, the upper cervical
spinal cord. Often, these veins, by means of an emissary vein through
the posterior condyloid foramen, are brought in relation with the lateral
sinus. The blood from the pons Varolii, medulla oblongata and a part of
the upper part of the spinal cord passes into the sinuses of the brain
that are in relation.

The rami spinales veins drain a part of the cord, its coverings and
the vertebrae. The result then of a lesion would necessarily be a venous

APPLIED ANATOMY.

disturbance in the parts drained by the vessels that are compressed.
This venous congestion affects nutrition of nerve cells located in the
affected segments, hence an atlas lesion, by affecting drainage of the
first and second cervical segments, disturbs the function of the nerves
arising from them.

The arteries in relation with the atlas are the vertebral and its lateral
spinal branches which go to the cervical spinal cord. The vertebral,
after passing up through the foramen in the transverse process of the
atlas/makes an abrupt change in its direction by curving backward and

RECTUS CAPITIS
LATERALIS

,BASILAR ARTFRY
'RIGHT LEFT VERTEBRAL ABTCRY

STYLOID PROCESS
FrRSTCERVlCAt N
SECOND CERVICAL N
THIRD CERVICAL H
VERTEBRAL VEIN

RECTUS CAPITIS
POSTICUS m'n

RTERU PRINCEPS
CE RYIC1S ART

SEMISPINALS

Fig. 4. — Showing the course of the vertebral artery. Note the curve around the
superior articular process of the atlas on account of which lesions at the occipito-
atlantal articulation readily affect it.

inward behind the articular process. It passes through a foramen
formed by the posterior occipito-atlantal ligament into the spinal canal.
It then becomes intra-cranial by passing up through the foramen mag-
num. It joins with its fellow and forms the basilar. Before uniting
to form the basilar there is given off the rami spinales, posterior men-
ingeal, anterior and posterior spinal and the posterior inferior cerebellar.
The rami spinales supply the muscles and spinal cord. The posterior
meningeal supplies the bone and dura mater of the occipital fossa. The
anterior spinal joins the corresponding artery on the opposite side and

APPLIED ANATOMY.

runs the entire length of the spinal cord, being reinforced by branches
from the vertebral, ascending cervical, intercostal, lumbar, ilio-lumbar
and lateral sacral which follow the corresponding nerves into the spinal
canal and accompany the nerve roots into the substance of the cord.
The posterior spinal remain separate, extend the entire length of the
spinal cord and are similarly reinforced. Church says that the arterial

RECTUS CAPITIS
POST. MINOR

RECTUS CAPITIS
POST. MAJOR

TRACHE.LO MASTOID

SUR OBLIQUE
INT OBLIQUE

.* SPLENIUS CAPITIS

Fig. 5. — Showing deep muscles of back of neck. These muscles are commonly
contractured in upper cervical lesions and can be palpated as cord-like bodies which
are tender on pressure. The vertebra are approximated by such contracture.

twigs from these arteries entering the cord are of the "terminal variety
and therefore do not anastomose. " The posterior inferior cerebellar
supplies the medulla oblongata, a part of the cerebellum and the fourth
ventricle, internal ear and cerebrum especially the occipital and tem-
pero-sphenoidal lobes.

The vertebral arteries are affected by a lesion of the occipito-atlantal
articulation. Pressure on these arteries is the most common effect.
As a result the parts supplied by the artery are likely to be affected un-
less the anastomosis is complete, which thing is almost impossible on

APPLIED ANATOMY.

CQMPLE XUS

-RECT. CAP POST. WN.

\ RECT. CAP POST. M J

ANASTOMOTIC wrr H GRT. OCC I PITA L
INT. AND EXT. CAROTID BRAS.

ANT N

SUP. CERV.
GANGLION
LARYrt66AL BRAHC
2? CERVICAL

! CARDIAC BRA.

LOOP

BRA.TOMASTOID
AND

To OCCIPITO-ATLANTO ART'N
ERTEBRAL PLEXUS

R C.A.WN

VAGUS

PHARYN6EAL.BRA.
'stOSSAL
-/-RECT CAP.
LATERALIS

GLOSSOPHARYNGEAL

HYPOGLOSSAL

BRA.TOGLOSSO-
r, PHARYNGEAL

GENIO-

DESCENDENS >■

DESCENDENS
HYPOCLOSSI

ANSA CERVICALIS

OMOHYOID

THYRO HYOID,
(STERNOHYOID

Fig. 6. — First cervical segment of the spinal cord showing branches and

connections.

28 APPLIED ANATOMY.

account of the branches being end arteries. The parts to suffer are the
spinal cord and its coverings, medulla, pons, cerebellum and quite a
large part of the cerebrum, especially the centers for vision. Recalling
the function of these parts one can readily see an explanation for dis-
turbances of the eye and other parts whose nerves have their cells of
origin here. Vaso-motor nerves accompany and control the size of
these arteries. The source of the nerve energy transmitted by these
nerves is a point below perhaps in the upper thoracic segments of the
spinal cord.

The nerves directly in relation with the atlas are the cerebro-spinal
nerves and their branches and communications coming from the first
and second cervical segments, the sympathetic gangliated cord with
some of its branches and communications, and the vertebral plexus.
The anterior and posterior divisions and grey ramus with the vaso-motor
nerves of the lateral spinal arteries carry impulses that pass through the
intervertebral foramen between the occiput and atlas while the gangliated
cord with its ganglia and branches are in relation with the transverse process.

In all lesions affecting the occipito-atlantal articulation the sub-
occipital nerve is involved. This nerve supplies the recti capiti, ob-
liquii, complexi, genio-hyoid and infra-hyoid muscles. It supplies the
mastoid process of the temporal bone, the occipito-atlantal articulation
and, in some cases, sensation to the back part of the head. Some say
that it helps to supply the meninges of the brain. It communicates
directly with the second cervical nerve, ninth and twelfth cranial, superior
cervical ganglion and the vertebral plexus around the vertebral artery
in relation.

In all lesions involving the atlanto-axial articulation the second
cervical nerve with its branches is involved.

A lesion at the occipito-atlantal articulation affects the grey ramus
which connects the gangliated cord with the suboccipital nerve. This
nerve carries vasomotor and secretory impulses. A filament is given
off which joins the recurrent nerve which is distributed in the interior
of the spinal canal. Langley says "Intermixed with the pale fibers in
the grey rami communicantes there are also a few medullated fibres of
varying size, even in regions where distinct white rami do not exist."

The superior cervical ganglion may be affected by an atlas lesion
but not so readily as by lesions lower in the neck. This ganglion is sit-
uated in relation with the anterior part of the transverse .process of

APPLIED ANATOMY. 29

the second and third, sometimes the first cervical vertebra. Clinically
an atlas lesion readily affects this ganglion, judging from the various
conditions and effects ordinarily attributed to such lesion. Anatomically
the superior cervical ganglion is affected either by direct pressure from
the displaced bone or indirectly from contracture of muscles or tighten-
ing of tissues, or through interference with ascending branches which
are in relation with the upper cervical vertebrae.

The ganglion being located anteriorly to the transverse process, it is
the exception for it to be affected by direct pressure, but common for
its functions to be disturbed by a tightening of tissues in relation with
it. These tissues are always irritated and put on a tension by sublux-
ations of the upper cervical vertebrae. This tightened condition affects
the ganglion by direct pressure on it, pressure on its branches and com-
munications, and by pressure on the blood-vessels supplying and drain-
ing it.

This ganglion gives off ascending branches which divide into an
external or carotid plexus and an internal or cavernous plexus. The
external connects with, or send filaments to, the fifth and sixth cranial
nerves, external carotid artery, dura mater, Gasserian ganglion, the
tympanic plexus through the small deep petrosal, and the sphenopala-
tine ganglion. The internal connects with, or sends filaments to, the
third, fourth, ophthalmic division of fifth cranial nerves, internal carotid,
ophthalmic and central artery of retina, ciliary ganglion and the pitui-
tary body. The internal branches of this ganglion send filaments to
the ninth and tenth cranial, superior and external laryngeal, pharyngeal
plexus and superior cardiac. The inferior branches connect with the
middle cervical ganglion. The anterior sends filaments to the carotid
artery and its branches, sub-maxillary ganglion and the middle meningeal
artery. Its branches connect with the ninth, tenth and twelfth cranial
and help to supply the nose, tonsils, brain, meninges, medulla, spinal
cord and heart.

The function of the superior cervical ganglion seems to be that of a.
relay station for impulses reaching it from points below. Langley says:
"The upper part of the thoracic spinal cord sends out fibers by the an-
terior roots of the spinal nerves of this region. The fibers make no halt
at the ganglia until they reach the superior cervical ganglion. This is
a relay station for the sympathetic nerve supply of the whole of the
head; in it all the nerve fibers form nerve endings each nerve

ACCOMPANYING BRANCHES OF [NT. CARO'iiU ARTERY
TO SIXTH

TO CILIARY GANGLION
TO FIFTH N.

TO TYMPANIC BRA.OF GLOSSOPHARYNGEAL

to ganglion of root of vagus

to petrosal ganglion of
glosso-pharyngeal

from first cervical nerve
from second cerv. im.
from third cerv. n
from fourth cerv.n.
from fifth cerv.n
From sixth cerv. im.
from seventh cerv.n

plexus surrounding
vertebral art. '-^

from eighth cerv.n

plexus sur

rounding
subclavian art
ano its branches

from fl rst thoracic 'n

fromsecondtho.n

VIDIAN N.TOSPHENO-

- PALATINE GANGLION

"TO THIRD N

TO GANG. OFTRUNKpr VAGUS LARGESUP PETROSAL FROM FACIAL
■— -TOHYPOGLOSSAL

UNITING WITH BRANCHES OF VAGUS

ANO GLOSSO-PHARYNOEALTO
FORM THE PHARYNGEAL PLEXUS

CARDIAC BRANCHES FROM VAGUS
AND RECURRENT LARYNGEAL

NFERIOR CARDIAC

. TO LEFTANT
(\_si? PULMONARY
NERVES

CARDIAC PLEXUS

FROM SEVENTH
THORACIC N. =?As

Fig. 7. — Scheme of the cervical sympathetica with their connections, (.after Flower).

APPLIED ANATOMY. 31

cell sends off a nerve fiber, which runs to the periphery, where it branches
and supplies a group of unstriated muscles or gland cells. On the course
of a nervous impulse from the spinal cord to the periphery, there are
then two nerve cells, one with cell body in the spinal cord, the other
with cell body in the local sympathetic ganglion. " Few if any impulses
are generated in the superior cervical ganglion; most if not all of them
so far as it can be determined, come from the upper thoracic and lower
cervical spinal cord. Without doubt there is a nerve line of communica-
tion existing between the various parts of the head and face and the
upper thoracic spinal cord and the superior cervical ganglion, and the
ganglion acts as a relay station, it being on the line of communication.
According to Langley, stimulation of thesuperiorcervicalganglioninthe
cat produces the following effects: (1) dilatation of the pupil, (2) re-
traction of the nictitating membrane, (3) contraction of the blood-ves-
sels of the skin and mucous membrane of the head and of the salivary
and other glands, it being marked in the conjunctiva, the iris, and in
most animals in the skin and adjoining mucous membrane of the nose
and lips and in the mucous membrane of the hard palate; and (4) secre-
tion from the salivary glands, the lachrymal glands, the glands of the
mucous membrane of the mouth, nose and pharynx, and from the sweat
glands of the skin where these occur. This ganglion also exerts a tonic
effect on the vaso-constrictor fibers, the pupillo-dilator and the motor
to the non-striated muscle fibers which it supplies."

Clinically, an atlas or upper cervical lesion produces effects in the
parts mentioned above; that is, there are vasomotor, secretory, motor,
or trophic disturbances in some part supplied by fibers coming from
the superior cervical ganglion. This lesion may be irritative. In such
cases it can be substituted for the means used in experiments in which
the ganglion is stimulated or inhibited. At any rate the lesion -breaks
or otherwise impairs the line of communication existing between the
base of supply, the nerve cells, and the periphery, some part above.
The blood-vessels of the head, face and throat, the involuntary muscles,
and the glands' and secretory membranes all receive their impulses
almost, if not entirely, from or rather by way of, the superior cervical
ganglion.

The vertebral plexus of nerves surrounds the vertebral artery and
is affected in atlas lesions. This plexus is formed by the lowest cervical
and first dorsal ganglia which give off slender grey branches which ascend

32 APPLIED ANATOMY.

along the vertebral artery furnishing to it and its branches and the
basilar arteries, vasomotor impulses. Since this artery supjjlies the
spinal cord, medulla, pons Varolii, cerebellum and part of the cerebrum,
especially the center for vision, and since the amount of blood passing
through it is controlled by the size of the vessel and the vertebral plexus

POST CERERRALV POST. COMMIh MIDDLE CEREBRAL ^

llCATING / IB'

SUPCERESELLA V / ANT CEREBRAL /.%gj? SUPRAORBITAL

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VERTEBRAL- - .. _ LWLi^^^ba^^/'.:^\,\-5N&"\ 'w/]?5Bfe- -?$%

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profunda j v^s^/ ■■/^"i'li^r^^s^r^

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'''faiKM ' *LjT^$l**Ji^L-L l-lh — — occipital

' '"/ l^^RSk-Ti ":v- ^5-" FACIAL

\«\t\/W''lJ^Bt^=*Ci>»*TJliE_^-i- -^^""Vl — LINGUAL

VvJ £V„ J /rt ?Bt«--'-*-- --flff ^— COMMON CAUUi

I(,ig. 8. — Showing the arteries of the cervical region. Note their relation to the

vertebra?.

controls its size, it therefore; follows that many disorders of the above
mentioned structures will arise in case the vertebral plexus is disturbed.
It is disturbed by all atlas lesions, since it passes through the fora-
men and bends around the articular process, therefore being subject to
pressure in all deviations of the atlas.

APPLIED ANATOMY. 33

The writer has noted in dissections of this artery that it is surrounded
by connective tissue that is closely adherent to it and the parts of the
atlas with which it is in relation. Any irritation of this connective tissue
therefore, as in sprains or other lesions of the neck, would affect this
artery.

Branching from the anterior division of the suboccipital nerve and
the ramus communicans are two filaments which unite to form the
recurrent or meningeal nerve. It enters the spinal canal through the
intervertebral foramen where it is distributed to the vertebrae and lig-
aments, to the blood-vessels of the cord and to the dura mater (Luschka).

In lesions of the atlas the recurrent nerve in relation is affected,
this in turn producing trouble with the parts supplied, viz., the atlas
and its ligaments, the dura mater in that part of the canal and the blood-
vessels of the spinal cord in relation.

The first cervical segment of the spinal cord is likely to be affected
by an atlas lesion since this lesion interferes with its nutrition, drainage
and vaso-motor nerve supply, the vessels and nerves being in relation
with the atlas. This segment contains the cells which give rise to nerve
impulses that supply the recti capiti, obliqui, complexi, genio-hyoid and
infra-hyoid muscles. A disturbance of this segment would cause atony
or contracture of some or all of the above named muscles. Every mus-
cle fibre has a cell in the spinal cord which supplies it with tone. If
this cell is inhibited there is loss of muscular tone; if this cell is stimulated
there is increased tone or contracture. An altered circulation to the
cell will cause some pathological effect in the muscles supplied. This
segment furnishes a pathway over which impulses pass to or
from the upper part of the neck, occipito-atlantal articulation, and the
various blood-vessels in relation that supply the muscles, ligaments,
vertebra?, meninges and spinal cord. The vaso-motor nerves connect
with predominant center in the bulb.

A great many muscles attaching below the atlas connect the head
and spinal column. By their contracture the head is drawn tightly down
on the spinal column. As a result the tissue between the head and atlas
is thinned and the foramina lessened in size, thus impinging on some or
all of the structures passing over the posterior arch of the atlas. Such
a lesion is diagnosed by the tightened condition of the muscles, absence
of irregularity at the atlas, and by approximation of the head and atlas.
Tenderness is usually present in and around the joint.

34 APPLIED ANATOMY.

The atlas is subject to lesions similar in character to lesions of any
vertebra. In nearly all cases the occipito-atlantal articulation is not
involved, but the head and atlas are abnormally moved on the axis;
that is, the lesion in atlas subluxations is in the atlanto-axial articula-
tion. It is the exception for there to be any relative change between
the atlas and occiput other than approximation.

Torsion is the most common atlas lesion. This may come from
sudden or abnormal movement of the head or it may follow muscular
contracture, especially that of the splenitis capitus. This form of lesion
is diagnosed by tenderness at the articulation, irregularity of the trans-
verse processes, they not being symmetrical, and by impairment of
mobility of the joints involved, that is the patient has trouble in ex-
tending the neck or rotating the head through an arc of 180 degrees.

Posterior luxations of the atlas are practically impossible except
to a very slight degree, such being prevented by the odontoid process of
the axis. Anterior luxations are fairly common. Such are diagnosed
by the way the patient holds the head and by palpation of the trans-
verse and articular processes.

"The relation of the pharynx to the cervical vertebrae makes it
possible to diagnosticate vertebral fractures and dislocations by inspec-
tion and palpation through the oral cavity; for example, from the rela-
tion of the anterior arch of the atlas to the posterior pharyngeal wall,
it is clear that when the atlas is dislocated anteriorly it may be recognized
as a hard prominence in the posterior pharyngeal wall. It will also be
readily understood that diseases of the cervical vertebra? (such as caries)
may lead to retropharyngeal abscess or to perforation and the extrusion
of jDieces of bone into the pharynx."*

This does not apply so well to the minor subluxations of the upper
cervical vertebra?, but even in such cases it is possible to palpate, by way
of the oral cavity, the irregularity caused by an anterior subluxation of
the atlas or other cervical vertebra? but not advisable in the average
case.

The transverse processes are abnormally near the angle of the jaw
and the articular processes quite tender, with undue prominence of
tissue over them.

Lateral deviations are unusual, and in case one transverse process
is more prominent than its fellow it is probably due to its greater length,
the two rarely being of the same length. Such a luxation is diagnosed

*Schu]tze's Applied Anat. p. 58.

APPLIED ANATOMY.

partly by the prominence of the process and partly by the tenseness of
tissues in relation.

Approximation of the head and atlas is very frequent. In such
cases the lesion is commonly at a point distant from the atlas.

Atlas lesions result from trauma, especially sudden and unexpected
twists of the head, muscular contractures and from Injury during birth.
Anything that carries the head or neck beyond the normal range of move-
ment will produce a lesion of some or all of the cervical articulations.
There is often found as a complication, a sprained condition of the lig-
aments of the affected joint and contracture of the muscles in relation.

Pain is present to some degree in all cases but varies in amount in
different cases on account of the difference in the degree of the injury

CRT.OCCIPITAL
TRAPEZ

.„' V-'«sif4»- ^".-V. v^f: MF^^Ww, '£ ■ Jt— BRANCH-TO

VERTEBRAL ARTERY cu
POST PRIM.DIV. FIRST CE
INFERIOR OBLIQUE ^
RECTUS CAR POST- MJ

COMPLEXUS cur
CREAT OCCIPITAL
POST. PRIM.DIV FIRSTCERVICAL
NASTOMOTIC
■THIRD CERVICAL
THIRD OCCIPITAL
INFERIOR OBLIQUE

Fig. 9. — Showing course of great occipital nerves. (After Testut)
on this nerve is often effective in the relief of headaches.

Pressure

and manner of its occurrence. In the average case, nature soon
overcomes most of the acute effects and the condition settles into a
chronic state. Almost any form of disease of any or every viscus or
structure above the point of lesion may occur, the effects coming on
gradually in most instances, that is, the lesion acts as the predispos-
ing cause while the abuse is the exciting one. In lesions involving the
occipito-atlantal and occipito-axoidal articulations there will be some
impairment of practically all the structures of the head and face,

APPLIED ANATOMY.

but the eye and its appendages are most frequently and noticeably
affected.

The eye affections follow such lesions as a result of the disturbance
of the various nerves that carry motor, trophic, sensory and secretory
impulses to and from the eye and the upper spinal segments. These

CLOBEOFTHEEYE
CILIARY NERVES
OPTIC NERVE

CILIARY

OPHTHALMIC OR
LENTICULAR GANG,

CASSERIAN GANG,

UPPER
LOWER
BRANCH

CAVERNOL
'LEXUS

1S1XTH OR ABDUCENT M
INT. CAROTID PLEXUS

CERVICAL GANGLION-

FIG. 10. — Showing nerve pathway from superior cervical ganglion to the eye
and to the second, third, fifth and sixth cranial nerves.

impulses, that is the motor, secretory, trophic and vaso-motor impulses
arise as low in the spinal cord as the third dorsal segment and pass to
the eye via the gangliated cord, superior cervical ganglion,, ascending

APPLIED ANATOMY. 37

branches thence over the various connecting fibers to the eye and its
appendages.

Motor disturbances of the eye and its appendages result from
lesions that hinder the origin of the motor impulses or their transmission
to the eye. These impulses arise in the spinal cord and pass to the eye
by way of the vertebral plexus and superior cervical ganglion. Atlas
lesions interfere with the line of communication existing between the
upper segments of the spinal cord and consequently the muscle fibers
become weakened. The point of obstruction is the result of direct
pressure from the subluxated bone but more commonly from a tightening
of the adjacent tissues. It has not been satisfactorily demonstrated
that motor impulses pass from the spinal cord to the voluntary muscles
of the head and face yet it has been demonstrated that some of the
cranial nerves derive at least some of their impulses from the spinal
cord. It has been satisfactorily demonstrated that trophic impulses
travel from the spinal cord to the different parts of the head and face
and in this way the motor effects can be explained.

Strabismus follows a weakening of one of the ocular muscles thus
permitting the unopposed muscles to draw the eye to the opposite side.

Convergent squint is due to a paralysis or other impairment of the
sixth cranial nerve. This nerve receives a part of its impulses from
the cavernous plexus. These impulses are principally trophic in charac-
ter but according to some, they are partly motor as well. Judging from the
immediate effects of certain forms of lesions on the eye, the writer
is of the opinion that motor as well as trophic impulses reach the
sixth nerve. by way of the cavernous plexus.

The common forms of strabismus are due to disturbances of the
oculo-motor nerve which receives impulses directly from the spinal cord
by way of the cavernous plexus. Paralysis of the fourth cranial nerve
permits the drawing of the eye-ball up and inward; this being an unusual
type of strabismus. Since the cavernous plexus acts as a medium of
transmission of trophic and other impulses from the spinal cord to the
above named cranial nerves, it follows that any lesion affecting it will
cause disturbances in the parts supplied by its branches and communica-
tions. A lesion of the atlanto-occipital or atlanto-axoidal articulations
will interfere with this transmission of impulses.

The most frequent bony lesion that affects the origin and exit of
these impulses is an upper thoracic one. It is a well known fact that

APPLIED ANATOMY.

often a blow on or other injury of this part of the spinal column, will
produce strabismus almost instantly. A case was reported to the writer
in which the physician could produce at will a convergent squint by
pressure at the spine of the second thoracic vertebra.

Fig. 11. — Showing the vertebral arches and occipital bone cut away, exposing
the cord, etc.; 6th C. G., Ganglion on 6th cerv. n.; S. A. N., Spinal Accessory n.;
V. A., Vertebral Artery; V., Vagus n.; G., Ninth n.; Tri., Fifth n.; T., Trochlearis;
C. Q., Corp. Quad.; L., Lingula C'erebelli; F. & A., Facial and Auditory; H., Hypo-
glossus; 2nd C. G., ganglion on 2nd n.; L. D., Lig. Denticulatum.

APPLIED ANATOMY. 39

Myopia and hypermetropia in acquired cases, are similarly ex-
plained that is they are due principally to trophic disturbances caused
by neck lesions. Accommodation of the eye is controlled by the action
of the ciliary muscles. Contraction of these muscles increases the con-
vexity of the crystaline lens. If this is of such a degree that the rays
are focussed before they reach the retina, it is called myopia. If ac-
quired it is the result of an irritative lesion that causes contraction of the
ciliary muscles but if congenital, it is due to the marked convexity of
the lens from faulty development. If these muscles become weakened,
the lens becomes flattened and the rays of light are focussd behind the
retina or rather they are not focussed soon enough and the patient has
trouble in adapting the eyes to near-by objects. In either myopia or
hypermetropia little can be done aside from the wearing of lenses, if
the condition is a congenital one, but if acquired, the conditions can be
benefitted by the neck treatment in quite a large majority of all cases.
It has been noted by the writer that many patients treated for other
disorders caused by neck lesions, have had to change their lenses, the eyes
becoming remarkably stronger under the neck treatment. This effect
applies better to, or rather is more common in cases in which the eyes
are weak but in some apply to cases of near and far sight edness. This
clinical fact demonstrates that neck lesions affect the eye, that impulses
pass from the spinal cord to the eye, and that almost any acquired dis-
ease of the eye may be benefitted by appropriate neck treatment in
which adjustment of the vertebral articulations is secured.

Astigmatism, which is commonly characterized by an unequal curva-
ture of the corneal meridians, can be explained in a similar way, if it is
an acquired case. The ciliary nerves supply the cornea and crystalline
lens. These nerves may be affected by atlas lesions in that impulses
to them pass through the superior cervical ganglion, which is involved
in lesions of the upper cervical vertebrae. These impulses are carried
by way of the ascending internal branch of the superior cervical ganglion.
The plexus thus formed (cavernous) sends a branch to, or rather forms
a root of, the ciliary ganglion.

The branches of the ciliary nerves supply the cornea forming a
plexus around the periphery and forming in the substance of the cornea
the stroma plexus. The function of these nerves is not well known but
it is supposed that they exert a trophic and motor effect on the cornea,
thus controlling its degree of curvature. Morris says that the cornea is

40 APPLIED ANATOMY.

richly supplied with nerves, particularly in its most superficial layers.

Abnormal dilation of the pupil, mydriasis, may come from the
same cause and is similarly explained.

McLachlin in his applied anatomy says in speaking of the relation
of the sympathetic nerve to the eye: "In addition to the ordinary vaso-
motor action, the sympathetic is the motor nerve to the dilator pupillae
and also to Muller's muscle — a layer of non-striped muscular tissue
bridging across the sphenoidal fissure. The center is probably situ-
ated in the medulla, but the fibers pass down the cord some little dis-
tance (cilio-spinal region) leaving it through the last cervical or the
first two dorsal nerves and entering the corresponding ganglia of the
sympathetic trunk, up which they pass to the base of the skull, then
along the plexus around the internal carotid artery (carotid and cavern-
ous plexuxes), pass along the sixth nerve and then join the ophthalmic
division of the'fifth, forming part of its nasal branch, and thence through
the long ciliary twigs of the nasal nerve to the radiating fibers of the
iris. " An upper cervical lesion will interrupt or disturb in some way the
passing of these impulses, since they go by way of the cervical sym-
pathetic, which is in relation with the cervical vertebra?. Clinically it
is not unusual for dilatation or contraction of the pupil to accompany
neck and upper thoracic lesions.

The opposite of mydriasis which is called myosis, follows from in-
hibition or paralysis of the sympathetic or irritation of the third cranial.
Myosis is usually divided into irritation myosis and paralytic myosis.
Irritation myosis most frequently comes from diseases of the brain and
meninges. The paralytic form comes from cervical lesions and lesions
of the cord above the dorsal vertebra. These effects are explained by
the relations and connections of the superior cervical ganglion with the
third cranial nerve. Deaver says "Ligation of the vertebral produces
dilation of pupil on same side. " If ligature of this artery and plexus
produces an effect on the pupil, lesions which affect the vertebral artery
or its plexus will also have an effect. Clinically we are warranted to
make the statement that atlas lesions affect the vertebral artery and
plexus.

Ptosis follows paralysis of the third cranial nerve. This paraly-
sis comes from neck lesions which involve the superior cervical ganglion
or vertebral plexus. The internal division of the ascending branches

APPLIED ANATOMY. 41

of the superior cervical ganglion transmits impulses to the third nerve
with which it is directly connected.

Blepharospasm, which consists of a spasmodic contraction of the
orbicularis palpebrarum muscle, may be caused by an atlas or other
cervical lesions affecting the anterior branches of the superior cervical
ganglion, which connect directly with the seventh nerve.

This condition is usually accompanied by choreic symptoms, such
as a histrionic spasm and some jerking of the head, that is, of the parts
supplied by the seventh cranial nerve which is the principal one involved.

Vaso-motor troubles of the eye and appendages are explained by
the fact that the superior cervical ganglion either contains the vaso-
motor centers, or transmits vaso-motor impulses, for the head and face.
Upper cervical lesions affect this .ganglion, either increasing or decreas-
ing the impulses, and therefore disturb the size of the blood-vessels of
the eye and eye-lids since it is controlled by the condition of this ganglion.

Pterygium consists of a dilated condition of the vessels of the con-
junctiva often resulting in its thickening, most frequently at the inner
canthus.

This dilated condition comes from some interference with the trans-
mission of vaso-motor impulses to these vessels. Conjunctivitis is
caused in a similar way. Granulated lids, an advanced form of con-
junctivitis, and characterized by the formation of minute abscesses,
occurs in chronic eases. A sty or hordeolum is a slightly different form
of vascular disturbance but it may come from a similar lesion; most
cases however come from infection at the point of a diseased hair follicle.
This infection acts as the exciting cause, the lesion being the predis-
posing cause. The vaso-motor impulses to the above parts of the eye
are carried by way of the plexus around the ophthalmic artery, the
branches of which supply blood to the eye. This plexus is derived from
the cavernous plexus which in turn is derived from the superior cervical
ganglion, at least the impulses pass through this ganglion. Contrac-
tured muscles of the neck cause congestion of the eye. The patient
says that he has cold in the eye. The explanation is like that mentioned
above, that the vaso-motor impulses to the eye are inhibited by con-
tracture of the cervical muscles hence a slowing of the current of the
blood and increase in size of the lumen of the vessels.

The ophthalmic artery through its branches almost entirely con-
trols the amount of blood to the eye and its appendages. The inner-

42 APPLIED ANATOMY.

vation of its branches comes from the cavernous plexus, which surrounds
the artery and sends off filaments with each of its branches. Conges-
tion of one part is commonly accompanied by congestion of other parts;
for example, the eye-lids are usually red and slightly inflamed in cases
of congestion of the eye ball, as in cases of headache from overuse of the
eye. In cases of alcoholic intoxication, the eyes and the tip of the nose
become red on account of the action of the alcohol on the vaso-motor
nerves, which is an inhibitory one.

Nutritional disorders of the eye, such as cataract, keratitis and spots
before the eye or muscae volitantes, occur from cervical lesions, since the
fibres which carry trophic impulses to the eye pass through the superior
cervical ganglion. Atrophy of the optic nerve is brought about in a
similar way. The optic nerve is pierced by an artery called the arteria
centralis retinae which artery is innervated by the principal terminal
branch of the "cavernous plexus.

Secretory disturbances, such as lacrymation, follow disturbances
of the ophthalmic division of the fifth nerve. This nerve receives im-
pulses from and is more closely connected with the cervical sympathetic
than any other of the cranial nerves. These impulses pass by way of
the superior cervical ganglion and over both the internal and external
divisions of the ascending branches.

Summary of eye. Atlas lesion disturb the function of the superior
cervical ganglion. This ganglion possibly originates some and trans-
mits mo'st, if not all, of the impulses to the eye by way of its ascending
and anterior brandies. These branches connect with the second, third
and fourth, ophthalmic division of the fifth, sixth and seventh cranial
nerves, which nerves have to do with the eye and its appendages. The
vertebral plexus of nerves is affected by atlas lesions. This nerve con-
trols, or at least has to do with, the nutrition of the floor of the fourth
ventricle at which place are located the cells of origin of nearly all the
nerves of the eye. Also this plexus controls nutrition of the occipital
lobe of the brain in which is the center for vision.

Cervical lesions, and particularly lesions of the articulations of the
atlas and axis, produce ear disturbances. Earache or otalgia is caused
by a disturbance of the sensory innervation of the external auditory
meatus, which is supplied to a great extent by the auriculo-temporal
branches of the fifth cranial and the auricular branches of the vagus.
Pain is most commonly due to pressure. In earache the 'pressure is

APPLIED ANATOMY.

CAROTID ARTERY

SUP. CERVICAL GANGLION

SMALL OCCIPITAL

GREAT AURICULAR

PHRENIC

MIDDLE CERVICAL GANGLION

INT. CERVICAL GANGLION

F1RSTTHORACIC GANGLION

VERTEBRAL PLEXUS

ANSA VIEUSSEUII^
Fig. 12. — Showing cervical nerves and their sympathetic connections.

44 APPLIED ANATOMY.

most frequently a vascular one, that is congestion of the auditory canal,
especially of its nerves. Exposure, which so often in children results in
contracture of the cervical muscles, is in this way responsible for many
cases. These muscular contractures affect the cervical sympathetic
ganglia which are directly connected with the fifth and tenth cranial,
which supply sensation to the affected part, the fifth by way of the
ascending branches which connect with the Gasserisji ganglion; the
tenth by direct filaments that go from the superior cervical ganglion to
the vagus. Atlas and other cervical lesions predispose to muscular
contractures, after which the exciting cause, such as exposure, the more
readily affects the part. There are other causes, viz., decayed teeth
and a dislocated inferior maxilla, in which the fifth nerve is involved.
Hilton cites cases in which a decayed tooth produced chronic earache.
All vascular disturbances of this part of the ear are very painful on ac-
count of the almost inelastic lining of the external auditory canal. In
acute attacks heat applied to the back of neck will relieve, sometimes cure,
if the trouble is entirely due to contracture of cervical muscles, which is
the exception. The correction of neck lesions will cure most chronic
cases since these lesions are responsible for the trouble.

Tinnitus aurium is a condition in which the tympanum is in a state
of too great tension which results in constant vibration. The impulses
generated by the passing of the blood through the internal carotid artery,
which is in relation, set in motion the tightened ear drum. The tone
of the ear drum is controlled by the tensor tympani muscle. Patholog-
ically, the desiccation of cerumen or contracture of this muscle results
in an increased tension. The stopping of the Eustachian tube, which
prevents the entrance of air into the middle ear, allows the external
air pressure to force the ear drum inward thus interfering with normal
vibration. Sound is supposed to be carried by waves. These waves
strike the ear drum and set it in motion. If the ear drum is unusually
tense it will vibrate longer and more easily than it otherwise would.
Neck lesions affect the superior cervical ganglion which, by way of its
ascending branches, connects with the fifth nerve, which by way of the
Otic ganglion sends filaments for innervation of the muscle that con-
trols the degree of contraction of the tympanum, the tensor tympani
muscle. The stapedius is supplied by the seventh, which connects with
the superior cervical ganglion by way of its anterior branches. This

APPLIED ANATOMY. 45

connection is probably only a vasomotor one by which the nerve is
nourished.

The mucous membrane of the ear is supplied by the tympanic
plexus which is formed by filaments from the ninth, carotid plexus,
great superficial petrosal and small superficial petrosal (Morris). The
superior cervical ganglion directly connects with nearly all the above
nerves. In vascular or secretory disturbances of the mucous mem-
brane of the ear the tympanic plexus is implicated, usually it is at fault,
and since its vaso-motor and secretory impulses pass through or arise
in the superior cervical ganglion a lesion of the atlas or axis may cause
catarrh of the ear, a lessened or increased secretion, otitis media, or
even abscess.

The auditory nerve, as far as we can ascertain, has no direct connec-
tion with the superior cervical ganglion. In the aqueductus Fallopii
' it connects with the seventh and its blood supply is in a measure regu-
lated by the vertebral plexus. The internal auditory artery, a branch
of the basilar, supplies the internal ear. The vertebral plexus supplies
the basilar artery and its branches. Lesions of the upper cervical ver-
tebrae affect the vertebral plexus, hence would in many cases affect the
blood supply of the internal ear. Vascular disturbances of the middle
ear come from lesions affecting the innervation of its arteries, which
are: the tympanic branch of the internal maxillary, petrosal of the
middle meningeal, and stylo-mastoid of the posterior auricular. The
vaso-motor nerves of these arteries come by way of the superior cervical
ganglion by way of its anterior and superior branches. The anterior
sends filaments to the middle meningeal artery and its branches; the
ascending branches supply the carotid and its branches.

Deafness, partial or complete, may come from impairment of the
mechanism receiving the sound impulses or from an impairment of the
mechanism conveying them. The first is due to disease of the auditory
nerve, the second usually to disturbance of the tympanum or ossicles.
Neck lesions, as pointed out above, affect both. To differentiate be-
tween the two, use the sound test. If the patient can hear at all the
auditory nerve is not paralyzed ; if patient can not hear watch or tuning
fork, when placed in relation with the ear but can hear it when placed
between teeth or against mastoid, the trouble is in the sound-conveying
mechanism.

Summary. Sensory disturbances of the ear follow cervical lesions

46 APPLIED ANATOMY.

affecting directly or indirectly the vagus or fifth cranial; disturbances
of the tympanum from lesions affecting the fifth, seventh or ninth cranial
nerves; disturbances of the inner ear from cervical lesions affecting the
vaso-motor supply which comes from the vertebral and carotid plexuses.

The nose may be affected as a result of atlas or other cervical
lesions. Catarrh of the nasal mucous membranes is the most common
affection.

Catarrh is a condition characterized by congestion of a mucous
membrane with disturbed secretions. This congestion is most frequently
the result of vaso-motor inhibition which permits an increase in size of
the blood-vessels affected. This vaso-motor disturbance in the head
and face comes from neck lesions. The connection is traced through
the ascending branches of the superior cervical ganglion and their con-
nection with the fifth cranial, the branches of which supply the nasal
mucous membrane. The ophthalmic and internal maxillary arteries
through their branches supply most of the nasal mucous membrane,
and these arteries are supplied by the cavernous plexus and anterior
branches of the superior cervical ganglion. A simple experiment would
clinically prove the connection between the neck and nose. Expose
the back of the neck to a draught. Within a few minutes the nose will
begin to feel stopped and coryza sets in. The thermic stimulation
causes the cervical muscles to contract. This contraction interferes
with the passing of vaso-motor impulses through the sympathetic.
Since the nose gets its vaso-motor supply from this source its mucous
membrane necessarily suffers. If the atlas or axis is displaced there is
chronic congestion of the nasal mucous membrane and we call it chronic
catarrh. These lesions predispose to muscular contracture of the neck,
that is, the muscles more easily contract, hence a very slight thermic
stimulation would readily affect them. On this account a case with
cervical lesions and in a bad climate is hard to cure.

Hay fever, being a vaso-motor disease, is explained in a similar way.
The cervical lesions impair the passing of nervous impulses to the nasal
mucous membrane. It becomes diseased, thus more irritable, and
certain kinds of stimuli affect it more readily than others. The pollen
of flowers acts as an exciting cause, the lesion being the predisposing
cause. Change of climate may relieve because the exciting cause is
removed, or rather the patient is removed from the exciting cause, but
not cured. As in other cases in which cures are effected, the predis-

APPLIED ANATOMY. 47

posing cause, the bony lesion, must be corrected. This lesion is most
often found at the articulations of the atlas and axis. In general, all
vaso-motor and secretory disturbances in this region are similarly ex-
plained.

Anosmia may come as a result of disturbance of the fifth nerve
since a certain amount of secretion is necessary to the normal sense of
smell.

Enistaxis may also come from neck lesions. The application of
cold to the back of the neck will often stop it, this indicating a connection
between the neck and the nose. The explanation is that the cold has a
tonic effect on the vaso-motor nerves controlling the blood-vessels of the
nose.

The various affections of the brain most often come from neck le-
sions. This is explained by the fact that the vaso-motor supply arises
in or passes through the cervical sympathetic. These impulses thus
generated follow the plexuses around the arteries, viz., vertebral and
carotid arteries and their branches. The amount of blood in these ves-
sels is controlled by their size. Their size is controlled by the condition
of the vaso-motor nerve supply to them. If lesions exist which dis-
turb this there must be some effect in the part supplied. Cervical le-
sions do affect these vaso-motor nerves, hence the vascular and sensory
disturbance. Although many cerebral troubles come from other sources,
such as abuse, many come from lesions in the neck. Apoplexy, cerebral
softening, congestive headache, motor and sensory disturbance, such as
spasms and pain, depend on the amount and character of the blood
sent to the brain.

According to Langley,it has not been definitely demonstrated that
the blood-vessels of the brain have vaso-motor nerves but according to
the observations of many, there seems to be no doubt about it. In
speaking of the blood-vessels of the pia mater Landois says: "The blood-
vessels of the pia mater are naturally in part under the influence of the
vaso-motor nerves accompanying them; in part their size may be in-
fluenced from remote parts of the body. Irritation of the sympathetic
affects only the vessels of the same side, but does not alter the blood
pressure upon the other side. Paralysis of the vaso-motor nerves, also
by means of narcotics, causes dilatation of the vessels. The vessels
contract strongly in death. " From observations made in clinic cases
it seems to be demonstrated beyond a doubt that the vessels of the

APPLIED ANATOMY.

meninges and possibly those of the brain substance have nerves which
have their origin in the spinal cord, at least lesions of the spine affect
the circulation of blood through these vessels.

The vaso-motor,motor and secretory supply to the face comes from
or is controlled to a great extent by the cervical sympathetic. The
vaso-motor impulses travel by ■nay of the superior cervical ganglion,
anterior and ascending branches, to the carotid artery, thence over

Fig. 13. — Showing connections of superior cervical ganglion; the upper cer-
vical; and 9, 11 and 12 cranial nerves with the carotid arteries and the pharynx.
1, 2. 3, 4, first four cervical nerves; II hypoglossus; V., vagus; G. P. , glosso-pharyngeal ;
I-C, internal carotid; E. C, external carotid; G., superior cervical ganglion. (After
Cunningham).

facial branches to the face. Sometimes we are inclined to the belief
that the nuclei of the seventh nerve are affected by vascular changes,
these following neck lesions affecting the vertebral artery.

Since it has not been conclusively demonstrated that any motor
impulses pass to the voluntary muscles of the head and face by way of

APPLIED ANATOMY. 49

this ganglion, or at least the physiologists disagree about it, we are
forced to the conclusion that these motor effects that undoubtedly come
from neck lesions, are the results of vaso-motor disturbances that affect
the nutrition of the nerve cells or as stated above, the nuclei of origin
of the seventh nerve.

In regard to the passing of motor impulses to voluntary muscles of
the eye Landois says: "The motor fibers for the unstriated muscles of
H. Muller in the orbit and the lids and for the external rectus, pass in
part through the dorsal nerves from the first to the fifth (in the cat)."
These impulses pass by way of the superior cervical ganglion; that is
according to this, it does send, by way of its ascending branches, im-
pulses to voluntary muscle fibers, since the external rectus is a volun-
tary muscle.

Sensory disturbances follow lesions affecting the fifth cranial nerve.
These sensory disturbances are explained by (1) the effect of lesion
on the blood supply or nutrition of the cells of origin of the fifth cranial
nerve and (2), disturbance of its long or descending root which is sensory
and runs as low in the spinal cord as the third cervical segment. The
cervical lesion affects the circulation in the cervical spinal cord where
the cells of this root of the fifth cranial nerve are disturbed.

Under vaso-motor disorders of the face we have classed eruptions,
blotches, pathological blushing and anemia. Under motor disturbances,
Bell's paralysis, tic douloureux and histrionic spasms. Under sensory
affections, facial neuralgia, toothache and sensory paralysis.

The above mentioned nervous and vascular distribution and con-
nections explain these various troubles since atlas and other cervical
lesions affect all the nerves mentioned. This has been proven clinically
as well as anatomically. Secretory disturbances may follow cervical
lesions, the most striking being hemidrosis, that is sweating of a lateral
half of the face. The fifth cranial is supposed tocontrol secretion of sweat
of the head and face. This nerve connects with the cervical sympathetic.

The writer has treated a few cases of hemidrosis and with uniform
success. In all the cases, there was found a lesion at the atlanto-axoidean
articulation. In some of these cases, only a few treatments were neces-
sary to reduce the lesion and thus effect a cure.

The pharynx is supplied with blood by the ascending pharyngeal,
ascending palatine branch of facial, and the posterior palatine from
the internal maxillary. The nerves, vaso-motor, motor and sensory,

50 APPLIED ANATOMY.

are derived from the pharyngeal plexus which is formed by the vagus,
glosso-pharyngeal and branches from the cervical sympathetic. The
principal disease is pharyngitis which consists of an inflammation of
its mucous membrane. Most frequently the congestion preceding and
accompanying the inflammation is from a vaso-motor disturbance.
This comes from a variety of causes, but the cervical lesions are most
important in chronic sore throat. Referring to the arteries, it is
seen that the vaso-motor supply would be affected by cervical lesions
since the vaso-motor impulses arise in or pass through the cervical
sympathetic, thence to the pharynx by way of the ninth and tenth
cranial nerves. Dysphagia and "sore throat" are secondary to the
inflammation.

The tonsils are often affected by neck lesions, either through their
nerve or blood supply. Their nerve supply is from the ninth cranial
and Meckel's 'ganglion. Both of these nerves are connected with the
superior cervical ganglion. The ninth cranial gets most of its motor
impulses from the upper spinal cord. The nerves following the arteries
are. many, since the tonsil is exceptionally vascular. The external
carotid by way of the ascending pharyngeal, the facial, through the
tonsillar and ascending palatine, the lingual and the internal maxillary
send branches to them. These arteries are supplied with vaso-motor
impulses through the superior cervical ganglion, by way of the ninth
cranial hence vascular disturbances in the tonsil when this ganglion is
affected. ,

The larynx, which forms the entrance to the respiratory tract and
is the organ for the formation of the voice, is affected by cervical lesions.
The nerve supply to the larynx is through the superior and recurrent
or inferior laryngeal nerves. These connect by way of the vagus with
the superior cervical ganglion and cervical nerves.

The innervation of the hyoid muscles comes almost entirely from
the upper three cervical segments by way of the cervical plexus. These
muscles when contractured draw the hyoid bone out of normal position
and the voice is affected. The blood supply comes from the superior
and inferior thyroid arteries. The superior is a branch of the external
carotid, hence is innervated by branches of the cervical sympathetic.
The inferior thyroid is a branch of the thyroid axis and is innervated by
the inferior cervical and stellate ganglia. The veins, the superior,
middle and inferior thyroid, empty into the internal jugular.

APPLIED ANATOMY. - 51

The salivary glands may be affected by cervical lesions. The
parotid gland is innervated by the facial, great auricular, glosso-pharyn-
geal, by way of the auriculo-temporal branch of the fifth and the carotid
plexus. All these nerves connect with or are supplied by impulses
from the cervical sympathetic system.

Some secretory impulses arise in the upper thoracic spinal cord,
pass out over the anterior nerve roots, common nerve trunk, anterior
division and white ramus, into the gangliated cord, thence upward by
way of the superior cervical ganglion.

It also may be affected through its blood supply or drainage.

The other salivary glands are in a similar way affected by a neck
lesion.

The mastoid cells are innervated by a branch from the suboccipital
nerve. Lesions of the occipito-atlantal articulation always involve this
nerve, hence the effect on the mastoid cells.

Atlas lesions often irritate the nerve innervating the rotator muscles
of the head. This results in chorea or other forms of disease character-
ized by spasmodic contractions of the cervical muscles. It is a well
known fact that chorea or some form of tic, comes oftenest from lesions
in the upper cervical region. The explanation is that the lesion inter-
feres, by pressure or other means, with the regular transmission of motor
impulses to the muscles of the neck. There being a spasmodic trans-
mission of these nerve impulses, there is a spasmodic effect characterized
by irregular muscular contractions.

Spasms may also be caused by atlas lesions. In such cases, per-
haps the medulla is affected as a result of the lesion interfering with its
blood-supply which is controlled by the vertebral vessels and plexus of
nerves.

Epilepsy may come from a similar cause if the higher centers are
involved. The circulation to the brain is governed to a certain extent
by the superior cervical ganglion hence any vascular disturbance, of
which epilepsy is one, may come from a lesion involving it.

Summary of the atlas. Lesions of the atlas involve the atlanto-
axoidal articulation oftener than the occipito-atlantal. When this
articulation is disturbed the cervical sympathetic system is impaired.
The superior cervical ganglion sends filaments to, or communicates
with, all the cranial and upper four cervical nerves, hence the varied
effect of a lesion involving it. This ganglion is in relation with the

APPLIED ANATOMY.

atlantoaxial articulation and would be affected by a lesion of it. The
vertebral plexus is also in relation and would necessarily be involved
by a lesion. As a result the spinal cord, medulla, pons, cerebellum,
pituitary body, fourth ventricle and a part of the cerebrum would be
disturbed by an atlas lesion.

Vaso-motor effects occur from atlas lesions in all parts supplied by
the superior cervical ganglion and vertebral plexus, since these impulses
pass through the ganglion and possibly the plexus. Motor effects in
the involuntary muscles, that is the smooth muscle fibers, result from
effect of lesions on the superior cervical ganglion through which these
impulses pass on their way from the spinal cord to the muscles. The
motor effects on the voluntary muscles are best explained by the dis-
turbance of circulation to the motor cells in the brain. . In proportion

Articular Surface
for Ant. Arch of Atlas

Fig. 14. — Showing front view of axis. Note the superior articular surfaces.

to the trophic disturbance of these cells, so is the effect on the muscles
supplied. The vaso-motor nerves control the amount of blood to, hence
the trophic condition of, the cells. Some of the secretory and probably
all vaso-motor effects from atlas lesions, are explained by disturbance
of the superior cervical ganglion, since the secretory and vaso-motor
impulses to the glands above, pass through this ganglion. The trophic
effects are explained by the vaso-motor disturbances. The sensory ef-
fects are explained by the disturbance of nutrition of the sensory cells
of origin of the long or descending root of the fifth cranial, and by the
fact that the ascending branches of the superior cervical ganglion con-
nect with the Gasserian ganglion and thus the pain is a referred one.
As in motor disorders the effect on the sensory nerves is explained by
the trophic disturbances of the cells giving origin to those nerves.

APPLIED ANATOMY. 53

In the explanation of the effects of an upper cervical lesion we
assume that the superior cervical ganglion is affected. Clinically there
is no doubt about it. If the lesion affects this ganglion the. rest of the
explanation is simple. In all cases of lesions of the articulations of the
atlas, the adjacent tissues are affected and I believe that the best ex-
planation of the distal effects is that the tightening of the tissues dis-
turbs the function of the ganglion. The continued drawing of the mus-
cles and ligaments interferes with the function of all structures in rela-
tion.

THE AXIS.

The axis, so named because it forms a pivot upon which the head
and atlas rotate, is the strongest and next to the atlas the most peculiar
vertebra in the cervical region. The most striking peculiarity is the
odontoid process which represents the displaced body of the atlas.
The check ligaments, which limit rotation of the head, are attached to
it. This process is of interest in that in hanging or in dislocation from
any cause it is thrown directly against the spinal cord, the transverse
ligament being broken. The lamina? are exceptionally strong, being
thick and prismatic on cross section. The spinous process is very large,
markedly bifid and deeply grooved on its under surface. This process
forms an important osteopathic landmark of the neck. The superior
facets are placed over the pedicles and the anterior root of the transverse
processes. They are nearly circular, slightly convex and face upward
and outward. The second nerve passes out posterior to the facet which
is true only of the atlas and axis. The inferior facet is not directly
beneath the superior as in other vertebrae but posterior, thus resulting
in the weight of the head being transmitted through an angle instead
of a straight line. The transverse processes are short, sometimes
rudimentary, and are perforated by the foramen for the passage of the
vertebral artery.

The atlanto-axoidal articulation permits of nearly all movements,
the facets being very shallow. Rotation of the head and atlas on the
axis is the most important and most marked. In a supposed lesion of
this articulation a test of mobility should be made, there being some
restriction to the normal degree of rotation of the head if a lesion exists.

The principal landmark of the axis is the bifid spinous process. It
is ordinarily the first bone to be palpated below the occiput in the median

APPLIED ANATOMY.

line of the neck. The articular processes can quite distinctly be out-
lined and particularly so if a lesion of the atlanto-axoidal articulation is
present. In such cases there is a prominence of the joint, which is best
palpated midway between the spinous and transverse processes, which
is partly the result of the irregularity and partly the result of a thicken-
ing of the muscles and ligaments over it.

The ligaments involved by an axis lesion are those uniting the axis
to the atlas, the occiput and the third cervical.

Those uniting the atlas and axis are the anterior and posterior

POST. COMMON LIGT.

OCCIPITO AXOID LIGT.

i -MIDDLE ODONTOID LIGT.

— ODONTOID OR CHECK

VERTICAL PORTION OF

■TRANSVERSE OR
CRUCIA.LLIGT.

ACCESSORY BANDOF ATLANTO
AXIAL CAPSULAR LIGT.

Fig. 15. — Showing the vertebral arches cut away exposing the ligaments connect-
ing the axis and atlas and occiput.

atlanto-axoidean, two capsular, the transverse ligament and the atlanto-
odontoid.

The atlanto-axoidean ligaments are thin, but strong, elastic mem-
branes. In that strength with mobility is necessary, these ligaments
are well adapted.

The posterior atlanto-axoidean is attached above to the lower edge
of the posterior arch of the atlas and inferiorly to the upper edge of
the lamina of the axis. It has a layer of elastic tissue in it. It is in
relation with the inferior oblique muscles and is perforated by the sec-
ond cervical nerve. This is of interest in that in subluxations of the

APPLIED ANATOMY. 55

axis this ligament is more or less involved hence a disturbance of this
nerve as it passes through the ligament.

The anterior atlanto-axoidean is in its middle portion, a continu-
ation upward of the anterior common spinal ligament, and it in turn is
continued upward and helps to form a part of the anterior atlanto-
occipital ligament.

The important ligaments uniting the occiput with the axis are the
check or lateral occipito-odontoid and the central odontoid or sus-
pensory.

The capsular are important in that they are necessarily injured in
all dislocations since they completely surround the atlanto-axoidean
articulation.

The most important of these ligaments is the transverse, so far as
the life of the individual is concerned. It is attached on either side to
a tubercle on the lateral mass of the atlas and passes behind the odon-
toid process, thus dividing the spinal foramen into two parts, the an-
terior containing the odontoid process and the posterior, the spinal cord,
if this ligament were to become broken, the odontoid process would
be forced into the spinal cord and instant death result. Posteriori}',
there is found a vertical portion which is attached above to the anterior
margin of the foramen magnum, and on this account it is called the
crucial ligament. ■&•

This latter ligament is sometimes injured in hyper-extension of the
head. Morris says: "The suspensory ligament is tightened by exten-
sion and relaxed by flexion or nodding; the lateral odontoid not only
limit the rotatory movements of the head and atlas upon the axis, but
by binding the occiput to the pivot, round which rotation occurs, they
steady the head and prevent its undue lateral inclination upon the spine. "

These ligaments restrict movements of the head and help to poise
it on the spinal column. In speaking of the occipito-atlantal and the
atlanto-axoidean joints, Morris further says: "The ligaments which
pass over the odontoid process to the occiput are not quite tight when
the head is erect, and only become so when the head is flexed. If this
were not so, no flexion would be allowed; thus muscular action, and not
ligamentous tension, is employed to steady the head in the erect posi-
tion. It is through the combination of the joints of the atlas and axis,
and occiput and atlas (consisting of two pairs of joints placed symmetric-
ally on either side of the median line, while through the median line there

56 APPLIED ANATOMY.

passes a pivot, also with a pair of joints) that the head enjoys such free-
dom and celerity of action, remarkable strength and almost absolute
security against violence, which could only be obtained by a ball and
socket joint; but the ordinary ball and socket joints are too prone to
dislocations by even moderate twists to be reliable enough when the
life of the individual depends on the perfection of the articulation,
hence the importance of this combination of joints. " These twists do
take place which impair the joint itself and some or all of the structures
in relation. A lesion will cause tenderness in, thickening of, and some-
times rupture or at least a stretching of these ligaments. These liga-
ments are subject to sprains as are the ligaments of other more freely
movable joints. Moullin, in speaking of sprains of the back and neck
says: "One of the most singular features in connection with these
sprains is the way in which the backbone itself and the muscular and
ligamentous structures around it are overlooked and ignored. Even
in the ordinary accidents of every day life there is a great tendency to
lay everything that is serious or lasting to the spinal cord. In railway
cases there is no hesitation at all; if any serious result ensues it must
be the result of damage this structure has sustained, or of inflamma-
tion following it; little or no attention is paid to anything else. Yet it
is difficult to see why the other structures should enjoy immunity.
The vertebral column may be strained, especially in the cervical and
lumbar regions; the ligaments torn or stretched; the nerves bruised or
crushed; the smaller joints between the segments twisted and wrenched;
the muscles detached from their bed and torn across or thrown into such
a state of cramp that they become rigid and unable to act with freedom;
or the fibrous sheath which contains them and helps to secure the bones
laid open and filled with blood. " Undoubtedly these ligamentous, and
muscular disturbances as well as bony lesions are often overlooked.
In trauma in which there are marked lesions, these ligaments are torn
at many points and such heal with difficulty.

The muscles in relation with and which would be affected by an
axis lesion, are the longus colli, inferior oblique, rectus capitus

POSTICUS MAJOR, SEMISPINALS COLLI, INTERSPINALES, MULTIFIDUS
SPIN^E, SCALENUS MEDIUS, SPLENIUS COLLI, INTERTRANSVERSALES,

levator anguli scapula and transversalis cervicis. The lesion
affects the muscles in one of two ways, either by interfering with the
nerve and blood supply or by change of position of the axis thus ap-

APPLIED ANATOMY. 57

proximating or separating the origin, and insertion. This effect of
change of position will be considered here; that from nerve disturb-
ances under effect on nerve.

The longus colli has to do with flexion, rotation and lateral flex-
ion of the neck. The vertical portion is attached anteriorly to the
lateral part of the body of the axis and is the principal part directly
involved by axis lesions. When impaired, there is difficulty in flexion of
neck or else the neck is held in position of partial flexion, that is, exten-
sion is incomplete, the patient not being able to look directly upward.

The inferior oblique has its origin in the side of the spine of the axis
and is inserted in the tip of the transverse process of the atlas. If
irritated it approximates the origin and insertion, that is the atlas is
tilted or the transverse process is twisted backward. The head with
the atlas is drawn to one side and backward. This muscle seems to be
affected in all lesions of the atlas and axis and can be palpated quite
deeply in, as a hard, contractured band in relation with the articular
process of the axis, its course being up and out. I believe it is more fre-
quently affected than any other of the cervical muscles.

The rectus capitus posticus major has to do with extension of the
head and is involved in the various tics and choreas. In disturbances
of the finer movements of the head this muscle is usually at fault.

The semispinalis has to do with extension, lateral flexion and rota-
tion to the opposite side. This muscle is also involved in most of the
motor disturbances of the head and neck.

The interspinales extend the neck and have to do, when irritated,
with approximation of the vertebra?.

The cervical portion of the multifldus spinse muscle arises from the
articular processes of the fourth to the seventh cervical vertebrae and is
inserted into the spines of the vertebrae above. It has to do with ex-
tension, lateral flexion and rotation to opposite side. It is one of the
deep muscles of the neck and its condition has to do with the circula-
tion of the spinal cord. If it becomes contractured, there is obstruc-
tion to venous drainage of the spinal cord in that region. It is also in-
volved in chorea, hysteria and spinal meningitis. Curvatures of the
spine in general, come in part from atrophy of this muscle.

The splenius is important on account of the part it plays in many
cases of torticollis, especially recent cases. McClellan says: "The action
of the splenii aids that of the sterno-mastoid muscles. When the two

APPLIED ANATOMY.

muscles on both sides contract together they assist in holding the head
erect. The action of either of them (the two portions working together)
is to draw the head and the upper cervical vertebra? toward its own side.
When this contraction is permanent it may produce wry neck and may

Fig. 16. — Showing the muscles that have to do with producing torticollis. Note
the sterno-mastoid and splenius.

be confounded with the action of the opposite sterno-mastoid muscle,
which produces the same effect. " Lesions of the axis affect the splenius
usually producing contracture of it from which results impaired move-
ment of the head and neck.

APPLIED ANATOMY. 59

The interspinales, when affected and working together, produce
impaction of the vertebrae.

The levator anguli scapulae, when affected either draws upward
the scapula or extends and laterally flexes the neck. Osteopathically
it is of importance in that it is involved in most cases of "cold in the
head" it being contractured and tender.

The scalenus medius arises from the upper surface of the first rib
between the subclavian groove and tuberosity and is inserted in the
posterior tubercles of the transverse processes of the lower six cervical
vertebras. It is the strongest of the scaleni muscles and has to with
lifting the rib when the fixed point is above, or lateral flexion of the
neck when the fixed point is below. Axis lesions impair its function,
usually producing contracture of it. The most common effect is ele-
vation of the posterior part of the first rib. (See lesion of first rib for
effects.)

Axis lesions impair the above named muscles by change of posi-
tion. The effects are, disturbance of movements of neck, spasmodic
contraction or twitching, especially involvement of the finer movements
of the head, torticollis, secondary lesions and disturbance of circula-
tion of the spinal cord, cervical portion.

The arteries directly involved by an axis lesion are the vertebral
and its branches, muscular and spinal. Those indirectly involved are
the terminals of the vertebral and the carotid arteries and their branches.
This involvement comes through their nerve supply, viz., vertebral
plexus and superior cervical ganglion, which are affected by an axis
lesion. The lesion produces pressure on the arteries in relation thereby
lessening the amount of blood passing through them. The muscles in
relation are improperly nourished, and the spinal cord is deprived of
its normal arterial supply. Varied effects follow these conditions.
(For effect on vertebral see arteries under atlas.)

The veins that would be affected by an axis lesion are those in re-
lation. They are the vertebral, lateral spinal and muscular, which
latter drain the muscles in that region. The vertebral drain the cer-
vical spinal cord, cervical vertebras and muscles. The lateral spinal
drain the cord and empty into the vertebral. An axis lesion especially
affects the size of the intervertebral foramina, usually lessening it. As
a result the lateral spinal veins are compressed, venous congestion of
the spinal cord follows which impairs its function, sometimes increas-

APPLIED ANATOMY.

ing, sometimes decreasing activity, this depending on the degree of con-
gestion, length of standing and function of part involved. The chronic
effect is one of lessened activity. A certain amount of localized toxemia
follows congestion. This may irritate the cells in the cord thus pro-

CONNTS WITH5M/ILL OCCIPITAL N
CONN'TS WITH IstCERVICALN
SPLEN1US- CAPITIS

TRACHELO- MASTOID-

SUPERFICIAL FASCIA OF SCALP
ABOVE SUP. CURVED LINE

AURICULAR BR \ I

' ,.GK. OCCIPITAL Vi

OCCIPITAL BRA

COM with 6R OCCIP.iGRTAURIC
MASTOID BRA'S
VAGUS

Fig. 17. — The second cervical segment showing its branches and connections.

APPLIED ANATOMY. 61

ducing pain and muscular contracture. The lesion would also affect
the vertebral. Since these veins drain the cord, vertebrae and muscles
in relation, congestion of these parts follows a lesion of the axis.

The nerves involved by axis lesions are the second and third cer-
vical nerves, recurrent meningeal, gangliated cord or superior cervical
ganglion and vertebral plexus and their branches and connections.
Indirectly all branches of these nerves may be affected by an axis lesion.
Only the nerves in relation with the atlanto-axial articulation will be
considered here.

The second cervical nerve, like those below it, divides immediately
on its exit, into an anterior and posterior division. The posterior pri-
mary division in turn divides into a small external and large internal.
The external supplies the muscles in relation. The internal is the great
occipital nerve which is important in osteopathic therapeutics in that
in headache in the back part of the head this nerve is supposed to be
involved. It pierces the complexus and trapezius muscles after which
it divides into terminal branches which ramify in the superficial fascia
of the scalp as far as the posterior part of the parietal bones. Morris
says that "occasionally one branch reaches the pinna and supplies the
skin on the upper part, of its inner aspect." It also communicates
with the first and third cervical nerves. Pain in the area supplied by
great occipital nerve must be in that nerve. Hilton says: "Suppose
a patient to comjjlain of pain upon the scalp, it is essential to know
whether that pain is expressed by the fifth nerve or by the great or
small occipital. Thus pain in the anterior and lateral parts of the head
which are supplied by the fifth nerve, would suggest that the cause must .
be somewhere in the area of the distribution of the other portions of
the fifth nerve. So, if the pain be expressed behind, the cause must
assuredly be connected with the great or small occipital nerve, and in
all probability depends on disease of the spine between the first and
second cervical vertebrae." From our viewpoint this disease is a sub-
luxation at this point and Hilton's idea bears out our practice.

The anterior division of the second cervical nerve, unites with the
first, third and fourth to form the cervical plexus. The branches of
this plexus that receive their impulses from the second cervical segment-
are the small occipital, great auricular, superficialis cervicis and mus-
cular branches to the muscles in relation.

The small occipital follows the posterior border of the sterno-

APPLIED ANATOMY.

mastoid muscle and gives off twigs to the skin over the upper portion
of the triangular space. After perforating the deep fascia it reaches
the scalp where it terminates in cutaneous filaments. It breaks up
into three branches, the auricular, occipital and mastoid terminal
branches.

Fig. 17. — Showing sensory innervation of back of head (Hilton). G. O., great
occipital; S. O., small occipital; A. T., auriculo-temporal. Headache from cervical
lesions are referred in general, to these areas.

The auricular branch of the small occipital, is distributed to the
skin of the scalp and communicates with the great occipital. The mas-
toid, is distributed to the skin over the mastoid process. The occipital
branches ramify over the occipitalis muscle and supply the skin of the
scalp. They communicate with the great occipital nerve.

In axis lesions the small occipital nerve is usually involved, hence

APPLIED ANATOMY. 63

a sensory effect in the above named points of distribution of the nerve.
Headache with tenderness of the scalp is very common when this nerve
is involved.

The great auricular divides, in relation with the sterno-mastoid
muscle, into three branches, — mastoid, auricular and facial. The mas-
toid supplies the integument covering the mastoid process, communi-
cating with the mastoid branch of the small occipital. The auricular
supplies the back and lower part of the pinna. The facial is distributed
to that portion of the integument of the face over the parotid gland.
Some filaments enter the gland and communicate with the lower divi-
sion of the facial nerve. When this nerve is involved, as it often is in
axis lesions, pain will be referred to the area supplied by the above named
branches. Hilton cites a case of a "kernel" or enlarged gland lying
close to the second nerve, causing earache. Muscular contracture will
cause a similar effect.

The superficial or transverse cervical nerve has to do with supplying
sensation to the integument of the lateral and anterior portions of the
neck. It communicates peripherally with the cervical branch of the
facial.

The muscular branches supply the sterno-mastoid, rectus capitus
anticus major, longus colli, genio-hyoid, the infra-hyoid muscles, ob-
liquus inferior, complexus, splenius and trachelo-mastoid muscles.

Axis lesions affect the muscular branches receiving impulses that
pass out through the second cervical foramen, therefore these muscles
would be affected, that is contracted or relaxed. The sterno-mastoid
would thus be affected by an axis lesion. The most common effect is
that of contracture producing torticollis. This muscle has its origin
in the manubrium and clavicle and is directed up and back to the mas-
toid process and adjacent portion of occipital bone. It flexes laterally
the head and neck, rotates the face to opposite side, and when act-
ing conjointly with its fellow, raises the manubrium and clavicle or flexes
head or neck. In torticollis from contracture of this muscle, the face is
drawn toward the sound side. In some cases the disease is supposed
to be congenital, but I think most of such cases occur at childbirth, for
in such cases much traction, or rather improper traction, is exerted on
the neck and a lesion of the axis is produced, which in turn affects the
second nerve, hence this muscle. The rectus capitus anticus major has
to do with slight flexion of the neck, hence this movement would be

64 APPLIED ANATOMY.

abnormal in axis lesions. In some there is a fibrillary twitching as a
result of irritation of this nerve.

The longus colli has been considered above. The genio-hyoid
muscle by contracting, draws the hyoid bone upwards and forwards or
pulls the lower jaw downward. As a result of a lesion involving the
nerve supply of this muscle, the hyoid bone would be drawn out of place,
hence disturbances of the vocal organs. The infra-hyoid muscles, viz.,

STERNOHYOID, OMO-HYOID, STERNO-THYROID and THYRO-HYOID, are

supplied by the second cervical nerve by way of the loop joining the
hypoglossal nerve. They, as their names indicate, are attached to the
hyoid bone and by their unusual contraction or relaxation the bone
assumes an abnormal position. As suggested above, the vocal organs
would be involved since they are in relation with this bone. Aphonia
is the most common effect.

The oblIquus inferior and splenitis have been considered. See
page 57.

The complexus is involved in axis lesions, thus interfering with
extension and lateral flexion of the head and rotation of the face. In
colds of the head this muscle is usually contractured.

The second cervical nerve connects with the ninth, tenth, eleventh
and twelfth cranial nerves and the superior cervical ganglion. The
vagus is reached by filaments to the lower' ganglion or ganglion of the
trunk, which is placed below the base of the skull.

The impulses passing over this nerve go from the superior cervical
ganglion to the pneumogastric. On this account they are supposed
to be vaso-motor and secretory in function. From a clinic point of view,
it appears that motor impulses pass from the ganglion to the vagus
since vomiting occasionally occurs from a lesion of the axis. In other
cases seen by the author, asthma and violent attacks of coughing re-
sulted from the lesion. This nerve filament is in relation with the atlanto-
axoidean articulation and is affected in some lesions of this joint.

The eleventh unites in the sterno-mastoid muscle with the mus-
cular branches of the second cervical supplying the sterno-mastoid.

This nerve is affected by an axis lesion both along its course and at
its spinal origin. Contracture of the sterno-mastoid muscle will cause
it to be impinged on. The spinal portion arises as low in the spinal
.cord as the fifth cervical segment. The filaments pass out or the lateral
column of the white matter of the spinal cord and forming a few strands,

APPLIED ANATOMY. 65

pass upwards through the foramen magnum into the cranial cavity.
As soon as it leaves the skull, it communicates with the vagus, and its
accessory fibers continue into the recurrent laryngeal, cardiac, pharyn-
geal and superior laryngeal branches.

The axis lesion interferes with the nutrition of the spinal seg-
ments in which are located the cells of origin of the spinal portion of
this nerve, hence the effects on its function. This interference is the
result of circulatoiy derangements of the supply and drainage of this
segment.

The hypoglossal nerve receives fibers from the first and second
cervical nerves that supply the infra-hyoid muscles. The spinal origin
of the nerves of these muscles has been proven by experiments on animals.

The superior cervical ganglion communicates with the second cervical
nerve by means of a grey ramus uniting with the anterior division.

The ninth cranial, connects with the superior cervical ganglion by
a fine communicating filament. This nerve filament is supposed to
carry vaso-motor impulses from the ganglion to the nerve, hence to
parts supplied by the nerve viz., the pharynx, tonsils and tongue.

To summarize -the effects on the second cervical nerve, there would
be pain in the back of the head, ear, parotid gland and part of face,
that is headache, earache and neuralgia; torticollis, chorea and various
other disturbances of the cervical muscles; aphonia, and other impair-
ments of the voice; various secondary effects on the tenth, eleventh and
twelfth cranial nerves and structures supplied by them; also some effect
on the superior cervical ganglion.

The recurrent meningeal would be affected in a way similar to that
in atlas lesions.

The second cervical segment would probably be directly af-
fected by this lesion. Vascular disturbances of the cord, meninges,
ligaments and column are the important effects of disturbance of the re-
current nerve. The effects and diseases caused by the superior cervical
ganglion have been considered (see p. 31.) This ganglion being in relation
with the axis is more easily and more commonly affected by an axis
than by an atlas lesion.

The vertebral plexus surrounds the vertebral artery and is more
or less affected by the lesion. This plexus sends filaments over the
lateral spinal arteries into the cord. The blood supply of the cord,
perhaps the second segment more than any other, would be affected by

66 APPLIED ANATOMY.

disturbance here of the vertebral plexus. The meninges are affected
in all marked lesions. A part of the coverings of the cord passes out
with each nerve and is attached to the vertebra, hence would be affected
by every abnormal change of position. These coverings are also affected
through the blood and nerve supply. Meningitis and other disturbances
follow such lesions. The spinal cord is affected through its blood sup-
ply or by direct pressure, in which case there is usually paralysis of the
parts below, resulting in death. Arterial supply to and drainage of the
cord are impaired and, as mentioned above, the cells in the various
centers fail to properly perform their function.

Summary. The axis is the most frequently subluxated of all the
vertebrae, at least the atlanto-axoidean articulation is oftenest affected.
This comes from the free mobility of this joint and lever action of parts
above. The articular processes of the axis can be more readily palpated
than those of the other cervical vertebrae, they being best felt at a point
about midway between the spinous and transverse processes. A strain of
the ligaments will cause a thickening, which irregularity may be mis-
taken for a bony lesion. A unilateral thickening or lump over the artic-
ular process is indicative, if not diagnostic, of a strain of the ligaments.
This is quite often but not always accompanied by a subluxation. This
explains why in many cases in which faithful and persistent work has
been given the irregularity, the lump or thickening, remains and the
articulation continues to be tender. Strained ligaments heal slowly.

An axis lesion may produce almost any form of disease in organs
and tissues above it. The diseases most commonly associated with
axis lesions are eye affections, headaches and vascular disturbances of
the head.

The vaso-motor effects of this lesion are similar to those of an atlas
lesion and are explained in a similar way. In addition it might be
stated here that some of the vaso-motor effects in parts supplied by the
ninth, tenth and twelfth cranial nerves, are the results of this lesion
affecting the superior cervical ganglion and its branches of communica-
tion to these nerves over which the impulses pass.

The motor effects are most marked in the cervical muscles, the
throat and hyoid muscles and the involuntary muscle fibers of the eye.
The secretory, are the same as for an atlas lesion. The sensory and
trophic effects are best explained through the vaso-motor connections.

APPLIED ANATOMY. 67

THIRD CERVICAL.

The third cervical vertebra is the smallest of the vertebrae. The
laminae are especially light, thus permitting of fracture which occurs
oftenest in this vertebra. It is located farther anterior than the other
cervical vertebrae, partly on which account this region is weak. Mc-
Clellan says: "The weakest point, not only in the neck but also in the
entire spirxal column, is between the second and third cervical verte-
brae." The Superior Facets of the third cervical face upward and
backward, are slightly concave and somewhat smaller than the cor-
responding ones of the atlas and axis. The shape of the superior facets
would permit of almost any form of movement, but antero-posterior
motion as in nodding the head, is most pronounced. The spinous
process is shortest of all the vertebral spinous processes and can, in the
the normal neck, be felt with difficulty unless flexion is used. If il
cannot be palpated when the neck is flexed, or if it can be palpated with-
out flexion of the neck, it is ordinarily regarded as abnormal, especially
so if tenderness is present over the spine or articular process. This
shortness permits of freer movements. The transverse processes
are perforated for passage of the vertebral arteries as are those of the axis,
but are not so well developed as those below, yet are usually longer
than those of the axis.

This bone and its articulations are subject to displacement and
injury as are all vertebrae and their articulations. The most common
lesions are an anterior or posterior subluxation, or torsion. This ver-
tebra is possibly dislocated as an individual bone, more often than any
other cervical vertebra. Usually, in a "lesion" one part of the spinal
column is moved on another, hence only two articular facets are in-
volved and it is not so common for both the superior and inferior facets
to be involved as would be the case in a subluxation of a single vertebra.
The exception seems to be in the third cervical vertebra, since its most
common subluxation is one in which it is forced either forward or
backward, that is, both superior and inferior facets are involved. The
diagnosis is based on irregularity, tenderness and disturbance of motion.
In making tests for weak places or lesions in the spine in general, Dr.
G. D. Hulett advised extreme flexion. In this test there will be pain
at the weakest points. This can with advantage be used in cases of
suspected lesions of the neck.

68 APPLIED ANATOMY.

The intervertebral discs in the cervical region are not very thick
but are thicker anteriorly than they are posteriorly. The curve of the
neck depends on this rather than on the size of the bodies of the vertebrae.
Curvatures in the cervical as well as in other regions, are partly the re-
sult of changes in thickness in the intervertebral discs. These discs are
elastic, have blood-vessels and nerves, and their function is impaired by
bony lesions of the corresponding vertebrae, and as they become thinned,
the foramina become smaller.

The effect of a lesion of the third cervical on the ligaments is sim-
ilar to that of an axis lesion, that is they become as a rule thicker, and
tender, which conditions can best be ascertained by palpation over the
articular facets. The ligaments attaching the third cervical vertebra to
the axis and fourth, are the regular spinal ligaments while the atlas and
axis have, on account of the extra strain, special ligaments to reinforce
the common spinal. The ligaments common to all the vertebrae
are the intervertebral discs, anterior common, posterior common,
ligamenta subfiava, capsular, supraspinous, interspinous, and inter-
transverse. These ligaments quite securely bind the vertebrae together,
limit the movements of the individual vertebrae, and assist in the pro-
tection of the spinal' cord and its nerves branching from it. They are
to a certain extent elastic and are subject to contraction and relaxation
since they have both blood-vessels and nerves. No detailed description
of the ligaments common to the spinal column is deemed necessary,
but attention is called to the intervertebral discs, the capsular and
supraspinous ligaments. The supraspinous ligament, or ligamentum
nuchae, in chronic lesions is usually so much thickened that it can be
readily palpated by pressure directed against the spinous process. The
best sign of chronic lesions, especially in the thoracic and lumbar regions,
is a softening and thickening of the supraspinous ligament. In most
cases these changes are followed or accompanied by a shortening, hence
approximation of the vertebrae. This in turn thins the discs, lessens
the size of the foramina and changes the contour of that part of the
spinal column.

The principal muscles of importance attached to the third are the
anterior and middle scaleni, rectus capitus anticus major, longus colli,
levator anguli scapulae, splenitis, transversalis colli and multifidus spinae.
All but the scalenus anticus and transversalis colli muscles have been
discussed. (See page 57.) The scalenus anticus arises, from the an-

APPLIED ANATOMY. 69

terior portion of the transverse processes of the third, fourth, fifth and
sixth cervical vertebrae and is inserted into the tubercle on the upper
border of the first rib anterior to the groove for the subclavian artery.
It is of interest in that the first rib is drawn upward against the clavicle
when this muscle is in a contractured condition, which is often the case
when the vertebrae to which it is attached are displaced or its nerve sup-
ply affected. As a result there is trouble from pressure on structures
by the displaced rib and from disturbance of the sympathetic gangliated
cord, since the first dorsal and last cervical ganglia are located on the
head of the rib.

The arteries involved in lesion of the third cervical vertebra are the
vertebral and its lateral spinal and muscular branches. The effect here
is similar to, if not identical with, that outlined under the axis.

The third cervical segment would probably suffer more than other
segments, if the lateral spinal branch passing through the third cervical
foramen were disturbed. This artery, like those from below, passes up
the sheath of dura mater which envelops the roots of the spinal nerves.
A lesion of the third cervical vertebra would cause contraction of many
of the muscles supplied with blood by the muscular branches of the
vertebral. As a result, circulation through the vertebral and its other
branches would be impaired. This means a vascular disturbance of
the cervical spinal cord and perhaps medulla and brain with many pos-
sible effects ranging from a "cold in the head" to meningitis.

The veins involved are the vertebral and its spinal and muscular
tributaries. From this involvement comes congestion of the spinal
cord and the neck muscles in relation, which is accompanied by various
symptoms, they depending on the centers involved.

The nerves involved by a lesion of the third are the third and fourth
cervical nerves (only the third will be considered here) and their branches
and communications the superior cervical ganglion, vertebral plexus,
and the recurrent meningeal.

The third cervical segment gives origin to the following nerves, all
of which pass out of the foramen in relation with the articulation of the
axis and the third; small occipital, great auricular, superficial
cervical, supra-clavicular, branch of communication to the hypo-
glossal, third, or smallest occipital, muscular branches, and usually
a root of the phrenic.

The small occipital has been considered along with the great auricu-

APPLIED ANATOMY.

INTEC'MT OVER BACK OF NECK AMD SCALP.

trachelO-mastoid

SPLE.NIUS COMPLEXUS
POST N ROOTS

\SPINAL GANG. ,

LEVATOR ANGUL1 SCAPULAL"
CERVlCALISDESCENDtNSANDDESCHYPOGLOSd!

PHRENIC N. - " (STERNO-HYOID

ANSA-CERVICALIS WITH 3RAJS STERNOTHYROID

OMO-HYOID
INTEG'MT OVER SHOULDER ANDZ/JDsDELTOID -
SKIN OF LOWER NECK AND CHESTTO
LOWER BORDER OF MANUBRIUM

I PLEURA PERiTOneuM
PERICARDIUM
RT.AURICLE

( LIVER -01 ATHM
DIAPHRAGMATIC SUPRARENAL CAPSULE
PLEXUS ( 1M(r VEIMA CAVA

EbOPHASVJS

OMIO

INTEG'l
BREAST AS LOWAS
NIPPLE

FlG. 19.— The third cervical segment showing its branches and connections.

APPLIED ANATOMY. 71

lar, and superficial cervical as well as some of the muscular branches.
The effect on the above named nerves from a lesion of the third cervi-
cal is very similar to, if not identical with, that from an axis lesion. An
additional point regarding the superficialis colli nerve might be indi-
cated here. Deaver says that the ascending branch "sends filaments
to the external jugular vein, communicates with the inframaxillary
branch of the facial nerve, and supplies the platysma myoides muscle
and the skin of the front of the neck as far as the chin. " This is of value
since certain forms of jerking of the head or chorea are due to spasmodic
contraction of the platysma myoides. Such spasmodic contractions
result from an interference with the nerves supplying it, this interfer-
ence in many cases resulting from a subluxation of the axis or third
cervical.

The supraclavicular or descending branch of the cervical plexus
come almost entirely from the third cervical segment. This nerve
divides into an internal, middle and external or posterior branch. The
internal or suprasternal ramifies over and below the inner third of the
clavicle and terminates over the upper part of the sternum. Some
filaments are furnished to the sterno-clavicular articulation (Rudinger).

The middle or supra-clavicular, supplies the integument over the
forepart of the deltoid and the pectoral muscles as low as the third rib
and over the upper part of the mammary gland as low as the nipple.
These filaments communicate with the small lateral cutaneous branches
of the upper intercostal nerves.

The external branches innervate the integument over the acromion
and outer and back part of the shoulder, and above the spine of the
scapula. In conditions of pain, if cutaneous, in the above areas, this
nerve is usually involved. Contractures in the neck, and lesions of the
axis or third, readily affect this nerve which is manifest by sensory dis-
turbances in the above mentioned areas.

Deaver says: "Herpetic eruptions in the area of distribution of
the superficial branches of the cervical plexus (herpes cervico-occipi-
talis) are occasionally seen. In caries of the cervical vertebra, pain
may be referred to the areas of the skin supplied by these nerves. It
is through the descending branches of the cervical plexus that pain is
referred to the neck in carcinoma of the mammary gland. " Lesions
of the third cervical vertebra cause pain in the area of distribution of
the supra-clavicular nerve because it is in relation with the articulation

72 APPLIED ANATOMY.

and is irritated or otherwise affected by the subluxation.

The third or smallest occipital nerve, the inner branch of the pos-
terior division of the third cervical nerve, supplies the skin of the upper
part of the back of the neck, and part of the scalp in the region of the
external occipital protuberance. This nerve is involved in pain in the
back of the neck, coldness of the part and in boils and carbuncles which
so frequently attack the back of the neck on account of the great thick-
ness of the integument. If a lesion of the axis or third cervical vertebra
exists, the back of the neck is cold a great deal of the time. Coldness
of this part of the neck is accompanied or followed by nasal catarrh or
"sore throat. " If the back of the neck is always kept warm, I seriously
doubt the possibility of one "catching cold" in the head and throat.
Lesions of the third affect the third occipital, and since it is distributed
to the back of the neck, this region is in all probability affected, with
the above predisposition to nasal catarrh.

The muscular branches coming from the third cervical segment
supply, at least in part, the following muscles: Rectus capitus anticus
major, longus colli, trapezius, levator anguli scapulae, sterno-mastoid,
diaphragm, intertransversales, multifidus spina?, complexus, splenius
and the infra-hyoid muscles. All of the above named muscles except
the trapezius and diaphragm have been considered. The usual effect
on these muscles is that of producing a contractured condition which,
if unilateral, produces a muscular curvature, but if symmetrical, draws
the vertebra? more closely together thus lessening the size of the inter-
vertebral foramina.

The trapezius, one of the superficial muscles of the back, is of osteo-
pathic interest in that it is always tender in cases of cold in the head;
the more severe the attack the more tender the muscle. This area of
tenderness in colds corresponds to the distribution of the two trapezii
muscles. By contraction, it draws the head back, flexes the neck to-
ward the same side and turns the face to the opposite side. If the mus-
cle is in a contractured state, these movements are impaired, the cir-
culation through the muscle impeded, the circulation to the spinal cord
affected and the sympathetic gangliated cord deranged, as is evidenced
by the vaso-motor changes accompanying and following its contracture.
The diaphragm will be considered in the discussion of lesions of the fourth
cervical vertebra (see page 78).

The nerve communicating with the hypoglossal nerve is frequently

APPLIED ANATOMY. 73

involved by a lesion of the third as a result of which the hyoid muscles
are affected and from this, disturbances of the voice box. The phrenic
is also involved by this lesion, the effects of which are discussed with
that of effects on nerves in lesions of the fourth cervical vertebra.

The superior cervical ganglion is sometimes affected by this lesion
but not so frequently as by lesions of vertebrae above. For effects see
page 29.

The recurrent meningeal, which enters the spinal canal, is nearly
always affected by the lesion as a result of which, various pathological
changes take place in the structures innervated by it, viz., the spinal
cord, meninges, vertebra and ligaments. The vertebral plexus is also
involved, the effect being similar to that from an atlas or axis lesion.
The most important effect is that on the eye. According to Deaver,
contraction of the pupil on the same side follows ligation of the vertebral
artery. Probably the effect is through the vertebral plexus of nerves
rather than through the artery. If a ligature will produce an effect,
lesions of the cervical vertebral articulations will also in some way affect
the eye. At least the connection between the neck and the eye is proven.

Lesions of the axis and third affect the vertebral artery and its
accompanying nervous plexus, hence an effect on the eye.

The third cervical segment contains several centers of importance.
Motor centers are located here which control the amount of nerve force
to and nutrition of the muscles supplied by the third cervical nerve.
These have been named above. Sensation to the back of the head and
possibly the face or areas supplied by the fifth cranial are influenced by
this segment. The explanation is that one of the sensory roots, the
descending or long root, has been traced to the floor of the fourth ventri-
cle and to the grey matter in the lower part of the medulla oblongata
and as low in the spinal cord as the third cervical segment.

The spinal accessory nerve which is supposed to take the place of
the white rami in the cervical region, is affected by this lesion on ac-
count of its spinal origin. Most of the vaso-motor, motor, and viscero-
motor impulses passing out over the spinal accessory reach the pneu-
mogastric and are distributed with its branches. The spinal origin of
the eleventh cranial nerve is as low in the spinal cord as the seventh
cervical segment. On this account, its cells of origin are affected by
cervical lesions through interference with nutrition.

A lesion of the third cervical vertebra will affect the various nerve

74 APPLIED ANATOMY.

filaments connecting the superior cervical ganglion, ninth, tenth, eleventh
and twelfth cranial, and the upper cervical nerves.

A small filament connects the superior cervical ganglion with the
ninth. It is supposed to be vaso-motor in function, that is, the vaso-
motor impulses passing over the ninth are derived, at least in part, from
the superior cervical ganglion by way of this communicating branch.
As a result of the lesion there •will be vaso-motor disturbances in the
parts supplied by the glosso-pharyngeal nerve viz., the tonsils, tongue,
and throat.

There are several nerve strands that connect the tenth cranial and
the superior cervical ganglion. They pass to both ganglia of the nerve,
the ganglion of the trunk and the ganglion of the root. They are vaso-
motor in function and furnish the vagus with some if not a majority of
its vaso-motor impulses.

The hypoglossal receives vaso-motor impulses from the superior
cervical ganglion by way of a filament directly connecting the two.
Langley says in connection with this nerve: "The peripheral part of
the hypoglossal nerve has a slight vaso-constrictor action on the arteries
of the tongue. The vaso-constrictor fibres come in part, at any rate,
from the superior cervical ganglion. It has been supposed that some
issue with the roots of the hypoglossal nerve but the evidence is not sat-
isfactory. "

Clinically it seems without doubt that the vaso-motor impulses of
the hypoglossal nerve are derived by way of the superior cervical gang-
lion judging from the vaso-motor effects of a cervical lesion on the parts
supplied by the twelfth nerve.

Grey rami communicantes connect the superior cervical ganglion
and the upper four spinal nerves. Those branches to the third and
fourth, according to Quain, often pierce the rectus capitis posticus major
muscle. Contracture of this muscle from a lesion of the third cervical,
would interrupt this connection and lead to disturbances of function.
"Some of these fibres pass peripherally, some centrally." Of those
passing centrally "some follow the posterior primary division of the
nerve, others enter the sheath of the nerve, the surrounding tissue in
the intervertebral foramen, and the dura mater, running up the latter
in the posterior- root. " Quain further says: "The fibres passing dis-
tally in the anterior and posterior primary divisions of the nerves have
been shown by experiments on animals, to supply vaso-motor nerves

APPLIED ANATOMY. 75

to the arteries of the body wall and limbs, pilo-motor fibres to the mus-
cles of the hairs and secretory fibres to the sweat glands. " A lesion of
the third cervical vertebra will interfere with this connection, because
the grey rami are in relation with the articulations of this vertebra.

The external branch of the spinal accessory, according to Landois,
"anastomoses with sensory filaments from the posterior root of the
first, less commonly also of the second cervical nerve, which supply
muscle-sense fibers to it." It then supplies the sterno-mastoid and
trapezius muscles. Landois says further that the external branch anas-
tomoses also with several cers'ical nerves. "Either these fibres take
part in the innervation of the muscles named, or the accessory returns
to them, in part, the sensory filaments received from the posterior roots
of the two uppermost cervical nerves, which then constitute the cutan-
eous branches of these cervical nerves."

The filament connecting the upper cervical nerves with the hypo-
glossal nerve, carries motor and vaso-motor impulses to it, thus supply-
ing the hyoid muscles, and tongue.

The function of the fibres connecting the vagus and the upper cer-
vical nerves is unknown. Judging from clinical indications, it is proba-
bly sensory. The writer has known of cases in which pressure exerted
at the second cervical vertebra would produce nausea and vomiting.
Possibly the impulses were transmitted by these connecting filaments.

The ninth nerve is directry connected with the jugular ganglion
of the vagus but according to Landois, the function of this branch is
unknown.

He says in connection with the branches uniting the pneumogastric
and spinal accessory nerves that the "entire inner half of the accessory
nerve enters the trunk of the vagus. This transmits to the latter,
motor fibers for the larynx (through the recurrent branch of the vagus),
for the pharynx and the cervical portion of the esophagus and the
stomach (?), as well as the cardiac inhibitory fibres."

Some of these functions seem to be doubtful, since he marks them
as inconstant or uncertain.

The function of the filament connecting the vagus and the hypo-
glossal nerve is unknown.

The above statements concerning the effects on these communicat-
ing branches will apply equally well to lesions of the atlas and axis.

Some writers attribute vaso-motor functions to the third cervical
nerve that are independent of the superior cervical ganglion but Lang-
ley seems to doubt such statements.

76 APPLIED ANATOMY.

Summary of the third cervical vertebra. It is the most fragile
vertebra hence most easily broken; its articulations are quite freely
movable, thus lesions are common. As a result of a lesion of this bone,
certain disturbances fairly constant, are found, such as eye troubles,
especially weakness and impairment of vision. I have reference in the
above, to tendency to formation of tears on exposure to wind and pho-
tophobia if light is strong. In addition, there results headache (occipital),
roaring in the ear, and what some call a "beefy" neck which is charac-
terized by increase in amount of connective tissue which gives it a soft,
bulky feeling. There may be disease of any part of the head and face
as a result of lesion of this vertebra, but the eye is most frequently af-
fected of all parts.

THE FOURTH CERVICAL.

The fourth cervical vertebra has few if any peculiarities, it being
a typical vertebra. In size it is slightly larger than the third, the spinous
process is longer, the transverse processes slightly larger, while in most
cases it is not located so far anteriorly as the third. The superior facets
face upwards, backwards and inwards, are slightly concave and permit
of slight movement in all directions, perhaps the antero-posterior move-
ment being the most marked.

This vertebra is subject to lesions similar in character to those of
other vertebra, a torsion or lateral deviation being most common.

These lesions are characterized principally by a thickening of the
ligaments in relation with the articular processes. The ligamenta sub-
flava and the capsular are usually the ligaments most affected. By
careful and deep palpation over the articularprocesses,thatis at a point
about midway between the spinous and articular processes, these thick-
ened and tender ligaments can be distinctly felt thus furnishing one of
the most reliable of signs of a cervical vertebral lesion. In cases in which
the lesion was produced by trauma, these ligamentous changes are par-
ticularly noticeable.

In lesions of this bone the movements of the neck are impaired,
since its articulations are involved in the various movements of the
head and neck. As a result of a traumatic lesion the ligaments attaching this
bone to the adjacent vertebras are stretched, torn or otherwise affected,
this depending on the degree of lesion. This change in the ligaments
makes free movement of the head difficult, lessens the size of the for-
amina and weakens this portion of the spinal column. In other cases

APPLIED ANATOMY. 77

relaxation of the ligaments takes place, thus permitting too free mobil-
ity, and in marked cases the patient is unable to hold the head erect.
The discs are also stretched, torn or abnormally compressed, which
changes affect the normal curvature of the neck, thus laying the founda-
tion for spinal curvature of the cervical region.

The principal muscles attached to the fourth cervical vertebra and
which would necessarily be affected in some way in lesions of it, are the
following: Scalenus anticus, scalenus medius, rectus capitis anticus
major, longus colli, multifidus spinse, semispinalis colli,- complexus,
cervicalis ascendens and splenitis. The effect on these muscles is most
frequently that of contracture. The other attachments of these mus-
cles are drawn nearer the fourth or else it is drawn closer to them, that
is the cervical spinal column is drawn out of line. In either case there
would be a warping of the framework of the body, for muscles are gen-
erally attached to bones and are always shortened when contractured.

The arteries and veins correspond to those of the third and would
be affected similarly, the effects being about the same. The spinal cord
suffers most when these vessels are impinged.

The nerves having their origin in the fourth cervical segment and
passing out through the fourth cervical foramina are the posterior
division of the fourth, the supra-clavicular, muscular and phrenic.

There are various other nerves and connecting filaments in rela-
tion with this vertebra, and would, in all probability, be affected by the
lesion. They are, the recurrent meningeal, vertebral plexus, sympa-
thetic gangliated cord, and the filaments connecting the superior cer-
vical ganglion with the upper cervical and the cranial nerves. On ac-
count of the relation of the parts thus connected, these filaments are in
relation with the articulations of the fourth, and would be impaired by
the lesion. As to the functions of these nerve fibers see effects on nerves
of a lesion of third cervical.

The supraclavicular nerve and its distribution have been discussed
(see third cervical). The muscular branches supply the following:
Rectus capitus anticus major, longus colli, scalenus medius,
scalenus anticus, diaphragm, levator anguli scapulae, trapezius,
complexus, splenius, multifidus spin.'e, semi-spinalis colli and
interspinales. All of these have been considered with the exception
of the diaphragm which will be considered here, since its innervation
is almost entirely from the fourth cervical segment.

78 APPLIED ANATOMY.

The diaphragm is a dome-shaped, thin muscular sheet which sep-
arates the thoracic and abdominal cavities, forming the floor of the
former and roof of the latter. Its construction is peculiar in that it con-
sists of "muscular and tendinous portions which arise by numerous
digitations and, arching upward and inward, converge to be inserted
into a common central tendon. " It is attached above to the pericardium
which serves to maintain its arched position during respiration. It
arises from the lower six or seven ribs, the internal surface of the ensi-
form cartilage, the bodies of the lumbar vertebrae and the tendinous
arches over the quadratus lumborum and psoas muscles which are called,
from their shape and ligamentous character, the ligamentaarcuata externa
and interna. The external extends from the twelfth rib to the transverse
process of the first lumbar vertebra. The attachments to the bodies
of the lumbar vertebrae are known as the crura of the diaphragm. Their
fibers in passing upwards are so placed that they cross each other in
such a way that they form a figure-of-eight arrangement around the
various openings of the diaphragm. The fibers converge for insertion
into the central tendon.

In applying this knowledge of origin and insertion it can be seen
that displacement of the lower ribs or lumbar vertebrae will affect the
muscle and change the size of the openings in it. From its position and
relations, enlargement of the viscera in relation embarasses its action,
as is evidenced by shortness of breath after a full meal.

There are various openings through which pass important struc-
tures. The aortic is between the crura and gives passage to the aorta,
thoracic duct and the vena azygos major. The esophageal opening
transmits the esophagus and the pneumogastric nerves and esophageal
branches of the thoracic aorta. The opening for the inferior vena cava
gives passage to the inferior vena cava, a branch of the right phrenic
nerve and to some ascending lymphatic vessels from the liver. The
sympathetic chain and the greater and lesser splanchnics of the right
side pass through the right crus. The openings in the left crus transmit
the greater and lesser splanchnics of the left side and- the vena azygos
minor. These openings are affected in displacement of the muscle.
Lesions of the lower ribs displace the diaphragm. The aorta is obstructed
thus throwing more work on the heart, possibly causing regurgitation.
The veins are obstructed which causes congestion of parts drained by

APPLIED ANATOMY. 79

them. The nerves are involved, hence disturbances in viscera inner-
vated by them.

The nerve supply of the diaphragm comes principally from the
phrenic and the lower five or six intercostals. The diaphragmatic
plexus, which is formed by offsets from the upper part of the solar plexus
which ramify with the phrenic, reinforce the above named nerves to
the muscle. At the point where this plexus joins the phrenic nerve is
a small ganglion called the ganglion diaphragmaticum, which sends
filaments to the liver, inferior vena cava and the suprarenal capsule.
Lesions of the fourth cervical, lower ribs and lower thoracic vertebrae
will affect the innervation of the diaphragm, hence impair its action.

The action of the diaphragm is to deepen the chest. It is a power-
ful muscle of inspiration. It acts in conjunction with the abdominal
muscles in acts requiring an increase in the intra-abdominal pressure,
such as defecation, micturition, parturition, coughing, sneezing, vomit-
ing, etc. Its most important function is that of assisting in respiration.
Hilton calls attention to the action of the diaphragm on the liver. By
its contraction the liver is compressed, thereby assisting the circulation
of the blood through it. Exercise causes an increase in the frequency
and intensity of contraction of the diaphragm, hence is good for a tor-
pid liver. Enforced rest often causes jaundice.

The distribution of the phrenic to the diaphragm is an unusual
one. It pierces the muscle and is distributed to the under surface,
probably for the sake of protection since in respiration, pressure is
strongest against the upper surface of the muscle. In abnormal disten-
sion of the stomach, the nerves to the diaphragm are compressed or
otherwise affected and hiccough results. Gravity tends to prevent
pressure of viscera on this muscle by drawing the liver and stomach
down.

The phrenic has other functions than that of supplying motion to
the diaphragm. It supplies in addition, the pericardium, pleura, sends
a few filaments to the peritoneum and on the right side, the inferior
vena cava and the right auricle of the heart. It helps to form the
ganglion diaphragmaticum which sends branches to the supra-renal
capsule, hepatic plexus and the inferior vena cava. Lesions of the
middle cervical vertebras affect this nerve, hence would affect the above
named structures and organs which it directly or indirectly supplies.
The diaphragm is its most important distribution.

80 APPLIED ANATOMY.

The most common effect of a lesion of the fourth cervical on this
muscle is a spasmodic contraction, or hiccough. In some cases paralysis
of this muscle follows a neck lesion. The writer has examined cases in
which respiration was carried on apparently by the thoracic muscles,
the phrenic being partly or wholly paralyzed as a result of a cervical
lesion. The respiration in such cases is usually sighing and irregular.
In asthma the opposite condition exists, that is, the thoracic muscles
perform a very small part in respiration, it being carried on almost ex-
clusively by the diaphragm and abdominal muscles.

Experimentally, section of both these nerves, is followed by par-
alysis of the diaphragm. Death soon follows because of the inability of
the thoracic muscles to carry on respiration since the diaphragm becomes
so relaxed that it no longer furnishes a fixed point or fulcrum from which
the other muscles of respiration can act. On account of this, the air
already in the lung cannot be expelled neither can a partial vacuum be
formed by which air is drawn into the lungs. Section of only one phrenic,
is often followed by pneumonia according to McLachlin. A lesion may
so impair the action of this nerve that it will have a tendency to the
production of pneumonia. A lesion of the fourth may have either an
inhibitor, or a irritative effect. On this account, the lesion can be sub-
stituted for the means commonly used in experiments and the results
will compare favorably if the difference in amount of stimulation or in-
hibition used, is considered.

Usually in neck lesions some form of respiratory disorder compli-
cates on account of the effect on the phrenic nerve. This disturbance
may be a labored respiration, Cheyne-Stokes respiration, sighing, spas-
modic or irregular breathing. In treating such effects it does little good
to press on, or otherwise affect the trunk of this nerve, except in cases
in which only a palliative or temporary effect is wanted or a curative
one can not be obtained. In hiccough, this nerve should be examined
from origin to destination and especially at its spinal origin and exit and
the points of its distribution. The first has been considered. The sec-
ond part is as important since fatal attacks result from a diseased liver
pressing on the nerve on the under surface of the diaphragm, from dis-
placement of the lower ribs and the lumbar vertebrae and from enlarge-
ment or displacement of the viscera in relation with the under surface
of the muscle.

The more obscure effects of a lesion involving the phrenic nerve are

APPLIED ANATOMY.

ANT. PRIM.OIV.OF FOURTH -
CERVICAL N.

PHfXNIC-

BRACHIAL PLEXUS c:

RECURRENT LARYNGEAL^

VAGUS ■
PERICARDIUM

1 ~

-PHRENIC N.

INF. CERVICAL GANGLION
^RECURRENT LARYNtZAu

COMMC.BRAN.FR0M BRACHIAL
PLEXUS TO PHRZNIG N.

PERICARDIAL
BRANCH

RECURRENT LARVAL

ANT. PULMONASV

amt. pulmchvst

If' PLEXUS

a*0*

Fig. 20. — Showing course and distribution of the phrenic nerve.

82 APPLIED ANATOMY.

those on the pericardium, pleura, heart and supra-renal capsule. It is
supposed to be a sensory nerve to these parts, in which case pain in these
structures supplied is at least partly the result of disturbance of this
nerve. As to the effects on the abdominal viscera and structures to
which it is distributed, one can only conjecture. Since it indirectly
supplies the supra-renal capsule, peritoneum, liver and the inferior vena
cava, it is fair to assume that disturbances in these organs and struc-
tures come in part or wholly from an impairment of the phrenic nerve,
and since a lesion of the fourth cervical will affect this nerve the conclu-
sion is evident. The phrenic receives a direct twig of communication
from the inferior cervical ganglion and in most cases a branch from the
plexus subclavius. This explains the relation of a lesion of the first rib
and its effect on the phrenic. A dry hacking cough is sometimes the
result of disturbance of the phrenic. I would suggest a lesion of the
first rib as the cause in most cases.

The posterior division of the fourth cervical nerve, dividing into the
usual internal and external branches, supplies sensation to the integu-
ment over the lower part of the neck. The recurrent meningeal, verte-
bral plexus and superior cervical ganglion are affected in typical cases.
These effects are similar to those from an axis lesion, which see. The
fourth cervical segment is also involved, the lesion disturbing the cir-
culation to it, especially interfering with its drainage.

This segment contains very important centers, those for the phrenic
being the most important. The predominate respiratory center is sup-
posed to be in the bulb, with subsidiary centers in the spinal cord. In
either case impulses pass through the fourth cervical segment to the
phrenic.

Summary of fourth cervical. Lesions of this bone are most fre-
quently an antero-posterior displacement or a torsion.

The motor effects of this lesion are contracture or relaxation of the
muscles supplied by the fourth cervical segment. In the case of the
diaphragm, there would be, on stimulation, a clonic contraction or
hiccough. If the lesion is inhibitory, relaxation would be the result.
The sensory effects are characterized by pain, or anesthesia or numbness
of the integument over the lower part of the back of the neck, the upper
part of chest and over top of shoulder, and possibly in the parts supplied
by the phrenic nerve.

The vaso-motor effects depend on effect on the superior cervical

APPLIED ANATOMY.

(NTEG'MT.OvEHSHNpuS PROC anc TRAPEZIUS
COMPLEXUS

INTERSPINAL ES

BRA to LIVER
IMF VENA CAVA
SUPRA RENS&CA,
DIAPHRAGM— <5^T-S:
E50PHAGUS J^
BYWAY OF DIAPHRAGMATIC
PLEXUS

SENSATION
ovrR PECT MJ
BratoPERICAROIUM tp 30 Rig
PERiTOHEUM
RI AURICLEAND PLEURA

Fig. 21.— Showing the fourth cervical segment of the spinal cord and its
nerves with their distribution.

84 APPLIED ANATOMY.

ganglion, the grey rami and the recurrent meningeal nerves. Any
structure supplied by the above nerves is apt to be affected by a lesion of
the fourth cervical vertebra, since the nerves are in relation.

The secretion of sweat of parts above may be disturbed by this
lesion since the secretory nerves to the sweat glands of the neck, head
and face pass by way of the sympathetic nerves in relation with the
fourth.

With lesions of the fourth are associated hiccough, Cheyne-Stokes
respiration, and in fact any or all respiratory affections. Almost any
form of disease of any part above this vertebra may result from a lesion
of the fourth, but it is not so important a factor in the etiology of dis-
eases of the head and face as are lesions of the axis or third.

THE FIFTH CERVICAL.

The fifth cervical vertebra being a typical vertebra needs little separate
description. It is slightly larger than the fourth in every respect, and
the body more hooked, which prolongation fits in a corresponding depres-
sion in the body of the vertebra below. This is true of all the cervical, ex-
cept the atlas and axis. The obliquity of the spinous process is quite
marked, its tip being on a level with the disc between the bodies of the
fifth and sixth cervical vertebrae. Movement in this region is quite free.
Flexion and extension, though free, are not so marked as in the lum-
bar spine.

The effects on the ligaments of a lesion of the fifth cervical vertebra,
that is of the articulation between it and the fourth, are similar to those
from a lesion of the fourth. They become tender, thickened and thus
hinder normal movement. The size of the intervertebral foramina is
lessened, thus producing pressure on the structures passing through.
The discs are stretched, or abnormally compressed and soon their elas-
ticity is lessened.

The muscles attached to this vertebra are affected in some way by ■
a- lesion of its articulations. The principal muscles directly or indirectly
involved are the scalene muscles, splenitis, complextjs, multifidus,

SPIN^B, CERVICALIS ASCENDENS, TRACHELO-MASTOID and DIAPHRAGM.

The scalenus posticus is attached to the second rib and in irritative
lesions of the fifth cervical, the posterior part of the rib would be drawn
upward. This condition is often responsible for diseases of the thyroid
gland such as goitre, and for coughs, lung and bronchial disorders. These
effects are explained by the fact that the inferior cervical ganglion is

APPLIED ANATOMY. 85

affected by a lesion of the first rib. This ganglion sends a branch di-
rectly to the thyroid gland, and connects with the phrenic and recurrent
or inferior laryngeal nerve. The inferior cervical and stellate ganglia
are situated on the head of the first rib and are affected whenever it is
drawn up b)' contracture of the scalene muscles or from other causes.

The cervicalis ascendens is also attached to ribs; the vertebral
ends of four or five upper ribs. By its contracture, these ribs are drawn
upward at the vertebral end, this condition affecting structures, organs
and viscera in relation; lung and mammary disorders being most com-
mon. The trachelo-mastoid on account of its attachment to the
head, by its contraction draws the head securely against the spinal
column. Many a cervical condition attributed to an atlas lesion is in
reality the effect of a lesion lower in the spinal column with an effect in
the upper part of the neck through this and other muscles attached to
the head and upper thoracic spine.

The arteries directly involved by a fifth cervical lesion are the
vertebral, lateral spinal, muscular and spinal branches of the ascending
cervical. As a result of this lesion the parts supplied with blood by these
arteries would be affected, viz., brain, cervical spinal cord, medulla and
muscles of neck.

The corresponding veins would be involved, hence some disorder of
the spinal cord, column and cervical muscles and nerves.

The nerves involved by a neck lesion are the vertebral plexus,
fifth and sixth cervical nerves, recurrent meningeal, ramus com-
municans, middle cervical ganglion and the branches of the above
named nerves in relation.

The recurrent nerve is affected in a way similar to that in other
cervical lesions.

The fifth cervical nerve divides into the usual anterior and posterior
divisions. From this nerve is derived in part or in whole, the phrenic,
posterior thoracic or nerve of Bell, suprascapular, circumflex,
musculo-cutaneous, external anterior thoracic, subscapular,
muscular and sometimes the musculo-spiral. There is considerable
variation in the points of origin of these nerves, hence the variations in
the different texts. The phrenic nerve has been described (see fourth
cervical nerves.)

The posterior thoracic or expiratory nerve of Bell is of interest in
that it supplies with motor and trophic impulses, the serratus magnus
muscle. It arises by three roots from the fifth, sixth and seventh cer-

APPLIED AXAT0M1".

SCALENUS ANT.
SCALENUS MED.

SCAPULA
TURNED BACK

Fig. 22.— Showing attachments of the serratus magnus muscle. The relation it
bears to the ribs is clearly brought out.

APPLIED ANATOMY. 87

vical nerves, of which the upper two pierce the scalenus medius mus-
cle. On account of this, contracture of the scalenus would interfere
with this nerve. The serratus magnus muscle is of importance in that
its function is often disturbed by this lesion, which is followed by marked
weakening of the shoulder and scapula. It is occasionally made use of
by osteopaths in raising the ribs, this being practical on account of its
attachments. This muscle arises by nine digitations from the upper
eight ribs, the second getting two of the digitations. The fibers con-
verge to be inserted into the anterior surface of the vertebral border of
the scapula. Its action is to draw the scapula and shoulder forward,
or if the scapula becomes the fixed point its contraction will evert and
raise the ribs and push the sternum forward. It supports the shoulder,
as in carrying a weight on it, assists the deltoid in raising the arm by
fixing the scapula and holds the scapula closely against the chest wall as
is demonstrated in pushing.

The effects on this nerve of a disturbance of the articulations of the
fifth cervical vertebra are evident. If the nerve is partly or completely
paralyzed, as it is in some cases of cervical lesion, the arm cannot be
raised to any marked extent, the shoulder is depressed, the ribs get
"down" and the scapula becomes "winged." In complete paralysis of
this nerve, the arm cannot be raised above a horizontal plane, except
with great effort, and the other movements of the shoulder and arm are
markedly weakened.

In tuberculosis of the lungs, this muscle is involved in that it be-
comes atonic with other muscles in relation, thus permitting the scapula
to become winged. If this muscle retains its normal tone and func-
tion, respiration is usually normal so far as the action of the thoracic
walls is concerned; also the ribs remain in a fairly normal position. If
a lesion affects its innervation, respiration soon becomes shallow and
the ribs become more oblique, closer together and descend or get down.
These rib lesions are not always the direct result of an atrophy of the
serratus magnus but of atrophy of other muscles as well, the condition
of the serratus magnus being a fairly true indication of the condition of
the muscles that hold the ribs in normal position.

The suprascapular nerve is of importance in that it supplies im-
portant structures, the shoulder joint and the supra-and infra-spinati
muscles; and clinically is important on account of the frequency of its
disturbance. The branch to the shoulder joint has to do with the con-

88 APPLIED ANATOMY.

dition of the structures concerned, that is the synovial membrane, the
ligaments and vessels..

In lesions of the fifth cervical, the function of the shoulder-joint is
often impaired in that motion is limited and painful and the joint weak-
ened. If the joint is stiff or if movement of the arm produces pain, the
condition is popularly called rheumatism. "Rheumatism" of the
shoulder is in most cases due to a cervical lesion that in some way af-
fects the suprascapular or circumflex nerve or to a subluxated clavicle.
Contracture of the lower cervical muscles will impinge on the circumflex
nerve and cause pain to be referred to the shoulder joint because it is
one of the sensory nerves to it. Pain in, or rather irritation of, other nerves
coming fromthefifthcervicalsegment, will often be accompanied by pain
or ache in the shoulder. The effects of a shoulder lesion on this nerve
will be considered under the discussion of the circumflex nerve.

The nerve to the spinati muscles is involved in most cases of "cold"
in the head. In such cases the supra-spinati are invariably contrac-
tured and tender. In la grippe, rheumatism and in an ordinary cold
the joints ache, especially the shoulders. An involvement of these
muscles is probably the cause. The lesion here acts as a predisposing
cause, thus making it possible for the thermic and other influences to act.

The circumflex is quite often involved by a lesion of the fifth
cervical vertebra. As a result of a disturbance of this nerve several
important effects are noted. The shoulder- joint is affected in a way
similar to that resulting from a disturbance of the suprascapular. That
is, there may be motor, sensory, trophic, secretory and vaso-motor dis-
turbances since this nerve, as is best ascertained by clinical observa-
tions, contains filaments for all these functions. On account of this,
a lesion affecting the nerve will cause contraction or relaxation of the
ligaments, pain or numbness, atrophy, lessened or increased secretion
and congestion or anemia of the joint. Dislocations and sprains of
this joint produce pain in the integument -over the joint, back of shoulder,
and at insertion of deltoid muscle. Hilton says that in inflammation
of the shoulder-joint the skin over the joint becomes very sensitive.
"You will recollect that the same trunks of nerves which form the cir-
cumflex nerve transmit some posterior filaments to the skin over the
shoulder and the lower part of the neck; hence the pain is experienced
in this region, by patients suffering from disease in the shoulder joint."
A dislocation of the long head of the biceps which is decidedly unusual,

APPLIED ANATOMY.

has a similar effect, that is. the pain is most severe at the insertion of
the deltoid. Quite a common mistake is made by referring all such
pains to the dislocation of the biceps or injury to the shoulder-joint,
when in reality a lesion of the acromio-clavicular articulation is most
often the cause. This articulation, that is, the acromio-clavicular,

SUPRASCAPULAR M-
SUPRASPINATUS

P.BRANCH OF
IRCUMFLEX

}, \\V- DELTOID

8RA.0F
CIRCUMFLEX

TERES- MINOR

"■•ilK CUTANEOUS
BRANCHES

TRICEPS

TERES MAJOR

Fig. 23. — Showing relation of circumflex and suprascapular nerves to the shoul-
der-joint. Painful affections of and around the shoulder-joint are explained by the
above illustration.

is often affected by the carrying of weights on the shoulder and by un-
usual or sudden movements of the arm, and on account of its nerve sup-
ply, the effect is usually referred to the upper part of the arm. A typical
case may be cited here. The patient is unable to raise the arm above

90 APPLIED ANATOMY.

the level of the shoulder or is unable to draw the arm back as in putting
on an overcoat. In other words, any movement wherein the muscles
of the shoulder-girdle are used, produces a change of position of the
clavicular-acromial joint, hence the referred pain.

In sprains of the shoulder- joint the circumflex nerve is injured since
the capsular ligament is bruised or torn and thus the nerve is affected
since it pierces this ligament. Another filament supplies the deltoid
muscle. This muscle has to do with protecting the shoulder-joint, re-
inforcing its ligaments, rounding off the shoulder and with the move-
ments of the arm. This muscle is affected by lesions of the fifth cer-
vical, shoulder and acromio-clavicular articulations. As a result of
these lesions, the muscle does not properly perform its various func-
tions named above. In short, the shoulder is weakened, hence increased
tendency to displacement, it loses its round-like appearance and the
movements of the arm are impaired. These movements are forward,
backward, with outward rotation and especially elevation. The le-
sions of the acromio-clavicular and shoulder- joints most frequently im-
pair its function as is pointed out above. This muscle atrophies from
non-use, as in dislocations or fracture of the humerus, thus injuring the
nerve, in anchylosis, or in other diseases of the joint. In ascending
neuritis of the circumflex and in anterior polio-myelitis in this region
of the spinal cord it is usually atrophied. In atrophy of the muscle, the
acromion process appears to be prominent and sometimes, unless care
is used, atrophy may be mistaken for dislocation of the shoulder. The
writer has seen cases of atrophy of the deltoid follow lesions of the upper
thoracic vertebrae in some cases as low as the sixth thoracic.

The circumflex gives off cutaneous branches which supply sensa-
tion to integument which covers the middle and lower portions of the
deltoid muscle, also a small area of skin below the muscle.

Another filament of this nerve is distributed to the teres minor.
This is of importance in that this muscle adducts and rotates externally
the humerus, also assists in backward rotation and protects the back
part of the shoulder- joint. By a lesion of the fifth cervical, the teres
minor muscle may be affected, thus producing an interference with the
movements of the arm and a weakening of the shoulder-joint.

The motor effects on the circumflex nerve of a lesion of the fifth
cervical vertebra are paralysis or weakening of the deltoid and teres
minor, which impairs the movements of the arm. This results in almost

APPLIED ANATOMY. 91

complete loss of power to raise the arm, a very trifling degree of abduc-
tion by the supraspinatus alone remaining.

The sensory effects are characterized by pain, numbness or
anesthesia in the skin over the deltoid muscle and in the shoulder-joint.
In paralytic lesions, there is loss of sensation in these areas. It is most
marked in the skin over the lower part of the deltoid. Gowers says:
"Hitzig pointed out many years ago that the anesthetic area is often
the seat of vaso-motor paralysis. In some cases there is no anesthesia,
even when the muscle is wholly paralyzed; we have seen that this is
often the case in nerve lesions. " The vaso-motor effects are conges-
tion or anemia of the shoulder-joint and the deltoid muscle. The secre-
tory and trophic effects are characterized by dryness of the joint, the
forming of adhesions, atrophy of the ligaments and muscles and weak-
ness of the parts.

The musculo-cutaneous and musculo-spiral nerves come in part
from the fifth cervical. They will be discussed later on (see sixth cer-
vical). The upper or short subscapular nerve comes principally from
the fifth cervical. It supplies the subscapular muscle. This muscle is
of interest in that it has to do with internal rotation of the humerus,
with strengthening of the shoulder-joint and with holding the humerus
in place.

The external anterior thoracic nerve, a branch of the fifth cervical,
supplies the pectoralis major muscle. This muscle by its contraction
draws the shoulder and arm forward and downward. Deaver calls
it a hugging muscle. He also says, "It would be a powerful aid in dif-
ficult respiration if the arms are fixed. On account of its attachment
to the anterior portions of the upper ribs and to the arm, it is used to
elevate the chest or raise the ribs, " which is accomplished best by mak-
ing a fixed point at the vertebral end of the rib and extending the arm
above the head. A disturbance of its function results in impaired move-
ments of the shoulder and arm, a weakening of the attachment holding
the tendon of the biceps in its groove and a dropping of the anterior
ends of the ribs. Its degree of development is an indication of the
general strength of the patient.

The distinctly muscular branches supply the rhomboidei and sub-
clavius muscles. In colds of the head and bronchial tubes these muscles,
that is the rhomboidei, are markedly contractured. This contractured
condition interferes with the circulation to the spinal cord in that area and

92 APPLIED ANATOMY.

the position of the vertebrae to which they are attached. This condi-
tion finally leads to weakening of the bronchial tubes and lungs, and
predisposes to tuberculosis of the lungs. Repeated colds cause repeated
contractures of these muscles. After the lungs begin to waste these
muscles degenerate. In some cases they can be seen as fibrous cords.
In most chronic cases they are relaxed and the scapula becomes so loosely
attached to the thoracic wall and spinal column that the hand can easily
be inserted beneath it. In acute cases the scapulae are drawn together.
The muscles supplied by the fifth segment of the spinal cord are: the
longus colli, scalene, levator anguli scapulae, serratus magnus, sub-
clavius, supra-spinatus, infra-spinatus, teres minor, subscapularis, deltoid,
pectoralis major, biceps, brachialis anticus and multifidus spina?.

The fifth cervical nerve also furnishes filaments which supply the
humerus and its periosteum. This is of importance not because dis-
ease of the bone is not unusual, but because its nerve supply is seldom taken
into consideration. Nearly all cases of caries are attributed to tuber-
culosis, but back of all these so-called tubercular conditions are lesions
of some sort that impair the vitality of the bone. A lesion of the fifth
cervical will affect the nutrient nerve to the humerus and in some cases
this disturbance is sufficient to produce a change, possibly caries. An-
other branch passes to the brachial artery which appears to carry vaso-
motor impulses to it.

The size of the artery is partly controlled by this nerve. In vascu-
lar disturbance of the arm the trouble may be in this branch to the artery.

The fifth cervical segment supplies in whole or in part the shoulder-
joint, elbow and wrist. In many cases of "rheumatism" of the joints
of the arm the trouble is a lesion impairing the nerve supply. This
lesion may be in the articulation itself or at the fifth cervical, at which
point the nerve is in relation, that is, the cause may be in the spine but
the effect is in the joints of the arm. This may work in just the
opposite way, that is, the wrist, elbow, or shoulder-joint may be impaired
and the pain be felt in the cutaneous areas supplied with sensation by the
fifth cervical. A sprain of the wrist may cause pain to be felt the en-
tire length of the arm or between the shoulders. In most cases there
is a reflex contracture of the muscles supplied by the same segment.

The fifth cervical nerve supplies sensation to the integument over
the deltoid, middle and lower portions, radial aspect of forearm and in
most cases the ball of the thumb. It communicates with the fourth

APPLIED ANATOMY.

CERVICALCS ASCENDENS TRACHE|_0 MASTOID,

TRANSVERSALIS CERVICIS

COMPLExus

splenius CApmstT.c

INTEGUMENT over

'I NOUS PROCESS
SAPEZIUS

INTERTRANSVERSAUS
MULTIFTOUS SPINA!

SEMISPINALS

CONNECTS WITH 4ISCERV. N.
LEVATOR ANGULI SCAPULA1.
RHOMBOID NERVE
POST. THORACIC
NERVETO SUBCLAVIUS
SUPRASCAPULAR
OUTER CORD

POSTERIOR CORD
IMNER CORD

EXT. ANT. THORACIC
INT ANTTHQRACIC
CIRCUMFLEX

CADIAC PLEXUS

NERVEorWRISSERG-

Fig. 24 — Showing the fifth cervical segment with its nerves and their distribution.

94 APPLIED ANATOMY.

and sixth cervical and the middle cervical ganglion. The recurrent
meningeal is formed from the fifth cervical and the corresponding grey
ramus and is affected by the lesion. The vertebral plexus would be
involved similarly to that from a lesion of the vertebra above. The
posterior division of the fifth cervical nerve divides into the usual in-
ternal and external branches. The internal branch supplies the semi-
spinalis and complexus muscles, pierces the trapezius and supplies in
part the integument over the back part of the neck. The external
branch is small and helps to supply the muscles in relation, viz., splenius,
transversalis colli, complexus, trachelo-mastoid and the cervicalis as-
cendens. The posterior division of this nerve is often the seat of pain
referred from diseased conditions in which the anterior branches are
involved. In colds from exposure of the neck this nerve is the one
first affected. Lesions of the fifth cervical weaken the tissues supplied
by this division, hence the power to resist the effects of thermic changes
is lessened.

The middle cervical ganglion is located opposite the sixth cervical
vertebra in front of the bend in the inferior thyroid artery, hence it is
often called the thyroid ganglion. It seems to be formed by the coal-
escence of the fifth and sixth cervical ganglia and is sometimes wanting.
It gives off several efferent branches: the thyroid, which follow the
artery to the thyroid gland, the middle cardiac, branches to the common
carotid artery, and the external branches or grey rami that join the
fifth and sixth cervical nerves. From the loop, or ansa subclavia, con-
necting the middle and inferior cervical ganglia, spring branches which
supply the subclavian artery by way of the plexus subclavius, the
internal mammary artery and in some cases, communicate with the
phrenic nerve. Branches to the thyroid gland arise from the inner
side of the ganglion. These fibers communicate with the superior cardiac,
the recurrent and external laryngeal nerves. This explains, in a measure,
the throat and heart complications of exophthalmic goitre. Most of
these branches follow the terminal divisions of the inferior thyroid artery.

The middle cardiac (nervus cardiacus magnus) also comes from this
ganglion. It terminates in the deep cardiac plexus after communicat-
ing with the upper cardiac and the recurrent laryngeal. Clinically and
experimentally, this nerve has little or nothing to do with the action of
the heart. On account of the scarcity of cases of heart disorders from
this lesion, it proves one of two things; that either few if any impulses

APPLIED ANATOMY. 95

for the heart pass through the upper cervical sympathetic nerves or
else, a vertebral lesion will not, under ordinary circumstances, affect
the gangliated cord in relation unless impulses pass from the spinal cord
to the sympathetic chain at that point. The cardiac impulses arise in
the upper thoracic portion of the spinal cord and pass out of the spinal
canal through the intervertebral foramina in relation and at this place
they are interrupted.

The function of the middle cervical ganglion seems to be that of
transmission and distribution of impulses that arise in the upper thoracic
spinal cord. They are motor, secretory and vaso-motor in function,
and pass to the neck, head and face. Most of these impulses pass on
through the ganglion to parts above while a few are distributed by means
of the efferent branches of this ganglion, viz., vaso-motor to the thyroid
gland, and to the neck, shoulder, arm, cervical spinal cord and meninges.
Secretory impulses for the cervical sweat glands pass through this
ganglion and out over its efferent fibers to their destinations.

The conclusions we draw from this knowledge of the middle cervical
ganglion are: exophthalmic goitre may follow a lesion affecting this
ganglion because the vaso-motor nerves to the thyroid gland come in
part from this ganglion. Goitre seems to be a vascular disturbance,
and a lesion of the fifth cervical vertebra will affect the middle cervical
ganglion from which arise branches that supply the gland. The heart
may be involved on account of relation to, and connection with the
great cardiac nerve. The heart may be affected independently of the
disturbance of the thyroid gland but clinically it is rare for a lesion of the
fifth cervical to cause heart disturbances, although it does happen.
Throat disturbances, vaso-motor, motor and sensory, result from an
impairment of the middle cervical ganglion, which are explained by the
above named nerve connections. Arm troubles, especially such as
arise from a vascular disturbance, will in some cases result from a le-
sion affecting the middle cervical ganglion because the subclavian plexus
is derived in part from it. The parts supplied by the internal mammary
artery may likewise be involved because of a similar reason.

The fifth cervical segment contains nerve cells or centers that give
origin to motor impulses that result in movement of that part of the
spine, shoulder and arm, hence a lesion affecting this segment, and a
subluxation of the fifth cervical will in all probability do it, will impair
the movements of the head, neck, shoulder and arm.

96 APPLIED ANATOMY.

Sensation to the integument over the lower part of neck and over
deltoid muscle, the shoulder and acromio-clavicular articulations, also
the elbow and wrist and the ligaments of that part of the spine, is con-
trolled by the condition of the sensory cells in the ganglion on the pos-
terior root of the fifth cervical. The vaso-motor fibers supplying the vessels
of the shoulder, arm, fifth cervical vertebra, fifth cervical segment of
the spinal cord, meninges and muscles in relation, are more or less af-
fected by a lesion involving the fifth cervical vertebra because they are
in relation. The diseases to be associated with a lesion of the fifth cer-
vical are: disturbances of circulation to the brain, producing in some
cases epilepsy; eye diseases; goitre and shoulder disturbances, especially
the so-called "rheumatism of the shoulder." Goitre comes directly
as a result of the lesion by which the nerves and vessels to the gland are
involved, or indirectly through displacement of the first rib as a result
of muscular contractures.

The lesions in this part of the spinal column, that is the middle
cervical region, are not so important in the production of visceral and
vaso-motor disturbances in the parts above, as are those of the upper
part of the neck and the upper thoracic region. Clinically, it is the ex-
ception to find the cause of any cranial disorder in the middle or lower
cervical region, compared with the frequency of locating it in the upper
cervical and thoracic areas. There are, however, some cases in which
the visceral and vaso-motor disorders of the head and face are caused by
a lesion of the middle cervical vertebrae. The explanation, as it ap-
pears to me, is, that few if any vaso-motor impulses destined for the
head, pass through the intervertebral foramina in this region. Prac-
tically all, if not all of them, pass out of the spinal canal at a point below,
and reach their destinations by way of the gangliated cord and the
superior cervical ganglion, and its ascending branches. In ordinary
vertebral lesions, little if any pressure is exerted on the gangliated cord
in relation. Vertebral lesions produce most of their effects by lessening
the size of the intervertebral foramina. Therefore, a lesion of the fifth
cervical vertebra will not produce such a marked visceral or vaso-motor
effect, as would a lesion of the second thoracic or the axis,because but
few vaso-motor impulses for parts above pass through the fifth or sixth
intervertebral foramen, at which point they might be affected by the
lesion, but pass over the gangliated cord which is fairly secure from
pressure by the average subluxation.

APPLIED ANATOMY. 97

THE SIXTH CERVICAL.

The sixth cervical vertebra is also a typical vertebra, hence needs
little separate description. All its parts are slightly larger than those
of the fifth. The spine is longer and larger, the body more hooked or
beaked. The transverse processes are not always perforated for the
passage of the vertebral vessels. Immediately above the transverse
process of the seventh cervical the anterior tubercle or the front of the
transverse process of the sixth, can be palpated quite readily if the
head is moved from side to side. On account of its relation to the carotid
artery it has received the name of carotid tubercle. This bony enlarge-
ment or apparent irregularity, should not be mistaken for a lesion of
the sixth, even though it be quite prominent. The facets are directed
upward, inward and backward. The movement of its articulations
is less than that of the various articulations above, and the spinous pro-
cess is often very near the spine of the seventh. It approaches the
thoracic type of vertebrae.

It is subject to lesions very similar in character to lesions of the
vertebras above; perhaps as in the fifth, the most common lesion being
an anterior one. The effect on the ligaments is that of rupturing fibers
in them, this, as stated before, producing swelling and tenderness in the
ligament. The muscles involved, that are important, are the cervicalis
ascendens, trachelo-mastoid, multifidus spinas, complexus and splenius
colli. All of these muscles have been considered above.

The arteries are the vertebral and its lateral spinal branch and the
lateral spinal from the ascending cervical. A disturbance of them would
follow a lesion of the sixth, hence vascular disorders of the cervical
spinal cord and part of the brain. The corresponding veins would be
disturbed by this lesion in a way similar to that from a lesion of the
cervical vertebras above.

The nerves that have their center in the sixth cervical segment or
that would in some way be affected by a lesion of the sixth cervical are
the suprascapular, long or posterior thoracic, external anterior thoracic,
subscapular, circumflex, median, musculo-cutaneous, musculo-spiral,
muscular, recurrent meningeal, vertebral plexus, and the middle cervical
ganglion and its branches and connections.

By affecting the supra-scapular, there would be a pathological
change in the spinati muscles and the shoulder-joint.

98 APPLIED ANATOMY.

The long or posterior thoracic supplies the serratus magnus, hence
in lesions affecting it there is difficulty in raising the arm above the
horizontal position, the contour of that part of the spine is altered, and
the position and movement of the ribs changed.

A disturbance of the external anterior thoracic would affect the
pectoral muscles.

The subscapular nerve supplies the latissimus dorsi, subscapularis
and teres major. There are three of these nerves, the upper or short,
the middle or long and the lower subscapular. The upper is distributed
exclusively to the subscapularis muscle. The long supplies the latissi-
mus dorsi muscle, and the lower is distributed to the teres major. These
muscles strengthen and support the shoulder-joint, the bicipital tendon,
and help to fix the scapula. In affections of the nerve supplying the
subscapularis muscle, , inward rotation of the humerus is lessened. If
the long subscapular nerve is paralyzed, "forcible backward depression
of [the raised arm is lost, and the shoulder cannot be put back without
being also raised (by the trapezius). The teres major muscle has to
do with drawing the humerus backward and inward as in climbing.
In paralysis, the elevation of the shoulder, with the arm against the side,
is lost" (Gowers). In lesions of the sixth, the movements of the scap-
ula and humerus would be affected and the shoulder-joint weakened.

In lesions of the sixth cervical and shoulder-joint, the circum-
flex is involved hence impaired movements of the arm, pain in joint and
over shoulder, and sometimes atrophy and anesthesia. The deltoid is
also involved.

The musculo-cutaneous nerve is of importance in that it supplies
the coraco-brachialis, biceps and brachialis anticus muscles, the humerus,
its nutrient artery, the elbow and wrist-joints and sensation to the thenar
eminence and skin of the forearm, outer side, as far as the wrist. Le-
sions involving it would result in an impairment of the muscles inner-
vated, malnutrition of the humerus, stiffness of the elbow- and wrist-
joints and sensory disturbances of the posterior and outer aspect of the
forearm and thenar eminence of the hand.

The median nerve is of importance from a pathological standpoint
on account of the character of effects from involvment of it. This nerve
supplies sensation to the palm of the hand, palmar surface of three and
one-half fingers, and pulp under nails on first three and one-half fingers.
It supplies the muscles of the thumb, flexors of the wrist and long flexors

APPLIED ANATOMY. 99

of the fingers. The elbow, wrist, metacarpal and phalangeal joints
are supplied by it. ProgTessive muscular atrophy is manifest first by
atrophy or wasting of the muscles composing the thenar eminence.
The thenar eminence is composed of four muscles, viz., the adductor
pollicis, opponens pollicis, abductor pollicis and the flexor brevis pollicis.
All of these muscles with the exception of the adductor pollicis, are sup-
plied by the median nerve. Progressive muscular atrophy is due to pro-
gressive impairment of the motor and trophic cells in the lower cervical seg-
ments of the spinal cord, which is determined by the fact that the effect
of the disease is first manifested by atrophy or wasting of the thenar
eminence which is supplied by the median and ulnar nerves, they having
their origin in the lower cervical and upper dorsal segments of the spinal
cord. A lesion of the sixth cervical vertebra will affect the median
nerve either at its origin or exit and cause a paralysis, partial or com-
plete, with symptoms identical with, or very similar to the disease rec-
ognized as progressive muscular atrophy. There seems to be, judging
from clinic cases, trophic centers for the arm in the upper thoracic spinal
segments, (upper four), hence lesions in that area may cause this dis-
ease. From an osteopathic viewpoint, the lesions of the lower cervical
and upper thoracic vertebra? are the most important causes of this dis-
ease, these lesions causing the disease by disturbing the circulation
through the motor and trophic areas in which are located the cells gov-
erning the arm. These cells are in the anterior horns of the grey matter
of the spinal cord. These lesions alter the size of the intervertebral
foramina, thus producing pressure on the blood-vessels passing through
them; this interfering with the nutrition of these nerve cells. The causes
usually mentioned as responsible for progressive muscular atrophy are
recognized as exciting ones, but probably of themselves are not suf-
ficient to produce the disease.

The musculo-spiral nerve would be more or less affected by a le-
sion of the sixth cervical vertebra. It supplies the extensor muscles of
the elbow-joint and wrist, sensation to the posterior and outer aspect
of the upper arm, forearm and hand and sends articular branches to the
elbow, wrist, metacarpo-phalangeal and phalangeal articulations. This
nerve on account of its course, is more frequently injured than the other
nerves of the brachial plexus. Fractures of the humerus, pressure
from the use of a crutch, lead and alcoholic poisoning are important
causes of disturbance aside from the above mentioned lesions. Wrist-

100

APPLIED ANATOMY.

I Tl

IT.211

S E.C

I.ECS

p. \J

Fig. 25. — The musculo-spiral nerve and its branches. Note relation to humerus.

0. I. nerve to outer head of biceps; S. E. C. superior ex. cut; B. R., N. to brachio-
radialis; E. C. R. L., N. to extensor carpi radialis longior; I. E. C, Inf. ex. cut.; R.,
radial; P. I., post, interossous; An. N. to anconeus; I. T. 1 & I T. 2, nerves to triceps;

1. C, Internal cutaneous.

APPLIED ANATOMY. 101

drop follows a paralysis of the extensor muscles of the wrist, also wasting
of other muscles in relation. Other effects may follow lesions affecting
it since many movements of the forearm, wrist and fingers, depend on
this nerve. Dana says: "Its function is to extend and supinate
the forearm, to extend the wrist and fingers, and to adduct and abduct
the fingers slightly." These varied movements would of necessity be
impaired if the nerve were affected, which is the case in lesions of the
lower cervical vertebrae.

The important muscles supplied by the sixth cervical nerve are the
scalene, serratus magnus, subseapularis, teres major, deltoid, pectoralis
major, biceps, multifidus spinas, the extensors of the wrist and flexors
of the thumb. All of these have been considered except the biceps.
This muscle is of interest in that its long head is supposed to be subject
to "displacement. This head "arises by a long tendon from the top of
the glenoid cavity and the glenoid ligament and, arching over the head
of the 'humerus within the capsule of the shoulder-joint, pierces the
latter between the two tuberosities and descends in the bicipital groove
between them covered with a reflection of the synovial membrane of the
joint, which serves to lubricate it and facilitate its movements." It
is held fairly well in place by the attachments of the pectoralis major
muscle. Occasionally this tendon becomes torn loose from its mooring
and gets out of the groove, but I believe this to be an exceptional accident.
In most of the cases diagnosed as a dislocation or "slip "of this tendon,
the acromio-clavicular articulation was found impaired, in other words
a subluxated clavicle, acromial end, was found. If the tendon is dis-
placed, all the movements wherein the biceps muscle is used, are pain-
ful.

Pain in and over the muscle often comes from neck, shoulder and
clavicle lesions.

The extensor muscles of the wrist were considered with the mus-
culo-spiral nerve.

In spinal cord diseases,groups of muscles are affected since the seg-
ments of the cord are involved and, usually, all the muscles innervated
by the diseased segment are affected. This is especially true in an-
terior polio-myelitis.

The posterior division of the sixth is also involved by a lesion of
the corresponding vertebra. As a result, the muscles supplied are af-
fected and the integument over the lower part of the neck is disturbed
as to sensation.

102

APPLIED ANATOMY.

TRACHELO MASTOID TRANSVERSAL!! OERVICIS

CERVICALIS ASCENOENS
SPLENIUS CAP ET COLLI

INTEG-UMEUITOVER
SPINOUS PROCESS
AND TRAPEZIUS

INTERTRANSVERSALIS
MULTIFIDUS SPlNAi
SEMISPINALS
C0NTSWITH4TS CERV N
POST THORACIC N
CONTSWrTw 3? CERV N.
ANSA VIEUSSENS
TO SUBCLAVIAN ARTERV
RHOMBOID NERVE
SUBCLAVIUS
SUPRASCAPULAR
UTER CORD

POSTERIOR CORD
INNER CORD

EXT. ANT. THORACIC
INT.ANT.THORACIC
.CIRCUMFLEX

S4TERNALCUTANEOUS-

liERVEOT UBR1S8ERG-

Fig. 26. — Showing the sixth cervical segment with its nerves and their distribution.

APPLIED ANATOMY. 103

The recurrent meningeal which supplies in particular the sixth
cervical segment of the spinal cord, is usually involved by a lesion of
the sixth.

The vertebral plexus is in relation, usually entering the transverse
process of the sixth, and would be disturbed in some way by a lesion of
this bone. This furnishes an explanation of eye disturbances from le-
sions so low in the neck.

The grey ramus connecting the middle cervical ganglion with the
sixth nerve is very liable to injury in lesions of the sixth.

The middle cervical ganglion is in relation with the transverse pro-
cess of the sixth and is frequently affected in lesions of this vertebra.
This ganglion gives off branches that supply the heart, thyroid gland,
common carotid artery, ami, and indirectly sends filaments to the
phrenic and occasionally the mammary artery. It communicates with
the recurrent laryngeal, external laryngeal, superior cardiac, superior
and inferior cervical ganglia, on which account many disturbances of
the parts innervated by these nerves come from lesions of the lower
cervical vertebrae, those of the fifth and sixth, affecting this ganglion.

The parts affected by a lesion of the sixth cervical are: the first
rib, it being pulled out of place by the contractured scalene muscles,
this lesion affecting their innervation; the wrist-joint, the shoulder and
hand; the scapulae on account of the disturbance of the nerve of Bell;
the chest wall; the brain, such a lesion sometimes producing epilepsy
since the vaso-motor tracts are involved; and the eyes through the
cervical sympathetic and the vertebral plexus. There may be pain or
numbness of the arm and hand and between the upper parts of the scap-
ulae. The thyroid gland is often affected, exophthalmic goitre being
common. The heart is sometimes involved. The throat is affected, a
dry hacking cough being the most common condition. The eye, arm
and throat are most frequently affected by a lesion of the sixth cervical
vertebra. ■

These effects are not the results of pressure of the displaced bone
on the nerves as commonly as they are the results of a disturbance of
the nutrition of the nerve cells. Pressure of the displaced vertebra on
a cerebro-spinal nerve would produce some sensory disturbance, as is
demonstrated by pressure on the ulnar. These nerves are mixed, and
pressure on them will affect the sensory element in preference to the
motor. If the irritation is severe, there will be both a sensory and a

104

APPLIED ANATOMY.

motor effect. In lesions characterized by painful effects, the nerve is
affected external to the spinal cord. In spinal lesions in which there
is only a motor effect, the cells of the spinal cord are affected, as in an-
terior polio-myelitis. In short, if the disorder is in the cells of the spinal
cord, the effect is a motor one, but if it is external to the cord it may be
sensory or both sensory and motor, seldom is it a purely motor effect.
In a general way, use can be made of this in the diagnosis of the cause
of the particular pain or motor disorder, that is, in determining whether
the trouble is in, or external to, the spinal cord.

THE SEVENTH CERVICAE.

The seventh cervical vertebra is called a transitional vertebra in
that it has characteristics of both the cervical and thoracic. Its most
marked peculiarity is the very long, non-bifurcated spinous process
on which account, it is called the vertebra prominens. The transverse
process is quite large, especially the vertebral or posterior part, it ap-

SEVENTH
ERTEBRA

Fig. 27. — Showing cervical ribs. Drawn from a dissection made at the A. S. O.
On one side the rib was anchvlosed, on the other, the articulation was freelv movable.

proaching in appearance the transverse processes of the thoracic verte-
brae. It is seldom pierced by a foramen like those above, but in some
cases a small foramen is present which transmits a vein.

APPLIED ANATOMY. 105

The superior facets face almost directly backward and present a
flat* surface. The principal motion here is a gliding one although nearly
all the ordinary neck movements are present but considerably limited.
It is somewhat more posterior than the sixth, it taking part in the nor-
mal posterior swerve of the upper thoracic spine. The movements at
the articulation between the sixth and seventh cervical are very limited,
on account of which is the possible explanation of this articulation being
involved less frequently than those above in which movement is more
marked. Its most common lesion is a forward rotation by which the
spines of the seventh and sixth are approximated. As a result of this
there is a separation of the spines of the seventh and first thoracic ver-
tebra or what is ordinarily called a "break." As a rule in these breaks
or separations, the vertebra above the break is the one involved.

In this part of the spine the usual bony lesion consists of an altera-
tion in position of the articular facets caused by one part or section of
the spinal column being forcibly moved, to a pathological extent, on the
other. As a result of a lesion of the articulation between the sixth and
seventh cervical vertebra?, its ligaments, muscles and foramina; would
be disturbed in some way. The effect on the ligaments is usually one
of undue traction quite often to a pathological degree.

The ligamentum nuchae is attached to the spine of the seventh and
extends to the crest of the occipital bone, it being attached to the spines of
all the cervical vertebrae. Although it is more or less affected in any cer-
vical lesion it will be discussed here. In man it is rudimentary; in the
horse, ox, etc., it is well developed and constitutes an elastic support
of the head. In man it occasionalljr becomes contractured and tender,
which conditions are associated with occipital headache and a drawing
sensation in the back of the neck. Flexion of the head on the chest
causes pain if the ligament is shortened, as it is in most pathological
conditions, but such treatment is often helpful in relieving pain in the
neck. Care should be used in stretching this ligament lest too much
force be exerted on account of the leverage, the ligament be injured or
a vertebra pulled out of line. In palpating in the median furrow of the
neck, pressure should be made to one side of this ligament since by so
doing the condition of the deeper structures can the better be ascertained.

The important muscles attached to this vertebra and which would
therefore be affected by a lesion of it, are the trapezius, rhomboideus
major, serratus posticus superior, splenius, multifldus spina?, levator

106

APPLIED ANATOMY.

costse, scalenus posticus and medius, complexus and trachclo-mastoid.

Since the posterior part of the vertebra is usually rotated upwards and
forwards, the muscles attached to points below would be put on a ten-
sion. The serratus posticus superior in such a case, would pull up on

INTERSPINAL
MUSCLE

FORAMINA FOR
VERTEBRAL ARTERY

Fig. 28. — Showing ligamentum nucha?. This ligament often becomes contractured
and tender, which condition tends to produce headache accompanied by a drawing
sensation in the back of the neck.

APPLIED ANATOMY. 107

the angles of the upper ribs, this condition in turn affecting the thoracic
viscera by altering the position of these ribs. The disturbance of the
levatores costarum muscles would have a similar effect, that is the verte-
bral end of the ribs would be displaced or at least drawn slightly up-
ward. This is the usual form of rib displacement and probably is ac-
counted for by the above arrangement of the muscles. The scalene
help to produce this form of rib lesion in the upper two ribs.

It is not unusual for such a lesion to produce a painful contracture
of the above named muscles. In such cases there is a constant ache in
the lower part of the neck and the upper thoracic region and marked
flexion produces an acute pain. The patient complains of a dull, chronic
ache in the region of the seventh, catches cold quite easily and any ex-
ercise wherein these muscles are used, produces fatigue of this part.

The arteries involved by a lesion of the seventh, are the vertebral
and its lateral spinal branch (not constant), the lateral spinal branch
of the ascending cervical and the lateral spinal branch of the superior
intercostal artery. The corresponding veins are affected, thus producing
disturbance with the drainage of the muscles of this region and espec-
ially of the spinal cord and its coverings. The effects vary with the de-
gree of congestion and the function of the part involved. As a rule
passive congestion lessens activity, or at least the function of the part
congested is perverted.

The nerves involved by a lesion of the seventh cervical vertebra,
are those passing out through the foramina above and below it, these
being directly involved, while their communications and connections
are indirectly affected. On account of the extra cervical segment, both
sets of nerves will be considered in connection with the seventh, instead
of pnly the nerves passing through the seventh cervical intervertebral
foramen, that is the nerves above the corresponding vertebra as we
have done in the other cervical nerves.

The nerves in relation with the seventh are the posterior thoracic,
subscapular, ulnar, median, musculo-spiral, internal anterior thoracic,
internal cutaneous, muscular, recurrent meningeal, possibly the verte-
bral plexus and the inferior cervical ganglion and its branches and com-
munications.

The posterior thoracic is involved in winged scapulae, that is in re-
laxed conditions of the serratus magnus muscle, and has been considered.

The subscapular supplies the subscapular and latissimus dorsi mus-

108

APPLIED ANATOMY.

transversalis cervicis
cervical1s ascendens- —
splenius capitis et colli
cqmplevus trachelo-mast i;
post n. roots

>;;t eXTbranch

./jSsJ '^^\5PIN«LGAN(^-^

INTEGUMENT over

CERVICAL SPINOUS

PROCESSES

INTERTRANSVERSALIS

MULTIFIDU5 SPINA

SEMI SPINALIS

ANSA VIEUSSENII

TO SUBCLAVIAN ART.

To INT MAMMARV ART.

RHOMBOID

PHRENIC N

TO 5I» CERVICAL N

POST.THOHACIC N.

TOSUBCLAVIUS MUS.

SUPRASCAPULAR.

OUTER CORD

STERIOR CORO.
ER CORD

XT ANT THORACIC N.
INT ANT. THORACIC K.
1RCUMFLEX N.
MUSCULO SPIRAL

MUSCULO
CUTANEOUS

Fig. 29. — Showing the seventh cervical segment with its

tribution.

ULNAR NL

N.OFWRISBERG

nerves and their dis-

APPLIED ANATOMY. 109

cles and is principally motor, controlling the position of the scapula
and backward movements of the arm.

The ulnar, the "crazy bone" nerve is of interest to us. Pain or
other sensory disturbance in the hypothenar eminence, little finger,
ulnar side of ring finger, or back of hand (ulnar aspect) is the result of
direct or indirect disturbance of this nerve. Numbness in the little
finger, the left being more frequently involved than the right, is quite
a common condition in the aged and in patients subject to heart dis-
ease, particularly angina pectoris. Pain in the lower part of the fore-
arm is, to a certain extent, due to an interference with the ulnar nerve.
Many of these sensory disturbances are reflex from lesions of the elbow,
shoulder and lower cervical and upper thoracic vertebra?. The seg-
ments of the spinal cord that give rise to impulses that pass to the ulnar
nerve also give origin to impulses that supply the heart and lungs. Ap-
plying Head's law we then have an explanation of angina pectoris and
valvular disease producing numbness or pain in the little finger. Eckley
offers an explanation that is slightly different: *" (1) The heart is sup-
plied by sympathetic nerves by the cardiac plexus; (2) the sympathetic
nerves forming the cardiac plexus communicate with the somatic nerves
in the area where are given off the nerves forming the brachial plexus;
(3) as sensory nerves report pain peripherally, we may logically account
for the digital pain in valvular lesions in the distribution of the brachial
plexus in general, or in the specific distribution of the ulnar nerve in
particular. "

Since this nerve supplies the majority of the intrinsic muscles of the
hand, muscular disturbance of the hand, that is atrophy and contracture,
result from lesions involving the ulnar nerve, a lesion of the seventh
cervical not being unusual. In progressive muscular atrophy this nerve
with the median is primarily involved, at least the effects of this disease
are first evident in the parts supplied by them, viz., the muscles of the
thumb that form the thenar eminence. In eversion of the hand, as in
rheumatoid arthritis, this nerve is in all probability the first to be in-
volved. If the grip is weakened this nerve is affected, since it supplies
the deep flexors of the fingers.

The median nerve has been considered with the sixth cervical seg-
ment. The principal point to be remembered concerning it is its con-
nection with progressive muscular atrophy.

*Fractical Anatomy, p. 265.

110 APPLIED ANATOMY.

The musculo-spiral is at fault in wrist-drop and is often injured in
fractures of the humerus or by an improperly worn crutch.

The internal anterior thoracic nerve supplies the pectoral muscles,
hence in disturbance of them this nerve is usually at fault.

The internal cutaneous nerve is sensory, supplying the integu-
ment of the upper and inner aspect of the arm, and the posterior
and internal part of the forearm as low as the wrist. It communicates
with the musculo-spiral and ulnar nerves. Pain in these regions is
usually the result of disturbance of this nerve. The cause of the dis-
turbance may be at the seventh cervical vertebra or it may be reflex
from disease of viscera supplied by the same segment in which are the
cells that give rise to this nerve.

In addition to the muscles described as innervated by the above
nerves the posterior division gives off muscular branches that supply
the multifidus spina? and other muscles.

The articulations of the elbow, wrist and hand are also supplied by
the seventh and would be involved by a lesion of the seventh cervical
vertebra. Thus dryness of these joints, pain and rheumatic affections
are directly attributed to a lower cervical lesion. In some instances
the brachial plexus receives filaments from the left vagus. McClellan
states that in "two dissections made within the last year, the author
has found distinct branches passing from the pneumogastric on the left
side to the brachial plexus. " This is of value in associating pain in the
arm with cardiac disease, such as angina pectoris and valvular disease
or endocarditis.

The posterior divisions of the seventh and eighth cervical, do not
supply sensation to the integument in relation as do those above and
below. The cutaneous nerves of this region come from the posterior
divisions of the sixth and first thoracic nerves.

The interior eervical ganglion is in relation with the seventh cer-
vical vertebra, connects with the seventh and eighth cervical nerves,
and is involved in lesions of this vertebra. The branches of this gang-
lion are: grey rami communicantes which pass to the anterior division
of the seventh and eighth cervical nerves; the subclavian loop connect-
ing the inferior and middle cervical ganglia; a small branch, sometimes
wanting, which communicates with the recurrent laryngeal; inferior
cardiac; and branches that form the vertebral, inferior thyroid, and in-
ternal mammary plexuses of nerves.

APPLIED ANATOMY.

Ill

TRACHELO- MASTOID CER VI CAL1S ASCENOEN

THANSVERSALIS-CERVICIS
SPLENIUS-CAPITIS ET COLLI
POST.N ROOTS COMPLEXUS

\AN3A

SPINAL GANG

INTEGUMENT OVER
CERVICAL SPIHOUS
PROCESSES)

INTERTRANSVERSALES
MUlTIFIOUS SPIN*.
COMPLEXUS
SEMiSPINALiS
5IH CERVICAL N
6IB CERVICAL N
TO S'JBCLAVIUS MUS
SUPRASCAPULAR N
SCALENI ANO LONGUS COLLI
POSTERIOR THORACIC
EXTANT. THOR N.
IMT.ANT THORACIC N.
OUTER CORD
POST CORD
INNER CORD

MUSCULO
CUTANEOUS

CIRCUMFLEX

INF CARDIAC N

CAROIAC //'

PLEXUS J

INTER COSTO-HUMERALN><^
LATERAL CUTANEOUS N .
LESSER. INTERNAL CUTANEOUS N

Fig. 30. — Showing the eighth cervical segment with its nerves and their distribution'

112 APPLIED ANATOMY.

Not definitely knowing the kind and character of all the impulses
carried by the grey rami, it would be impossible to describe accurately
the effect of injury to them. Most all of the authors state that both
afferent and efferent impulses are transmitted by the grey rami, but the
efferent preponderate.

These efferent fibres carry vaso-motor impulses to the blood-vessels
of the skin supplied by the nerves derived from the seventh cervical
segment ; secretory and pilomotor impulses to the same area. Perhaps
a few sensory impulses from this area reach the cord by way of these
grey rami.

The ansa subclavia supplies the subclavian artery, internal mam-
mary artery and sends a communicating branch to the phrenic nerve.
Some authors have described a branch from this ganglion that goes
directly to the phrenic and clinically this seems to be the case. A le-
sion of the first rib will affect the phrenic and produce hiccough, and
this branch seems to be the best explanation of the clinical fact in that
the phrenic is affected through the inferior cervical ganglion. In dis-
sections made and seen by the author, this communicating branch to
the phrenic was quite often found.

As a result of a lesion affecting the ansa subclavia there would
follow: (1) vascular disturbances in the parts supplied by these arteries,
viz., arm, mammary gland and a part of the chest wall, and (2) derange-
ment of function of all or a part of the structures supplied by the phrenic,
viz., diaphragm, pleura, pericardium, peritoneum, heart and the dia-
phragmatic plexus.

The recurrent laryngeal nerve supplies motion to the larynx, hence
the relation between lower cervical and upper rib lesions and throat
affections, especially coughing. A better explanation of why lower
cervical and upper rib lesions produce throat disorders is that these
lesions affect the inferior thyroid artery by way of its nerve supply.
This artery supplies to a great extent, the esophagus, trachea, larynx,
the deep muscles of the neck and the phrenic nerve. If this artery is
affected, congestion or anemia of these parts follows. Congestion leads
to disordered secretions and other disturbances. Congestion in this
case is due to vaso-motor inhibition which causes the vessels to dilate.
This inhibition comes from a lesion that disturbs the middle or inferior
cervical ganglion, since the vaso-motor impulses to this artery come by
way of these ganglia, and especially the inferior. On account of this,

APPLIED ANATOMY. 113

a lower cervical or upper thoracic lesion will produce vascular changes
in the throat, hence the hacking cough, catarrh, dryness and disturbances
of the voice.

The heart may be, and often is, affected by lesions affecting the
inferior cervical ganglion and its cardiac branches. The impulses reach-
ing the heart via the inferior cardiac do not, according to the best author-
ities, arise in the inferior cervical ganglion, but at a point in the spinal
cord somewhat lower; the ganglion demudullating and otherwise chang-
ing the fibers. This cardiac nerve connects with the middle cardiac
and inferior laryngeal nerves. This explains some cases of hacking
cough accompanying and resulting from many forms of heart and lung
diseases.

The vertebral plexus would also be affected by a lesion of the seventh
cervical. This plexus sends vaso-motor filaments to the vertebral artery
and all its branches, which control their size, hence the amount of blood
passing through them. Thus the amount of arterial blood in the cer-
vical spinal cord and vertebral column, medulla, pons, cerebellum and
the posterior part of the cerebrum is governed to a marked extent by
the condition of the vertebral plexus of nerves. As a result of this le-
sion almost any disease or disturbance of function of the parts supplied
would arise, the principal one being eye affections. This is best ex-
plained by the fact that the centers for the eye, located in the floor of
the fourth ventricle and the occipital lobes, are dependent to a great ex-
tent for their nutrition on the vertebral artery and its branches, while
it in turn, is dependent on the healthy action of the vertebral plexus
of nerves.

Not only the artery and its branches are supplied but the vertebral
veins receive their vaso-motor impulses from this source.

The writer has seen cases of epilepsy, chorea and various circula-
tory disturbances of parts above result from a lesion of the seventh.
A great majority of nerve fibers located in the inferior cervical ganglion
have their origin lower, and transmit various sorts of impulses to parts
above. Since nearly, if not all impulses reaching the head from parts
below pass through this ganglion, it follows that any disturbance of it
would in some way interfere with the transmission of these impulses,
hence an effect in the points of destination. The inferior cervical gang-
lion, according to Quain, transmits pupillo-dilator fibers, motor fibers
to the involuntary muscles of the eyelids and orbit, vaso-motor fibers

114 APPLIED ANATOMY.

to the head and face, secretory fibers to the submaxillary gland, and
accelerator fibers to the heart. All of the above fibers are supposed to
originate in the upper thoracic portion of the spinal cord. The seventh
and eighth cervical segments of the spinal cord contain pupillo-dilator
fibers according to some observers.

Transverse myelitis often results from falls which dislocate or frac-
ture this part of the spinal column. The thoracic vertebrae are fairly
well fixed, hence the articulation between the seventh cervical and first
thoracic vertebra suffers most because of the change of mobility which
takes place at this joint. The writer has treated many cases of para-
plegia caused by a lesion at this articulation which in most of them set
up a myelitis.

Summary of seventh cervical. Lesions of this vertebra are asso-
ciated with affections of the upper extremity, such as pain, numbness,
swelling, paralysis, sensory and motor, and in short almost every form
of disturbance of the upper extremity; neck affections, eye diseases,
headache, heart disturbances, throat disorders, and especially vascular
disturbances of any or all parts above this vertebra. Eye diseases are
very often the result of a lesion in the lower cervical region. Progres-
sive muscular atrophy, Erb's palsy, Duchenne's paralysis, clawed hand,
wrist drop, "rheumatism" of the arm, neuritis and occupation neuroses
result in many cases from a lesion of the seventh cervical vertebra.

In all neck lesions there is tenderness. This tenderness is most
commonly deep, that is, in the ligaments and deep muscles. Occasion-
ally it is superficial, that is, in the integument. It is most pronounced
in the structures around the articular processes and is exaggerated by
pressure. The nerves involved are the posterior divisions of the cer-
vical nerves that supply the ligaments and deep muscles around the
cervical vertebrae. The tenderness is due to contracture of the deep
muscles attached to the vertebrae, pressure of the displaced bone directly
on the nerve, sprain of the ligaments which takes place to a greater or
lesser extent in all vertebral lesions or the tenderness is due to some in-
terference with the nutrition of the cells located on the posterior nerve
root. In most cases I believe that the tenderness is due to the injury
to the ligaments, that is, the ligament is partly or completely torn, be-
comes congested and swollen and is affected in a way similar to that
of a sprained wrist or ankle only to a lesser degree. The tenderness
in a contractured muscle is clue to mechanical pressure from the conges-

APPLIED ANATOMY. 115

tion and to the chemical irritation from the toxic material which has
formed in the muscle but has never been eliminated.

In the neck lesions the tenderness is found most frequently to be
over the spinous and articular processes or at least in relation with these
processes. It is present in many cases in which there is no bony dis-
placement, the lesion in such cases being a ligamentous one. Manip-
ulation of the joint will lessen it or even entirely remove it. This manip-
ulation consists of passive movement of the joint, that is, the function
of the joint is artificially restored.

THE REGION OF THE NECK.

The region of the neck. Anterior aspect. The sterno-mastoid

muscle is the great muscular landmark of the side and front of the
neck. Its degree of development and contraction determines to a
great extent the contour and size of the neck. It is affected in lesions
of the second and third cervical vertebra? and subluxations of the head
on the spinal column. The angle of the chin, and the way the head is
carried are determined by this muscle. It furnishes a reliable landmark
for the vagus and phrenic nerves and the carotid artery and jugular
veins, these structures being located immediately anterior to the middle
portion of the muscle. Deaver says: "Its anterior border is the sur-
geon's guide in the ligation of the common, external and internal carotid
arteries, the superior thyroid, lingual, facial and occipital arteries at
their origin, and the inferior thyroid artery as it enters the thyroid
gland; in exposing the spinal accessory nerve; upon the left side in the
operation of esophagotomy, and in all other operations upon the front
or the side of the neck." Torticollis is the principal disturbance of this
muscle.

The contour of the central part of the anterior part of the neck is
made irregular by the thyroid and cricoid cartilages. They are very
movable, their position being altered in swallowing and in -forced respira-
tion. The thyroid cartilage is the more prominent and forms in many
people, especially males with thin necks, a noticeable, angular promi-
nence. It is of importance on account of its relation to the vocal cords.

The cricoid cartilage is immediately below and can readily be out-
lined. Aphonia follows displacement of, or injury to this cartilage. -

The hyoid bone is located directly below the chin and its cornua
■can be distinctly outlined by pressure directed inward beneath the

116 APPLIED ANATOMY.

angles of the jaw. Its position is determined by the condition of the
various muscles attached to it. The vocal cords are in relation, or at
least would be affected by malpositions of this bone. Aphonia is very
commonly due to a displacement of it. It becomes displaced by colds,
which cause the muscles to contract, or by direct trauma as in choking
or other injury to the front of the neck. Its displacement may, in ad-
dition to that of producing aphonia and hoarseness, cause a chronic
hacking cough, sore throat and dysphagia. In whooping-cough it is
said to be displaced and that by drawing it forward away from the
laryngeal nerves, the spasm of coughing can be prevented or at least
lessened.

The supra-sternal fossa depends for its depth on the amount of
adipose tissue in the lower part of the neck and the position of the
clavicles. It is pathologically deepened in dyspnea as in asthma and
tuberculosis of the lungs. In laryngitis, pressure in this fossa produces
pain but gentle manipulation is beneficial.

The supra-clavicular fossa is the depression above the clavicle.
When increased in depth it is symptomatic of tuberculosis of the lungs.
It is also deepened in the emaciated and in the aged. When obliterated,
it is indicative of a depressed clavicle unless the patient is obese. In
tubercular patients this fossa and the adjacent tissues should be ex-
amined very closely by percussion and auscultation, since the apex of
the lung, which is in relation, is the first part to be affected.

The infra-clavicular fossa is the depression immediately below the
clavicle. It is of interest in that it is deepened in tubercular condi-
tions of the lung.

The platysma myoides muscle is a superficial one which has to do
with drawing down the lower lip and the raising of the skin and super-
ficial fascia of the neck lying between the lower jaw and pectoral muscles.
In some this muscle is remarkably developed, in others it cannot be out-
lined. It is of especial interest in that it is frequently the seat of a tic,
the muscle undergoing spasmodic contraction every few minutes. The
jaw is usually depressed and the shoulder raised and the face suddenly
drawn into a peculiar expression. These movements are spasmodic.
In such cases the cervical nerves instead of the seventh cranial, are most
frequently involved.

The skin on the front of the neck is very thin in contrast to that on
the back of the neck. Probably on this account, it is ■quite free from

APPLIED ANATOMY.

117

eruptions. It is highly sensitive, being supplied in the main by nerves
from the cervical plexus. The superficial vessels covered by it can or-
dinarily be outlined quite readily and the pulsations of the deep vessels
can be seen if the pulsation is abnormally hard.

The thyroid body is a very vascular gland which is situated over
the front and sides of the trachea and extending upward to the larynx.

Fig. 31. — Showing the platysma myoides muscle. Xote the direction of its fibers and
their insertion on the face.

118

APPLIED ANATOMY.

Fig 32. — Showing the platysma myoides muscle. (From photo).

APPLIED ANATOMY. 119

It is composed of two lobes with an isthmus connecting them. It is of
special interest because of enlargements or goitre occurring in it. Ordi-
narily the gland does not affect the contour of this part of the neck but
when enlarged the gland can be plainly seen, this of course depending
on the degree of enlargement. The gland varies in size in different in-
dividuals and at different periods in life. ' ' It is relatively larger in the
child than in the adult, and in the female than in the male." Exoph-
thalmic goitre is rare in the male, common in the female. The causes
of this disease seem most frequently to be lesions of the lower cervical
vertebra? and upper ribs, such lesions affecting the circulation of the
blood through and from the thyroid gland. The arteries are remark-
able for their size, number and free anastomosis. They are the superior
thyroid from the external carotid, the inferior thyroid from the thyroid
axis of the subclavian, and the thyroidia-ima which comes from the
aorta or innominate. From the above arteries it is ascertained that
the sympathetic nerves to this gland are derived from the cervical sym-
pathetic, the superior, middle and inferior ganglia. The inferior cervical
ganglion clinically seems to be most frequently involved. Since the
nerves to the thyroid are derived from the lowest part of the cervical
and upper thoracic region, lesions of the lower cervical vertebrae and
upper ribs, the first in particular, would affect it. The impulses reach
the gland by way of the branches that surround the thyroid arteries.

The veins of this gland are also large and very numerous, forming
a plexus which is drained by the superior and middle thyroid, which
empty into the internal jugular, and the inferior thyroid which empties
into the innominate vein. A displacement of the first rib, it usually
being backward and downward at the sternal end, upward and back-
ward at the vertebral, will directly or indirectly produce pressure on
these veins. A subluxated clavicle will in a similar way interfere with
drainage.

Atrophy or lack of development of the gland will produce myxede-
ma; in children, cretinism or idiocy.

Aneurism of the arch of the aorta or carotid arteries may change
the contour of the anterior part of the neck.

The trachea is located immediately below the cricoid cartilage, it
being about one and a half inches above the sternum, ft can only be
seen when the neck is in extreme extension. The trachea is sometimes
opened to relieve dyspnea, as in croup.

120 APPLIED ANATOMY.

The vessels that can be seen in the anterior part of the neck art!
the superficial veins that stand out so very boldly in many patients
during exertion, especially if the breath is held. The posterior and
external jugular are the most important. Experiments have been per-
formed in which oil was injected into the pericardial sac. In such
cases it was found that the superficial veins of the neck became dis-
tended. Clinically in cases in which there is a pericarditis or pleural
effusion by which the right auricle is compressed, the superficial veins
of the neck become distended. The explanation is that the venous re-
turn is obstructed, to a certain extent, by the pressure on the heart, and
the blood is forced back along the veins and the effect is most marked
in the superficial because they are not supported by muscles as are the
deep veins. In some types of organic disease of the heart, pulsation of
the superficial veins of the neck is quite noticeable. I have noticed that
children suffering with sore throat or tonsillitis often have enlargement
and distension of the veins of the neck.

The carotid arteries can be palpated and the pulsation, if unusually
hard, can be seen. Such latter pulsations of the carotid arteries are
very suggestive if not diagnostic of some form of heart disease.

The lymphatic glands of the neck' are often very much enlarged, so
that the contour is decidedly changed. Scrofula, tonsillitis or disease
of any part drained by the anterior cervical lymphatic glands will cause
their enlargement. In ordinary sore throat "kernels" form under the
angle of the jaw. Lesions of the neck sometimes produce these enlarge-
ments. Tuberculosis is the common cause of chronic enlargement of
these lymphatic glands, especially if the enlargement is marked. Ton-
sillitis produces an enlargement or swelling immediately anterior to
and below the angle of the jaw. This swelling or rather fullness, is
always present in chronic tonsillitis, therefore a fullness under the angle
of the jaw is almost diagnostic of disease of the tonsils or of adenoid
growths in the throat. Chronic tonsillitis predisposes to tuberculosis
of the lymphatic glands of the neck in that the tubercle bacilli enter the
crypts of the tonsils, thence into the lymphatic glands that drain the
tonsil. The lowered vitality of these glands permits the micro-organisms
to gain a footing in the body, and soon the patient has scrofula. The
kernels increase in size and finally an abscess forms. On this account,
children suffering with chronic sore throat or especially tonsillitis, should
be treated early and thus prevent infection through the tonsils.

APPLIED ANATOMY.

121

APONEUROSIS COMPLEXUS OCCIPITALIS

SPLENIUS
CAPITIS

TRAPEZIUS

L1CAMENTUM
NUCHA

SPLENIUS COLLI

Fig. 32. — Showing the relation of the superficial muscles of the upper part of the
back of the neck. These are first to be affected by thermic influences as in the catch-
ing of cold in the head.

122 APPLIED ANATOMY.

Tuberculosis may be the cause as stated above of these lymphatic
enlargements, but in all probability it is the result of the infection
that reached the glands through the throat and tonsils.

The nerves that are in relation with the superficial structures of
the front of the neck are the vagus, and phrenic. These nerves are
sometimes treated for a palliative effect by pressure directed over their
course. In hiccough the phrenic is inhibited; in disturbance of struc-
tures supplied by the vagus, this nerve is either stimulated or inhibited
by manipulation of it along its course. Such treatments are not cura-
tive and not always palliative, and are only advised when no better treat-
ment can be given. Pain near the angle of the jaw is usually in the
inferior division of the fifth cranial. Pain in the median line or near
by is suggestive of laryngitis. Pain in this region is seldom a referred
one in the sense that it is the result of disorder elsewhere, it being
due to direct, involvement by some local disturbance. The cause of
greatest pain in the front and side of the neck is some form of tonsillitis.
Acute laryngitis and diphtheria also produce marked pain in this region.

The contour of the back of the neck is governed more by the condi-
tion of the trapezii than by any other one factor. These muscles form
a furrow, the median furrow of the neck, along which the spines of the
cervical vertebra?, with the exception of that of the atlas, can be readily
palpated. The trapezius is contracted in colds in the head, uterine
headache, spinal meningitis and headache from weakness or other dis-
turbance of the eyes and is quite tender when contractured. This ten-
derness is possibly due in part to the fact that the muscle is markedly
congested when contractured. To the other or outer side of the inser-
tion of this muscle is a fossa, the sub-occipital fossa, which is a very im-
portant place from an osteopathic viewpoint, because the articular pro-
cesses of the cervical vertebras can be palpated along the furrow lead-
ing down the neck from it. Tenderness in the sub-occipital fossa is
almost diagnostic of an upper cervical lesion. In such cases deep pal-
pation reveals muscular contractures and a general tightness in the
upper cervical region. Pressure at this point-, applied by means of the
fingers, is the usual palliative treatment for headache. Headaches
caused by an upper cervical lesion can be relieved by such a treatment.
By deep pressure applied to this point is secured adjustment of the
vertebral articulations and relaxation of the contractured tissues.

The best place to apply this pressure in the treatment -of headaches

APPLIED ANATOMY. 123

is in the median line immediately below the occiput. By applying it
here the occiput is pried slightly off the atlas and the circulation to and
from the head freed, to a certain extent. This is an especially effective
treatment in cases in which the headache is due to a tightening of the
cervical tissues, that is in cases of congestive headache, especially the
form due to disorders of the eye, such as eye-strain.

In lesions of the cervical vertebra?, the irregularity can best be de-
termined by palpation along the above mentioned furrow. The artic-
ular processes are changed in position in lesions affecting the bones;
the articular processes are in relation with this furrow, hence in suspected
lesions of the neck, carefully palpate over the articular facets.

The bony landmarks of the neck are the transverse processes ot
the atlas and the spinous processes of the second and seventh. The
third may be regarded as a landmark since its spine is furthest anterior.
The greatest movement exists at the atlanto-axial articulation. Mo-
bility is also quite marked at the third cervical, it being subject to dis-
locations. It is also subject to fracture, at least it is most frequently
fractured of the cervical vertebrae. Always test for mobility of the var-
ious cervical articulations. This is best done by grasping and holding
the neck at points corresponding to the different articulations and then
with the other hand move the head in various directions.

The skin of the back of the neck is very thick and the circulation
through it more sluggish than through the vessels of the skin of the
front of the neck. On account of this fact and that it is subject to fric-
tion from the clothing, this part of the neck is subject to boils and car-
buncles. This is also true of the integument covering the upp-er part
of the back and shoulders, also that of the gluteal region.

The temperature of the back of the neck is indicative of the condi-
tion of the tissues beneath the skin. The condition of these tissues de-
termines the condition of many of the organs and structures above,
especially the mucous membrane lining the nasal fossa. If the back
of the neck is cold, it indicates a condition of low vitality of the part
which is most frequently the result of cervical lesions. Such conditions
are followed or accompanied by catarrh. The catarrhal effect will
come in a few minutes after sitting with the back of the neck exposed
to a draught. Coryza is the result. The explanation is that the thermic
stimulation readily affects the neck if the part is weakened by cervical
lesions, thereby setting up muscular contractures. These contractures

124 APPLIED ANATOMY.

affect the centers controlling the amount of blood to the head, espec-
ially the nasal mucous membrane. The impulses are so interfered
with that congestion follows in a very short time, which congestion is
manifest first by a sense of tightness followed by a "running of the
nose." If the patient can sneeze, often the cold will be aborted. These
vaso-motor centers are located in the upper thoracic segments and the
impulses pass through the superior cervical ganglion, from which they
pass up through the ascending branches to the fifth cranial nerve, thence
to the vessels of the nasal mucous membrane. The contractured cer-
vical muscles prevent, or rather interfere with, the normal amount of
impulses. The conclusion is, keep the back of the neck warm all the
time and the probabilities are that colds in the head can be prevented.
To do this, correct all cervical lesions that so weaken the neck that a
slight draught will affect the muscles thus made abnormal. If this is
done, every little change of weather and exposure to draughts will not
cause coryza or make the catarrh worse. Also be careful about need-
lessly exposing the back of the neck to a draught. Nature attempts
to prevent this by causing the hair to grow long. We destroy nature's
fortifications by wearing the hair closely cropped, as in the male, or
knotted or rolled up on top of the head as does the female.

The back of the neck is subject to many changes from atrophy or
enlargement of the parts composing it, or from deposits or new growths.
The muscles, as mentioned above, are subject to contracture. The
trapezius is affected in curvatures of the spine, hip dislocations; in short,
from limping from any cause, if chronic. In torticollis the sides are
not symmetrical. In hemiplegia the neck muscles are involved. Thick-
ening of the muscles may take place without affecting the contour of
the neck. In all head and throat affections, some of the posterior mus-
cles of the neck are always thickened, the obliqui, splenii, trachelo-
mastoid and multifidus spina? being most frequently contractured.

The ligaments become thickened from lesions of the articulations.
The thickening is most marked on the convex side. A thickening on
the left side over the articular process would indicate that the ligaments
had been partly torn by extreme flexion to the right side. The tender-
ness will be on the left. This explains unilateral tenderness from ver-
tebral lesions. If tenderness is about equal on each side, it indicates
stretching of both sides, that is, the lesion resulted from extreme flexion
or extension of the neck. The unilateral thickening or enlargement is
by far the more common.

APPLIED ANATOMY. 125

The lymphatic glands along the sides of the neck become enlarged
from causes similar to those producing enlargement of any lymphatic
gland : scrofulous conditions or formation of toxic material in area drained
by the gland.

The neck is the seat of many kinds of aches and pains. In most
cases the patient is not aware of possessing so many tender places in
the neck until an examination is made by palpation. Tenderness under
the occiput in the median line is indicative of eye affection. Tender-
ness over the articular processes is almost diagnostic of subluxation of
the vertebra or injury of the ligaments. Superficial tenderness or hyper-
esthesia is an accompaniment of recent injuries, meningeal affections
and lesions affecting the sensory innervation. Tenderness and pain
are increased by pressure, tightening of the muscles from the catching
of repeated colds, improper treatment of the neck, such as a sudden
and unexpected twist or pull, and disturbances of the spinal cord.

The neck as a region is more subject to injury than any other part
of the body. This is on account of its free mobility, exposed position
and its size. Childbirth, improperly handled, is responsible for many
cases of idiocy, paralysis usually of the spastic type or Little's disease,
monstrosities and various deformities of the head and body. Too much
or improper traction is used. Forceps are unnecessarily applied. Force
is used in a wrong direction, the neck twisted and traction exerted dur-
ing rotation of the head, and the neck is injured. The child's mental
and physical development are retarded and the trouble is attributed to
heredity. There are cases of hydrocephalus, microcephalus, spastic
paraplegia; retraction of the head, inability to talk, Little's disease,
non-control of movements of limbs, diseased gums with crumbling teeth
and many other forms of disease that, in the author's practice, were
found to be the result of injury at delivery.

Dr. Still has called my attention to the improper extraction of
teeth, in many cases, as a cause of neck lesions. The strain, the posi-
tion, the force, the sudden jerk that accompanies or follows extraction,
all tend to injure the neck, for it bears the brunt of the strain.

There are many other causes, such as colds, a sudden turn of the
head, improper treatment, occupation and the various injuries to which
the neck is subjected. The parts of the neck most frequently affected
are the atlanto-axial articulation and the articulations of the third
cervical, the points of greatest mobility and weakness.

126 APPLIED ANATOMY.

Many disorders of the cervical region are the result of lesions lower
in the spinal column. A lesion in the upper thoracic region will cause
contracture of the cervical muscles which in turn, interferes with move-
ment of the head and neck. In some cases seen by the writer, there
was a constant pain in the cervical region as a result of a lesion of the
fourth dorsal vertebra. The pain started from the point of lesion but
was greatest in the upper part of the neck. Perhaps most of these
secondary cervical disorders are the result of muscular contracture, while
some are due to direct interference with the innervation of the neck.
The point to be remembered in this connection is, that the lesion is not
always at the point of pain or where the effect is, but often at a place
somewhat distant from the manifest effect.

The effects of these lesions are manifold. The special senses, brain,
face, throat, arms and the neck itself are involved. The kidneys may
be affected, 0¥ a spinal curvature may result from a neck lesion as was
the case in a patient seen by the writer. Most of the diseases of the head,
face and throat have been considered with the discussion of effects of
lesions affecting the superior cervical ganglion. Some of the arm af-
fections have been described. In addition to those mentioned there might
be named the occupation neuroses, Erb's paralysis, wrist drop, pro-
gressive muscular atrophy, contractures and deformities of the forearm,
wrist and fingers, and the painful disturbance usually, called neuralgia.
In all occupation neuroses seen by the author in which the upper ex-
tremity was involved, a neck or thoracic lesion was found. These le-
sions weaken the arm and act as predisposing causes; the occupation is
the exciting cause. If the occupation were the only cause there would
be many more cases of telegrapher's cramp. As it is, only a very small
per cent of telegraphers are attacked. The same is true of the other
occupation neuroses. To cure such cases, remove both the predisposing
and exciting causes; that is, correct the neck lesion and advise the pa-
tient to rest.

Erb's paralysis involves the upper arm and shoulder, at least the
effect is there. Neck and upper thoracic bony lesions disturb the origin,
exit and nutrition of the nerves which supply these parts, hence the
effect. These lesions change the size of the intervertebral foramina,
which must of necessity affect the vessels and nerves that pass through
them. This effect may be motor, sensory, secretory, vaso-motor or
trophic. The conclusion is that in any or all effects in the upper ex-

APPLIED ANATOMY. 127

tremity the cause lies in the spinal column, especially the cervical and
upper thoracic portions, unless the trouble is due to trauma whereby
the nerve trunk is directly injured. Occasionally, the nerve is affected
by a dislocation of the shoulder, elbow or wrist, so it is well to begin at
the point of disturbance and follow the course of the nerve back to its
exit from the spinal canal since in this way it is easier to locate the lesion.

THE THORACIC VERTEBRA.

The dorsal or thoracic vertebrae being typical vertebrae, consist of
two parts, a body and an arch. The body is not quite circular but some-
what heart-shaped, it being wider transversely than antero-posteriorly.
It is concave above and below, in which concavities fit the interverte-
bral discs.- The bodies are somewhat concave from above downward
and are slightly beaked. The front surfaces are perforated for the
passing in and out of the various blood-vessels, the smaller transmitting
the nutrient arteries, the larger the veins (the venae basis vertebrarum) .

The arches give rise to seven processes. The spinous project
backward and downward and can be seen in most patients. The two
transverse processes project outwardly, are quite thick and terminate
in a clubbed extremity. Each articulates with the corresponding rib.
They give attachment to many muscles and furnish a powerful leverage
to them.

The two superior articular processes project upwards and bear
facets which project or rather face backwards, slightly upward and
outward.

The inferior facets face directly opposite to the superior. The
laminae are continuous with the spinous processes and complete the arch
posteriorly.

THE FIRST THORACIC.

The first thoracic is a transitional vertebra, in that it resembles
the cervical and thoracic types. Its spine is usually more prominent
than that of the vertebra prominens. It is thick, very strong and in
position is almost horizontal, projecting slightly downward. The
superior facets are almost flat and face backward, slightly outward
and upward.

The articular processes help to form the foramina, on which account
the least change in their position would affect the size of the foramina
formed by them.

128 APPLIED ANATOMY.

The transverse processes are typical of those of the other thoracic
vertebra and have facets for articulation with the first ribs. The facets
on the transverse processes face slightly upward, thus giving a better
support to the upper ribs. The body has two facets on a side for artic-
ulation with the heads of the ribs; the upper one is entire, the lower a
demifacet.

The movements of this vertebra are slight, rotation being, perhaps
the most pronounced. Flexion and extension are present but to a very
slight degree.

Lesions of various types are found affecting the articulations of
this vertebra. The vertebra is subject to anterior, posterior and twisted
conditions, this being determined by the character of the lesion. The
effects of lesions involving this vertebra, that is, the articulation with
the seventh cervical or with the second thoracic, depend on the degree
of disturbance of structures attached to it and the amount of change
in size of the intervertebral foramina.

The indications of a lesion of the articulations of the first thoracic
vertebra are tenderness over and around the spine, irregularity of the
spine, it being out of line or approximated to one above or below, and
disturbance of function of that part of the spinal column or of the vis-
cera innervated by the upper thoracic spinal cord.

The effects of a lesion on the articulations are similar to effects
from other vertebral lesions, that is, a thickening of the tissues attached,
the ligaments being congested or inflamed, hence tender. The supra-
spinous ligament is always affected in chronic cases, it becoming soft-
ened and thickened and quite smooth, sometimes entirely filling the
space between the adjacent spinous processes.

The important muscles attached to the first thoracic vertebra, hence
necessarily involved by a displacement of this bone, are the levator
costae, serratus posticus superior, multifldus spina?, rotatores spina?,
spinalis dorsi, transversalis colli, trachelo-mastoid and complexus. All
of these have been considered with the exception of the rotatores spins
and levator costae.

The levator costae muscle arise from the transverse processes of the
vertebrae and is inserted into the rib below at a point between the
angle and tubercle. The lower ribs receive two slips. The function
of the muscle is, as its name indicates, to elevate the rib, that is to assist
the external intercostals. The blood-supply is derived from the inter-

APPLIED ANATOMY. 129

costal arteries in relation. The nerve supply is from the intercostal
nerves that are in relation. Contracture of this muscle causes a dis-
placement of the ribs. In the upper thoracic region this is most fre-
quent, and thus there is a predisposition to lung affections. In all
cases of acute lung disease, these muscles are in a contractured state,
while in the lung affections characterized by wasting and atrophy these
muscles are atrophied as in tuberculosis of the lung.

The rotatores spinae muscles, as their name indicates, have to do
with rotation of the spine, a rather important movement of this region.
A disturbance of their function would result in impaired movement,
that is painful or otherwise disturbed rotation, of this part of the spinal
column. Their fibers run from above downward and outward and
can be palpated when contractured. As a result of a lesion of the first
thoracic vertebra the position and movement of the ribs would become
pathological, and flexion, extension, lateral flexion and rotation of this
part of the spine would be interfered with, the movements being re-
stricted or painful.

The spinal column would be weakened at the point of lesion. Fa-
tigue would be first and most marked at the first thoracic, if it were sub-
luxated. Colds would settle at this place and the patient would be
conscious of a weakness in this region. This weakness has a tendency
to produce change in contour of this part of the spine, flattening being
the common change.

The lower articulations of the thoracic vertebra; will be considered
instead of the upper as was the case in the cervical vertebra;; this is
done in order to make the nerve correspond in number with the verte-
bra. Only one articulation will be considered with each vertebra.

The first thoracic vertebra articulates with the second by two facets
and the body. Two foramina are formed through which pass vessels
and nerves. I believe that nearly all diseases caused by vertebral
lesions are the result of a lessening in size of the intervertebral foramina.
Every vertebral lesion causes a lessening in size of either the foramina
above, or below the affected vertebra. This affects the structures trans-
mitted by the foramen.

The veins passing through the intervertebral foramen between the
first and second thoracic vertebrae, are the lateral spinal. They drain
the vertebra, meninges and especially the first thoracic segment of the
spinal cord. This vein follows the sheath of dura mater that surrounds

130

APPLIED ANATOMY.

the first thoracic nerve. It is joined by the vein draining the muscles
in relation. The vein thus formed empties into the upper superior in-
tercostal vein, which in turn empties into the vertebral or innominate.
An obstruction to the intercostal or spinal veins would produce passive
congestion of the parts drained, viz., muscles, vertebra, ligaments, men-
inges and spinal cord.

SURINTE.RCOSTAI ART
1st THORACIC N
1st INTERCOSTAL N
2dlNT'C N

■ ANT.INTC,
ART'S.

INF.CERV.GANG.

INT. MAMMARY j/^ '/"" 'HI!
^3rf 4th.lNT'C A.VN. Ist^d.AORTIClNT'C A

Fig. 34. — Showing the upper intercostal arteries and their anastomoses and
branches. Note their relation to ribs.

The lateral spinal artery passing through the foramen below the
first, is derived from the superior intercostal which is a branch of the
subclavian. The nerve supply of it is derived mostly from the sub-
clavian plexus. The lateral spinal branch divides into three branches,
one going in front of the body of the vertebra, called preneural; one going
to the back of the spinal canal, or retro-neural; and a, middle branch

APPLIED ANATOMY. 131

which supplies the spinal cord and anastomoses with the anterior and
posterior spinal arteries from the vertebral. The nutrition to these
parts to which the artery is distributed will suffer to some extent, if the
arteries are compressed even though there is a fairly free anastomosis.
This would be the case in a subluxation of the first thoracic vertebra.

The nerves passing through the first thoracic intervertebral foramen
are the first thoracic nerve and the recurrent meningeal. The first
thoracic carries many impulses to and from the spinal cord.

They are composed of filaments that carry vaso-motor impulses to
the head, neck, arm and shoulders and integument; secretory to many
of the glands above; motor to the muscles supplied by this segment
and the -involuntary muscles of the orbit and to the heart; sensory to
to the viscera and integument supplied by this segment; and trophic to
the various structures named above. The impulses distributed by the_
cervical sympathetic ganglia come from the upper thoracic spinal cord,
hence a part of them pass over the first thoracic nerve, that is, through
the first thoracic intervertebral foramen. On account of this peculiarity
Hulett, in his Principles of Osteopath}' says: "The general statement
is not far wrong that any disorder produced by a cervical lesion may
be duplicated b_y an upper thoracic disturbance."

The first thoracic nerve divides into an anterior and posterior di-
vision. The anterior, gives rise to the internal anterior thoracic, inter-
nal cutaneous, lesser internal cutaneous or nerve of Wrisberg, ulnar,
median and first intercostal. The posterior divides into the internal
and external branches.

The internal anterior thoracic is of importance on account of sup-
plying the pectoral muscles. A disturbance of this nerve would cause
atrophy or other effects in these muscles, hence impairment of move-
ment of the arms and chest.

If the internal cutaneous nerve is involved by a lesion of the first
thoracic, there will be sensory disturbances along the inner and anterior
part of the forearm as low as the wrist and also along the inner and upper
part of the arm. It is a sensory nerve.

If the nerve of Wrisberg is involved there will be pain or other
sensory disturbances over the olecranon process and a part of the inner
aspect of the lower part of the arm. On account of this nerve communi-
cating with the intercosto-humeral nerve, the sensory disturbance may
be referred to the upper two or three intercostal spaces, or a lesion af-

132 APPLIED ANATOMY.

fecting the intercosto-humeral may cause the sensory disturbance to be
referred to the lower part of the arm and elbow. The ulnar and median
nerves have been discussed above.

The smaller division of the first thoracic nerve continues along the
first intercostal space as the first intercostal nerve, and supplies the in-
tercostal muscles and pleura in relation. It seldom supplies the integu-
ment over the first intercostal space, the lateral cutaneous branch being
absent. It occasionally communicates with the lesser internal cutaneous
and the intercosto-humeral.

The internal branches of the posterior division of the first dorsal
nerve supply the integument in relation; the external supply the muscles
in relation. These nerves are reflexly affected in bronchial, throat and
lung affections as is evidenced by the sensory and muscular disturbances.
Pain over the parts supplied by the posterior division of the first thoracic
nerve is indicative of (1), lesion of the first thoracic vertebra or first rib, or
(2), disease of the upper part of respiratory tract as in colds, bronchitis
and la grippe.

The first thoracic nerve controls, in part at least, flexion of the
fingers, pronation of hand, forward movement of the arm and shoulder,
movements of the upper ribs through action of the levatores costaruni,
serratus posticus superior and intercostal muscles, extension and lateral
flexion of the upper part of spine. The motor effect of impairment of
this segment from a lesion or from hemorrhage or inflammation (mye-
litis), would be most marked in the muscles of the hand, back and upper
part of chest. The rib muscles acting symmetrically would be little
if any affected unless both sides of the cord were involved. These mus-
cles are rarely jjaralyzed either by hemorrhage in the brain, as in hemi-
plegia, or in the spinal cord as in anterior polio-myelitis.

The first thoracic controls the sensory condition of the ulnar aspect
of the forearm, inner side of the upper arm, the integument of the back
in relation with the first thoracic vertebra, and the first intercostal space.

The recurrent nerve, which is vaso-motor to the arteries in relation
supplying the vertebra?, ligaments, meninges and spinal cord, would be
involved by a lesion of the first thoracic.

The stellate ganglion, which is in relation with the first thoracic
vertebra, will be affected in some way by a lesion of this vertebra. This
ganglion is irregular in form, slightly larger than the other thoracic
ganglia and often coalesced with the inferior cervical ganglion. It is

APPLIED ANATOMY.

133

PUPILO-DILATORS ORBITAND EYE-LID-
VASO-MOTOR TO HEAD AND FACE ANDARM '.
SECR'YTO SUBMAX'Y ANO SWE AT GLANDS \
VASO-GONSTfi'S PILO- MOTORS. \
CARDIAC ACCELERATORS --..
ERECTOR SPINAv

ROTATORES

INTEGUMENT OVERNtCKAS FAR AS MIDnLE orSCAPULA.

longlss i mos dorsi semispinals
/-accessorius multifious-spins.
/ intertransversalis
/^Interspinalis. \\

POSTTHORACIC
POST CORD

INF. CARDIAC N.
PULMONARY PLEXUS
AORTIC ,.
CARDIAC „■£?-'
CORONARY,,-^

MEDIAN

Fig. 35. — Showing the first thoracic segment of the spinal cord with its nerves and

their distribution.

134 APPLIED ANATOMY.

situated immediately in front of the head of the first rib and is in rela-
tion with the pleura and the superior intercostal artery. It is connected
with the ganglion above and below by the sympathetic chain and gives
off the following branches: Filaments to the first dorsal vertebra and its
ligaments, the thoracic aortic plexus and to the lungs and the grey
ramus communicans. This ganglion transmits all vaso-motor, secre-
tory, trophic, and possibly motor impulses destined for the parts above,
or at least all impulses arising in the thoracic spinal cord pass through
this ganglion on their way to the head and face. Some cells are located
in the ganglion but its function seems to be that of transmission of im-
pulses rather than that of originating them. Brubaker says that, in
the cat, cutaneous nerves for the fore-limbs have their origin from cells
in the stellate ganglion (first dorsal).

The white ramus communicans, which is usually present, passes
from the anterior division of the first thoracic nerve to the stellate gang-
lion, thus carrying impulses from the spinal cord to the gangliated cord.
Some of the fibers come from the posterior root. The gangliated cord
generates some impulses, at least motor impulses, but the cells are mostly
in the grey matter of the spinal cord. Quain says: "Some of the medul-
lated fibers are continued over the ganglia of the cord to enter the ef-
ferent branches; others end in the ganglia, often ascending or descending
for a considerable distance in the cord to reach ganglia at a higher or
lower level than that of the communicating branch by which they pass
to the sympathetic." These fibers are not confined to one ganglion,
sometimes passing to several ganglia above or below. The white rami
therefore transmit to the gangliated cord, impulses generated in the
spinal cord, some of which pass up, some down the gangliated cord,
others passing directly through, thus forming the rami efferentes. The
white ramus passing from the first thoracic nerve to the stellate ganglion
carriespupilIo-dilatorimpulses,and impulses to the involuntary muscles of
the eyelids and orbit, vaso-motor impulses to the head and face, accelerator
impulses to the heart and secretory to some. of the salivary glands.

The pupillo-dilator fibers originate in the upper thoracic segments
of the spinal cord and pass out over the white rami into the gangliated
cord, thence up the cord to the superior cervical ganglion, thence over
the ascending branches to the third and fifth nerves. These impulses
may arise as high as the seventh cervical and as low as the fourth thoracic.
Lesions affecting these segments or the white rami, will interfere with

APPLIED ANATOMY. 135

the origination or transmission of these impulses, hence an effect in the
parts supplied, that is the pupil. Contraction of the pupil may follow
injuries to the first thoracic vertebra when these nerves are affected.

The centers for the involuntary muscles of the orbit and eyelids are
also located in these segments and the impulses reach their destination
in a similar way. Strabismus often results from a lesion of the first
thoracic vertebra. The vaso-motor, or the above nerve connection will
explain it. Some claim that the voluntary muscles of the eye receive
impulses from this part.

Disturbance of the ciliary nerves is a common effect of this lesion.
Blepharospasm, pain in the eyeball, weakness of the eyes, photophobia,
conjunctivitis, and in fact almost any vascular disturbance of the orbit
and eyelids results from a lesion of the upper thoracic vertebrae, the first
in particular. The explanation is that the various impulses for the eye,
especially motor and vaso-motor, originate in the upper thoracic
spinal cord or there are subsidiary centers there and these impulses pass
over the white rami to the gangliated cord, thence through the cervical
ganglia to the nerves supplying the eye. Lesions of the first thoracic
affect both the segments and rami, and hence interfere with the centers
and the nerve tracts conveying the impulses. This has been practically
proven in three ways: (1) by physiological experiments on lower ani-
mals; (2) by dissection and (3), most important of all, clinically by taking
cases with the diseases, correcting the upper thoracic lesions and curing
the diseases.

The vaso-motor centers for the head and face are also located in
this region. It is possible and quite common for upper thoracic lesions
to produce vascular effects in the head, congestion being most common.
The writer has relieved many cases of headache by correcting a lesion
of the first thoracic vertebra. The explanation of such lesions affect-
ing the head is that they interfere or alter in some way, the passing of
these impulses; they, originating in the upper thoracic segments of the
spinal cord, pass out over the white rami to the gangliated cord thence
up the cord to the vessels of the head and face.

The accelerator impulses to the heart are transmitted in part by
the white ramus of the first thoracic nerve to the sympathetic gangliated
cord in relation, thence directly across to the cardiac plexus or up the
gangliated cord to the cervical ganglia, thence out over the cardiac
branches. Clinically most of these fibers emerge from a point lower in

136 APPLIED ANATOMY.

the spine, the fourth dorsal foramina being the most important. Con-
gestive headaches are often the result of cardiac disturbances. A le-
sion of the first thoracic vertebra may affect the heart, hence an effect
is in the head. Congestive headaches may thus result from a disturb-
ance of the vaso-motor nerves to the head or from heart affections. The
upper thoracic lesions will affect both.

The grey rami communieantes, as in the cervical region, arise from
cells located in the sympathetic ganglia and pass to the anterior pri-
mary division of the corresponding cerebro-spinal nerve. After reach-
ing the nerve Quain says that "the fibers are directed both peripherally
and centrally. Of those passing centrally some go off in the posterior
primary division of the nerve, others enter the sheath of the nerve, the
surrounding tissue in the intervertebral foramen, and the dura mater,
running up to the latter in the posterior root." The fibers passing
distally in the anterior and posterior primary divisions of the spinal
nerves have been shown, by experiments oh animals, to supply "vaso-
motor nerves to the arteries of the body-wall and limbs, pilo-motor
fibers to the muscles of the hairs, and secretory fibers to the sweat glands. "
Lesions of the vertebrae and ribs affect the grey rami.

A lesion of the articulations of the first thoracic vertebra will affect
the first dorsal ramus. As a result of this there are vaso-motor effects
in the body-wall in relation, vertebras, ligaments, meninges and spinal
cord, and secretory effects in the sweat glands. The predominating
sweat centers seem to be located in the upper thoracic region, thus a
lesion there will lessen or increase the amount of perspiration.

It seems that the spinal nerves, through filaments that pass through
the sympathetic gangliated cord, control or supply the viscera with
sensation. Quain says: "There is strong reason for believing that the
thoracic and abdominal viscera are supplied with sensory fibers derived
from the spinal nerves, and passing through the sympathetic." These
fibers pass from the posterior root to and through the sympathetic gang-
liated cord without interruption, to the viscera. This then offers an
explanation for referred pain. Head, after experimenting on animals
and from inferences drawn from clinical observation in man, formulated
a law, the substance of which is that a stimulus applied to an area of
low sensibility in close central connection with an area of high sensibil-
ity may result in pain being felt in the area of high sensibility. As an
illustration, an irritation of the heart will produce pain in the chest wall

APPLIED ANATOMY. 137

over the heart. Sympathetic nerves supply areas of low sensibility,
cerebro-spinal, areas of high sensibility. According to Head, the heart
and lungs are supplied in part with sensation by nerves that come through
the first thoracic foramen of the spinal column, that is by the first thoracic
nerve. The impulses pass over the sympathetic to the white ramus,
thence over the posterior nerve root to the spinal cord. Diseases of
the heart and lungs affecting these sensory nerves would cause pain to
be felt that is referred to the areas supplied with sensation by the upper
thoracic nerves, in this case, the first. The impulses from the heart
and lungs, and those from the areas supplied with sensation by the
upper thoracic nerves pass through the upper thoracic segments of the
spinal cord thence over a common tract to the sensorium. According
to Head's law, the sensorium is often mistaken as to the source of the
impulses and refers them to the areas of greater sensibility. This seems
very plausible since all of the. sensory impulses from the above region
pass through the upper thoracic segments of the spinal cord. As a
result of this confusion of impulses, the pain in heart affections is re-
ferred to the chest-wall and left arm, especially the ulnar aspect. In
lung affections, it is referred to the intercostal nerves that are derived
from the same segments of the spinal cord that supply the lung. The
conclusion that we are forced to draw, is that the segmental innervation
of viscera can be accurately determined by noting the points of pain in
disease of the viscus, that is by rioting the cerebro-spinal nerve that is
the supposed seat of the pain. To illustrate, if the heart is affected and
the pain is referred to the fifth intercostal nerve, the fifth thoracic seg-
ment of the spinal cord is the one that gives origin to the nerves of the
heart, especially do the sensory impulses pass through this segment on
their way to the sensorium.

In quite a large per cent of all cases of angina pectoris, there is pain
or numbness of the little and ring fingers of the left hand. The explana-
tion as stated above is that that the sensory impulses from both the hand
and heart pass through the same segment and there arises a confusion
as to the source since normally, such impulses come entirely from the
arm and chest wall.

Summary. Lesions of the articulations of the first thoracic vertebra
produce eye, brain, arm, bronchial, lung and throat disturbances. In
colds, the articulations of this vertebra are invariably involved either
primarily or secondarily through muscular contractures. Lesions of

138 APPLIED ANATOMY.

this bone produce pain in arm, chest and upper part of spine, muscular
contractures in the interscapular region, impaired movement of the fingers,
arm and spine and disturbances of sweat secretion in this area. The
thoracic aorta, coronary and bronchial vessels and the splanchnic nerves
may also be involved.

THE SECOND THORACIC.

The second thoracic vertebra is very similar to the first except that
it has two demi-facets for articulation with the ribs, instead of an entire
facet and a demi-facet. It is a typical thoracic vertebra. The spinous
process is a little more oblique than that of the first. The movements
of its articulations are very slight. Rotation is said to be the most
marked of these movements, although flexion and extension are also
represented. The superior facets face backward, slightly outward
and upward'the surfaces being nearly flat. The inferior, face the op-
posite way. The most common lesion is a lateral deviation if the sec-
ond alone is affected, but if several of the upper thoracic vertebrae are
involved, the most common lesion is an anterior deviation. Extreme
flexion of the head and neck is productive of pain at the articulations of
the second thoracic, if it is displaced. The other indications of a lesion
are the usual pain, tenderness, softening and thickening of the ligaments
and irregularity, or at least some change of contour.

Lesions of this vertebra, and by lesion I mean a subluxation, affect,
the ligaments attached to it, the muscles in relation, and the contour of
that part of the spine. These are affected in a way similar to that re-
sulting from a lesion of the first thoracic vertebra, which has been de-
scribed. The intervertebral foramina are lessened in size thereby com-
pressing a part or all of the structures passing through them.

The veins are the lateral spinal which drain the spinal cord, the sec-
ond thoracic segment in particular. They empty on the right side into
the right superior intercostal, which empties into the vena azygos
major; on the left they empty into the left superior intercostal vein
which empties into the innominate. A lesion of the second thoracic
vertebra or corresponding ribs will cause pressure on these veins, hence
passive congestion of the parts drained by them.

The arteries come from the superior intercostal. The spinal branch
as stated above, divides into branches which supply the vertebra and
the spinal cord with its coverings. Vascular changes in the cord would

APPLIED ANATOMY.

139

pup:lo-dilators ORBITANDEYE-LIO.
VASOMOT0RI0HEAD FACEANDARM ,
SECR"VTO 5UBMAXTAN0 5WEAI 6LASCS '.
VASO-CONSTR'S PILOMOTORS
CARDIAC ACCELERATORS --
ERECTOR SPINiE
ROTATORES

INT E&UMENT OVER BACK AT SPINE OF 2dTH0RACIG

INTERTRANSVERSALIS

SEMISPINALS DORSI

MULTIFIDUS SPINS.

-ACCESSORIUS

SERRATUS-POST1CUS

LEV. COSTARUM

LONGISS1MUS-
DORSI

8lh CERVICAL

Fig. 36. — The second thoracic segment of the spinal cord, with its nerves and

their distribution.

14(1 APPLIED ANATOMY.

follow change in size of the intervertebral foramen, and muscular disturb-
ances in that region.

The anterior and posterior nerve roots unite at the inner edge of
the foramen, while the trunk thus formed divides at the outer part,
into the usual anterior and posterior divisions. This nerve trunk formed
by the uniting of the two roots, carries many and varied impulses which
will be considered separately. They are motor, sensory, vaso-motor,
secretory and trophic. The size of the foramen through which these
nerve filaments pass, is determined by the position of the vertebra. In
flexion of the body, the foramina are increased in size while extension
lessens their size. An anterior lesion that is a subluxation, has a greater
effect on the size of the intervertebral foramen than does a posterior.
These lesions by thus affecting, that is, lessening the foramina, interfere
with the passing of nerve impulses through, and over the nerve involved,
and the effect varies with the degree of pressure and the nerves involved.

A motor effect is fairly constant in all lesions of the second thoracic
vertebra. The muscles most frequently affected are the erector spina?,
multifldus spina?, intercostal, levatores costarum and serratus posticus
superior, the common effect being a relaxation or contracture. If the
lesion is inhibitive, it will produce descent of the ribs, weakness of the
spine, and a flattening or lessening of the normal posterior condition of
this part of the spinal column. There are other causes of such effects
since chronic disease of the heart and lungs will cause atrophy of these
muscles and an increase in the width of the interscapular space. This
is particularly true of tuberculosis of the lungs.

Contracture of the above named muscles, and this is the result of
an irritative lesion, would displace upward the vertebral end of the upper
ribs, extend or laterally flex the spine, approximate the vertebra? if the
contracture is bilateral, thereby thinning the intervertebral discs and
lessening the lumina of the intervertebral foramina. Movements of this
part are painful and the muscles are tender on pressure. The circulation
through them is altered and the spinal cord fails to be properly supplied
with blood, hence disturbance of function of the various centers located
in this part of it. The dorsal branch of the intercostal artery divides
into a lateral spinal and a muscular branch, or rather a spinal branch is
given off and the main trunk of the artery passes out to the muscles.
By noting the relation of these branches it can be readily seen that a con-
tractured condition of the muscles supplied by the muscular branches would

APPLIED ANATOMY. 141

produce increased pressure in, and congestion of, the proximal branch, the
spinal. The contractured muscle is congested and offers an obstruction
ot the transmission of arterial blood. Thus the spinal cord suffers.

The sensory effect resulting from pressure on the spinal nerve, would
be anesthesia or pain or some perversion of sensation as in formication.
These disturbances would be marked in the second intercostal space,
between the scapula; and along the inner side of the arm. The last named
part is affected because of the connection of the second thoracic nerve
with the nerve of Wrisberg, by way of the intercosto-humeral. Dis-
turbed sensation in the above mentioned places is due to some disturb-
ance of the second thoracic nerve, this most frequently being the result
of a lesion of the second thoracic vertebra or the corresponding rib.
These sensory disturbances are explained in several ways. In some cases
they are the result of direct pressure on the nerve trunk. This produces
numbness, or a tingling sensation, and possibly a distinct pain in excep-
tional cases. The lesion may interfere with the blood supply of the nerve
trunk and in this way, that is, by producing a congestion, interfere with
its function. The subluxated vertebra may obstruct the circulation to
the second dorsal segment of the spinal cord in which are located the
cells that control the efferent impulses. Again, this lesion by causing
contracture of the muscles of the spine, causes sensory disturbances.
This effect is characterized by an ache or else the part becomes easily
fatigued on exertion. The sharp, lancinating pain is due to irritation
of the nerve ; the ache, to contractured muscles ; the numbness, to pressure
on the nerve trunk. These effects are in the main due to the direct result
of the lesion, but in some cases, they are due to heart and lung disorders
in which cases they are reflex.

The second intercostal nerve also supplies the pleura, the rib and
its periosteum. In the female it supplies the mammary gland. Thus
there may be pleurisy, caries of the rib and mammary affections.

The white rami join the anterior division of the nerve with the cor-
responding ganglion on the sympathetic cord. The fibers come from the
spinal cord, hence pass through, and form a part of, the cerebro-spinal
nerve as it lies in the intervertebral foramen. A lesion of the second
thoracic, by lessening the size of the foramen, would produce pressure
on at least some of these fibers, hence some disturbance of the parts
supplied by the impulses traveling over these fibers. These fibers con-
vey vaso-motor impulses to the head and face, hence eruptions on the

142 APPLIED ANATOMY.

face, headaches and any vascular disturbance of these parts may follow
a lesion affecting these fibers contained in this nerve trunk. Pupillo-
dilator fibers also pass out through the second nerve and reach their
destination by way of the cervical sympathetic nerves and their branches
as described in the discussion of the first dorsal vertebra. The invol-
untary muscles of the eyelids and orbit have a center in the second thoracic
segment of the spinal cord, the impulses from which, reach their destina-
nation by way of the white ramus and the cervical sympathetic and the
Gasserian ganglion. The submaxillary gland receives its secretory im-
pulses from this segment, they reaching it in a way similar to those
above described. A lesion of the second thoracic vertebra would affect
the passing of these impulses hence an altered secretion of the saliva.
The writer has treated cases of dryness of the mouth resulting from a
lesion of the second thoracic. The opposite condition may result.

Some of.the sweat centers controlling the secretion of sweat in the
arm are located in this segment. The impulses reach the arm by way
of the roots and trunk of the second thoracic nerve, white ramus, gang-
liated cord and brachial plexus. or subclavian plexus.

The vaso-motor centers for the arm are also located in this segment
and reach their destination in a similar way. Therefore, excessive or
lessened perspiration of the arm, congestion or coldness of the arm. in
fact any vascular change in it may follow a lesion of the second thoracic.

The vaso-motor centers for the retinal vessels and the blood-vessels
of the ear are located in this segment, the impulses from which pass out
over the white ramus to the gangliated cord thence to their destinations.
"Stimulation of the cervical sympathetic nerves produces contraction
of the retinal vessels. Stimulation of the upper thoracic sympathetic
nerves produces dilatation."

The vaso-constrictor nerves to the pulmonary vessels pass in part
through the second thoracic foramen. The size of the pulmonary ves-
sels is controlled by these nerves. If these nerves are inhibited the pul-
monary vessels dilate. As a result the circulation of the blood through
the lung for. aeration is lessened, the blood is not properly oxygenated
and the entire body suffers. The patient is tired because of impure blood.
Fatigue is due to impure blood. The better the circulation through the
lung the better the blood is oxygenated and the more rapid the recovery •
from fatigue. Again, the lung and body are predisposed to disease when
the pulmonary or bronchial vessels are dilated because (l).of the con-

APPLIED ANATOMY.

143

Fig. 37. — Showing the innervation of the heart.

144 APPLIED ANATOMY.

gestion of the lung and (2), because of the interference with oxygenation
of the blood and nutrition of the lung substance. Germs or toxic ma-
terial inhaled, are not readily destroyed.

The centers which give rise to accelerator impulses to the heart are
also located, in part, in this segment. These impulses pass over the an-
terior nerve root into the mixed nerve, out over the white ramus to the
second dorsal sympathetic ganglion, then either up the cord to the
stellate ganglion thence over the cervical cardiac branches, or else direct-
ly across to the cardiac plexus, as McClellan states. In several dissec-
tions the author has found quite a large branch connecting the vagus
with one or more of the upper thoracic sympathetic ganglia. The im-
pulses pass over the different filaments in the nerves in the foramen.
This nerve is subject to pressure from lesions, hence the heart trouble.
Not only is the cardiac plexus affected but the coronary plexus as well.
This plexus controls the nutrition of the heart.

The bronchi will be involved because of the disturbance of their
nerve supply. This conies principally from the pulmonary plexus.
This plexus is formed by nerves from the upper thoracic segments.
They pass out of the spinal canal through the intervertebral foramina.
A lesion of the second dorsal will affect, the passing of the impulses over
these filaments. Congestion of the respiratory tubes may follow. Na-
ture tries to expel the foreign body by coughing. The foreign body is
most frequently a thickened mucous membrane or exudate.

The vaso-motor innervation of the nasal tract comes from, at least
in part, the second thoracic segment. On this account, a lesion at this
point will affect the vascular supply of this part, hence any disease in
which the circulation is involved. Clinically, the lesion producing hay
fever, especially complicating asthma, is found at the second thoracic
vertebra. The explanation is that the subluxation intercepts the pass-
ing of the vaso-motor impulses, hence the congestion and hyper-secre-
tion of the nasal mucous membrane. These impulses pass through the
second thoracic intervertebral foramen and it is at this point that the
disturbance takes place.

The splanchnic nerve may arise as high as the second dorsal seg-
ment but this is to be doubted. In such cases the impulses pass out
over the cerebro-spinal nerve and the white ramus, thence down the
gangiiated cord to the fifth dorsal ganglion, from which they pass over
the ramus efferens. From this it theoretically follows that a lesion of

APPLIED ANATOMY. 145

the second dorsal will produce disorders in viscera supplied by this por-
tion of the splanchnic, if the transmission of the impulses is interfered
with by the lesion. Clinically it is unusual for a lesion so high to affect
the viscera supplied by the great splanchnic.

The impulses passing over the grey ramus enter the corresponding
cerebro-spinal nerve, thence to parts supplied by this nerve. As stated
above, the nerve fibers are, in all probability, medullated, and connect the
viscera with the spinal cord, they passing through without interruption to
the posterior nerve roots. In this way the heart and lungs are supplied
with sensation by the upper thoracic branches of the spinal cord. The pain
is usually referred to the intercostal nerves when these viscera are in-
volved. Note the "grip-like" pain over the heart in angina pectoris
and the stabbing pain of pneumonia. The pain in these cases being
in the intercostal, that is cerebro-spinal nerves.

The fibers that pass distalty in the somatic nerves "supply vaso-
motor nerves to the arteries of the body-wall and limbs, pilo-motor fibers
to the muscles of the hairs and secretory fibers to the sweat glands. "
Every nerve fiber passing through the second thoracic foramen is sub-
ject to pressure or other disturbance, from a lesion of the second dorsal.
All of these may be involved, or only a few may be affected; in every
case some of these fibers are disturbed. Disorder of the parts supplied
necessarily follows, hence the above named affections.

This lesion will affect the gangliated cord since it is in relation.
Although the main function of this cord seems to be that of demedullat-
ing fibers and transmitting impulses, yet some impulses arise in the
ganglia. A lesion of the vertebra? will thus produce disease by affect-
ing these ganglia, by interfering with their blood supply, rather than by
direct pressure on them.

The various centers located in this segment of the cord are subject
to impairment through a derangement of the circulation to the segment.
Again a diseased or simply a weakened condition of the viscera supplied
by the segment will reflexly affect the centers in it. A lesion of the sec-
ond dorsal vertebra will weaken the lungs and heart, thus the segment
will reflexly be affected. An error in diet will cause congestion of the
spinal cord and contracture of the muscles of the back. Excessive
coitus will congest the spinal cord, usually the lower thoracic segments.
Cold on the lungs will affect the second dorsal segment and produce con-
tracture of muscles in relation. In this segment are located the various

146 APPLIED ANATOMY.

centers named above, such as vaso-motor to head, face, arm, lung and
heart; motor to the muscles in relation, heart and eye; sensory, which
are really in the ganglion on the posterior nerve root, to the heart, lungs,
pleura and the integument over the second intercostal space and a por-
tion of the interscapular region; secretory to sweat glands of arm, and
to the submaxillary glands; trophic to the arm, rib, periosteum, liga-
ments and vertebra. Each of these centers may be involved, or only
one may be affected. From this can be ascertained the variety of struc-
tures that may become diseased from this lesion, also the kind of dis-
ease. Lesions of the second dorsal are clinically most commonly looked
for in diseases of the head, such as congestion, and vertigo; and inarm
and lung diseases.

THE THIRD THORACIC.

The third thoracic vertebra differs slightly from the second in that
its spine is slightly longer and more beaked or knobbed than the spine
of the second. The transverse processes point upward and outward for
articulation with the rib. This the better supports the ribs. The
facets on the transverse processes in many skeletons examined by the
author, face slightly upward, this also helping to support the ribs. The
superior articular facets face backward, slightly outward and upward
and their surfaces are plane. The mobility of the articulations varies
little from those of the second. The lesions are also similar, that is
any form of deviation may take place, a lateral rotation being most
common. As a result of a lesion of it the muscles and ligaments attached
to it, are always involved. The foramina are lessened and some or all
the structures passing through are involved.

The veins and arteries are analogous to those of the second.

The nerves passing through the foramen between the third and
fourth thoracic vertebrae, carry motor impulses to the heart, possibly
the lungs, pupil, and muscles in relation. The impulses to the heart
travel by way of the anterior root, common nerve, white ramus, gang-
lion and rami efferentes. Those to the pupil pass up the gangliated
cord and out over the fifth cranial.

Although it has not been demonstrated that motor impulses pass
from the upper part of the thoracic spinal cord to the bronchi and bron-
chioles, yet, judging from the effects of treatments applied in this region
in patients suffering with motor disorders of these parts/ one is almost

148 APPLIED ANATOMY.

forced to the conclusion that they do. In the paroxysm of asthma, the
attack can either be entirely stopped or at least lessened in severity by
treatment applied to this area. Sometimes pressure alone will relieve.
Although it is possible to explain these effects in a way, by means of the
vaso-motor connection, yet we do not believe this the true explanation.
Experimentally, stimulation of the anterior roots of these nerves in ani-
mals has no noticeable effect on the size of the bronchi, but clinically
in man, the correction of a rib lesion in the upper thoracic region will
almost instantly relieve an attack of asthma unless the case is a very
chronic or severe one.

The muscles supplied are the intercostals, levatores costarum, ser-
ratus posticus superior, multifidus spina; and erector spince. These
muscles will be either relaxed or contractured by a lesion affecting their
nerves.

Sensory impulses from the integument of the axilla and arm, third
intercostal space and upper part of back pass through this foramen.
Sensation of the heart and lungs is controlled by nerve filaments that pass
through this segment, the impulses therefore passing through this foramen.
The impulses from the integument pass up the anterior and posterior
divisions of the nerve, thence over the posterior root into the spinal cord,
usually directly across to the opposite side. The sensory impulses from
the heart and lungs are probably carried by special nerves that pass
through the sympathetic ganglia with little or no alteration, as Quain
points out. Some pass through the white rami, the third posterior root
and finally into the spinal cord. On account of these sensory connec-
tions, a disease of the heart or lung will give rise to impulses that travel
into the spinal cord, and the sensorium refers them to the areas of distribu-
tion of the upper thoracic nerves, principally the intercostals. To illustrate,
the pain in heart disease is described by the patient as in the precordial
region. It is referred to this point.

The pleura is supplied with sensation by the third intercostal, hence
pleurisy often follows a lesion of the third thoracic vertebra. The im-
pulses pass over the intercostal to the spinal cord thence to the sensorium.
False pleurisy results from some forms of vertebral lesions. The pressure
is exerted on the nerve while in the foramen, the impulses thus generated
pass to the sensorium over the usual route but are referred to the peri-
phery of the nerve, hence the "stitch'' in the side from a rib or vertebral
lesion.

APPLIED ANATOMY. 149

In the female, the mammae are supplied by the third intercostal
nerve. This nerve is principally sensory hence in painful conditions of
the breast the intercostal nerves are involved.

Again, lesions, such as that of the third dorsal, cause painful con-
ditions to be referred to the breast. In all cases of pain in the mammary
region ascertain if there is a local, organic disturbance, or if it is purely
reflex. The vertebral or rib lesion is responsible, in either case, for a
vast majority of diseases of the breast.

Vaso-motor impulses to the arm, head and face, lungs, heart, muscles
of back, spinal cord and its coverings pass in part through this foramen.
The different pathways are described above under the second dorsal.

The arteries involved by this lesion are those in relation and those
innervated by the vaso-motor nerves that pass through the foramina
in relation with the third dorsal vertebra. The intercostal arteries are
supplied with vaso-motor impulses derived from the third thoracic seg-
ment. These pass by way of the thoracic aortic plexus. On this ac-
count the lesion will affect this artery, either causing its constriction or
dilatation. This artery supplies the part of the chest wall in relation,
the pleura, the rib and its periosteum, the muscles of the back and the •
spinal cord. As a result of the lesion there are vaso-motor effects in
these parts. The lateral spinal arteries which are branches of the inter-
costal, are in relation with the vertebra and would be affected partly
on this account, and, partly on account of the relation of their vaso-motor
nerves to the third thoracic vertebra. This artery supplies the spinal
cord and its coverings, hence vascular disturbances of the part when
the vessel is increased or decreased in size.

The carotid arteries are affected since they receive their vaso-motor
impulses from the thoracic area. Some of these impulses pass out
through the foramina in relation with the third thoracic vertebra. As a
result of such a disturbance, the amount of blood in the parts supplied by
these arteries and their branches becomes pathologically changed.
Usually the artery is dilated and congestion of the parts is the sequel.

The vertebral artery receives its nerve supply from this part of the
spinal cord and thus would be affected by lesions of the second and third.
Its function and distribution have been considered before.

The pulmonary vessels receive their vaso-motor impulses partly by
way of the nerve passing through the third intervertebral foramen.
Consequently, there will be congestion or anemia of the lungs. This
predisposes to pneumonia.

150 APPLIED ANATOMY.

The bronchial vessels also receive their innervation in a similar way.
An upper thoracic lesion will thus affect the nutrition of the lung, this
predisposing to diseases of the lung tissue, such as tuberculosis.

The coronary arteries which control the nutrition of the heart's
muscle, receive their vaso-motor impulses from the upper thoracic spinal
cord. They pass out over the anterior nerve roots, the common trunk,
the anterior division and thence by the white ramus into the gangliated
cord and cardiac plexus. As a result of a lesion at the third thoracic
vertebra, the nutrition of the heart may be interferred with. Angina
pectoris is perhaps the best example of this form of disease.

The axillary artery and its branches are also innervated in part
from this segment, thus diseases of the arm often result from lesions
as low as the third thoracic vertebra.

A lesion of the third dorsal will interfere with the passing of these
impulses and the blood-vessels of the above named parts are affected.
The usual effect on the vessel is that of dilatation. The effect of a le-
sion pressing equally on all the fibers composing the nerve trunk is man-
ifest first in the weakest part. Although each may be affected, the
strongest resist longest and the weakest are affected first. A lesion of
the articulations of the third dorsal vertebra, may, in one case, produce
a vaso-motor effect in the eyelids, in another case, in the throat. The
explanation is, the weakest part is affected most if a lesion disturbs all
of these fibers alike, but ordinarily the lesion affects some fibers more than
others. A lesion of the third thoracic vertebra produces vaso-motor
disturbances in the above mentioned structures by producing pressure
on the nerve fibers as they pass through the foramen, by producing pres-
sure on the blood-vessels supplying or draining the spinal cord, or by
pressure on the gangliated cord or rami which are in close relation.

The sweat glands of the arm and back (upper part) and the sub-
maxillary glands receive impulses which are carried by nerve fibers
passing through the third thoracic intervertebral foramen. The effect
on these glands is variable; sometimes there is increased activity, some-
times lessened activity.

If there is a dry condition of the skin, or if there are night sweats,
the lesion is found most frequently to be in this region, the articulations
of the third thoracic being most commonly affected. Perhaps these
effects are the result of the direct disturbance of the sweat glands or per-
haps the result of general nutritive disturbances. The latter seems to

APPLIED ANATOMY. 151

be the better explanation since in practically all such cases, there js mal-
nutrition. If the sweat disorders are not accompanied by nutritive
changes, the sweat glands are directly affected, but this is the exception
rather than the rule.

Trophic fibers are derived from the third dorsal segment that supply
the arm, periosteum of the third rib, the third rib itself and all other
parts supplied by the third thoracic nerve. A general nutrition center
is supposed to be located here which will be considered later. The
writer has seen cases of caries of the ribs result from a spinal lesion.

Atrophy of the arm is not unusual by any means, as a sequel to a
lesion of the third dorsal vertebra. Several cases have come under my
notice in which the arm was completely paralyzed, both sensory and
motor, as a result of a hard lift or injury by which the third thoracic
vertebra was dislocated, or rather subluxated, thus producing a mono-
plegia. In many of such cases there is a dislocation of the acromial end
of the clavicle.

The third thoracic nerve connects with the third dorsal sympathetic
ganglion and occasionally sends a filament to the nerve of Wrisberg and
other filaments which communicate peripherally with the supra-clavic-
ular branches of the cervical plexus. Through the third ganglion com-
munication is established with the second and fourth sympathetic thor-
acic ganglia, pulmonary, cardiac, coronary and solar plexuses, and in
some cases the pneumogastric. The author has made and seen dissec-
tions in which was found quite a large branch directly connecting the
third and fourth sympathetic ganglia with the vagus.

The function of this connecting branch can only be surmised. It,
in all probability, carries impulses from the spinal cord to the thoracic
viscera or perhaps to other viscera and structures supplied by the pneu-
mogastric nerve. If the branch were constant, the various effects of
an upper dorsal lesion on the lungs and heart, could the more easily be
explained, especially asthma and motor disorders of the heart. So
far as I know, no experiments have been performed by which the func-
tion of this connecting branch could be definitely ascertained since it is
not recognized as a constant branch.

In marked dislocations of the third thoracic, as in other vertebrse,
transverse myelitis may develop, from pressure on the cord exerted by
the displaced vertebra. At the third thoracic vertebra, paralysis, both
motor and sensory, of all parts below would follow. The line of demarka-
tion can be definitely outlined, it following the intercostal nerve.

152

APPLIED ANATOMY.

PUPILO- DILATORS ORBITAND EYELIDS

VASO MOTORTO HEADANDFACE. TOARM \

JECRETORYTO SUBMAXILLARY
AND SWEAT GLANDS

CARDIAC ACCELERATOR

PILO-MOTOR

VASO-CONSTRICTOR

INTEGUMFNTOVEft BACKATSPINE
SEMISPINALS DORSI
MULTIFIOUS SPINA1
ERECTOR SPIWff.
LEV COSTARUM

RATU5 POSTICUS
CESSORIUS
LONGISSIMUS DORSI

Vertebra
aortic pi

CARDIAC

PULMONARY

CORONARY

Fig. 39. — Showing the third thoracic segment with its nerves and their dis-
tribution.

APPLIED ANATOMY. 153

The spinal cord is affected in ways other than by pressure directly
on it. Pressure on the posterior nerve root or ganglion will cause as-
cending degeneration thus involving some or all the sensory columns of
the spinal cord. Locomotor ataxia probably has its origin in pressure
or other disturbance of these posterior nerve roots. Pressure of the dis-
located vertebra on the blood-vessels affects the drainage, also the nutri-
tion, hence activity of the cord and its centers.

Clinically, there seems to be various centers in the spinal cord which
are affected by a lesion of the articulation of the third and fourth thor-
acic vertebra. The author has had patients complain of a weight rest-
ing, as it were, on their back and shoulders and in nearly all such cases
some disturbance of the third or fourth thoracic vertebra, was found,
upon the correction of which, the symptoms were relieved. Others are
hysterical and want to cry; some have hysterical fits of laughter. On
account of the effects of a subluxation of the third on the emotions it
has been given as an emotional center. Why it exerts such an influence
on the emotions no anatomical explanation will be attempted, only these
clinical phenomena above mentioned.

Subluxations of the third and fourth thoracic vertebrae, seem to
produce malnutrition »~>f the entire body, and from the frequency of dis-
ordered nutrition following such lesions, it is reasoned that there is a
center at or near this region, which controls the nutrition of the body.
This center is in all probability, in the grey matter of the third and fourth
segments of the thoracic spinal cord. The explanation that 1 would
offer is the fact that these segments have to do with supplying the vital
organs of the bod)', viz., the heart, lungs and stomach. Thus a lesion
affecting these segments would interfere (1) with the circulation of the
blood, the heart being weakened, (2) with the oxygenation of the blood
and (3) the process of absorption or power to take nourishment from the
ingested food. • Circulation of the blood is necessary to nutrition, ox-
genation of the tissues is indispensable, thus the general result, malnutri-
tion. The kind of lesion found, is a flattening of this area of the spine.

The cilio-spinal center is located, in part at least, in this segment.
Headache from eye disturbances can ofttimes be cured by correcting
a lesion of the second or third thoracic vertebral articulations which
affects the cilio-spinal center. This center is either irritated or inhibited
by the lesion. There is a vascular effect in the eye, the parts most
frequently becoming congested and headache follows. As stated above,

154

APPLIED ANATOMY.

Fig. 40. — Diagrammatic representation of the roots and ganglia of the spinal
nerves, showing their position in relation to spinal column (after Cunningham).
The ganglia are in the intervertebral foramina and are subject to pressure in sub-
luxations of the vertebrae on account of change in size of these foramina.

APPLIED ANATOMY. 155

the impulses pass out from this center over the anterior root into the
common trunk, white ramus, gangliated cord, thence up and out over
the third and fifth cranial nerves.

The center for the accelerator impulses of the heart is located in
part, in this segment. Palpitation, arrhythmia and other effects are
manifest when this center is disturbed.

The center for the lungs is also located in part, in this segment of the
spinal cord. A lesion of the articulations of the third dorsal will weaken
the lungs. Repeated contractures of the muscles of the upper part of
the back will also weaken the lungs thus predisposing the patient to
tuberculosis of the lungs. Repeated colds on the chest is an example.
Congestion of the lung will produce contracture of the muscles supplied
by this segment, also pain in the areas supplied with sensation by the
nerves of this segment. The sharp intercostal pain in pneumonia, and
the tenderness of the intercostal muscles in pulmonary tuberculosis,
are examples. The well known and much used counter-irritant, is an-
other illustration of how a stimulation of one part causes an effect in
another, through the spinal cord. The explanation is that the spinal
center, located in part in the third thoracic segment, controls the lung
and the sensory and motor nerves supplying the part of the chest wall
in relation, and the irritation of the peripheral nerve, will cause an effect
in this segment, hence in branches coming from the segment.

The arm has a special nutritional center in these upper spinal seg-
ments, as is evidenced by cases in which there is monoplegia resulting
from lesions of the articulations of the third thoracic vertebra. Per-
haps the vaso-motor centers and nerves have a great deal to do with the
nourishment of the arm, these centers being in this segment. If the
trophic center and nerves are separate from, and independent of the
vaso-motor nerves, we can offer no explanation as to the pathway of
these impulses which are supposed to pass from this segment to the
arm. Clinically, it is well known that a lesion of the upper thoracic
vertebral articulations, is often followed by an atrophic change in one
or both arms.

Sweat centers are also located here which control the amount of
perspiration of the upper part of the spine and arms. Localized sweat-
ing of a lateral half of the face most commonly results from a neck lesion,
but may come from lesions lower in the spinal column. Localized sweat-
ing along the median furrow comes from a lesion of an upper thoracic

156 APPLIED ANATOMY.

vertebra. Sweating along the course of a rib is suggestive of a rib
lesion (the one in relation). This produces a lowering of the tempera-
ture of the part. Abnormal dryness of the skn of the upper part of the
back and chest may follow a lesion of the third thoracic vertebra, which
in turn, disturbs the normal activity of the sweat centers for these areas.

Some forms of chorea result from lesions in this part of the spinal
column, judging from clinical observations. In some of the cases
treated by the writer, in which the arms were especially affected, the
lesion was found to be in the upper thoracic area and upon its correction
the choreic symptoms disappeared. I have no explanation to offer
for this unusual effect of the lesion unless it would be possible for the
subluxation so to interfere with the passing of motor and vaso-motor
impulses to the arm that they pass intermittently instead of constantly.
The obstruction to the passing of impulses over the nerve to the arm
produces a damming up of the impulses which after a time, when the
pressure gets to be quite strong, break over and thus the spasm or rather
the uncontrollable contraction of the muscles supplied. Clinically,
pressure applied near, or at the exit of the nerve from the spinal column,
will lessen or completely stop the choreic spasm. From this we con-
clude that the trouble is at the exit of the nerve, that is in the foramen.

Summary. A lesion of the third thoracic vertebra may produce
disease of the bronchi, lungs, heart, stomach, arm, vertebral column, spin-
al cord, upper part of chest and back, neck, pleura, mammary glands, and
structures in the cranial cavity, especially the eye, salivary glands, ear
and nose. The most common diseases following a lesion of this verte-
bra are pneumonia; pulmonary tuberculosis, the lesion in these diseases
so weakening the lungs that the different pathogenic micro-organisms
gaining access to the lung set up pathologic processes; arrhythmia, pal-
pitation, angina pectoris, chronic cough (dry or hacking); disturbances
of vision; mammary diseases; pleurisy; paralysis of arm; chorea; writer's
cramp; pain between shoulders; stiffness of neck and headache.

THE FOURTH THORACIC.

The fourth thoracic vertebra is one of marked importance on ac-
count of frequency of subluxation and the profound effects from lesions
of it. It is located in a rather weak part of the spinal column, is sub-
ject to great strain when the arms and shoulders are used as in strong
muscular exertion, and is the seat of trauma of different kinds, especially

APPLIED ANATOMY. 157

that resulting from a sudden' push or blow between the shoulders as in
the case of school children, one suddenly and forcibly pushing another
at an unexpected moment. This produces an anterior condition and
often is the starting place of Pott's disease of the spine and spinal curva-
ture.

The fourth, seems to be the point of division between the upper
and lower parts of the spinal column. Dr. Still has often told me that
in disorders of parts above, that is of the head and face, look as low in
the spine for the lesion as the fourth, while in affections of parts below,
look as high as the fourth. The explanation of this is that the heart is
at this level, that is all parts above the fourth are supplied with blood
by the ascending branches, while all parts below this vertebra, are sup-
plied by the descending branches. This is true in the main. In a gen-
eral way, expect the lesion to be between the part affected and the heart.

The superior facets of the vertebra in this region are so placed that
a directly anterior displacement without separation, is practically im-
possible, but they may rotate in various directions. The anterior rota-
tion causes an approximation of the spines of the third and fourth ver-
tebrae and a separation of the spines of the fourth and fifth dorsal. The
break is below the lesion, and is a point of increased mobility. At the
point of approximation of the spinous processes, mobility is lessened
and is the place that most needs treatment. The object in the treat-
ment of such a condition, as in all vertebral subluxations, is the restora-
tion of normal mobility. Lateral rotation of a single vertebra, results in
a lessening of the size of the intervertebral foramen on the side to which
the vertebra is turned. The opposite intervertebral foramen is either
not affected or is increased in size. In such cases there is a unilateral
effect as in monoplegia, an upper extremity being involved. Usually in
such a lesion, there is a palpable irregularity although this does not hold
true in every instance. The author has seen dissections in which no
bony lesion could be palpated by external examination, so far as con-
tour was concerned the spines being very regular, but on dissecting the
articular processes, quite an irregularity or subluxation was found.

These lesions of the fourth dorsal, affect structures attached to it,
blood-vessels and nerves in relation, and centers and viscera depending
for their activity upon normal position of the bone; an abnormal posi-
tion interfering with their nutrition and motor, vaso-motor or sensory
supply.

15S APPLIED ANATOMY.

The principal muscular effect of a lesion of the fourth thoracic ver-
tebra, is manifest in the erector spinas muscle. At first it becomes con-
tractured but after a while, atrophies or becomes degenerated and hard-
ened. The median furrow, which is formed principally by the two
erector spinas muscles, is widened in chronic cases, at the point of lesion
and especially so, if several adjacent vertebrae are involved. The other
muscles involved by this lesion are the levatores costarum, rotatores
spinae, multificlus spinae, intercostals and serratus posticus superior.
As a result of these muscular disturbances flexion, extension and rota-
tion of this part of the spine are painful and difficult or weakened. The
rib movements are impaired or in some cases, the ribs are subluxated
by the continued contracture. In other cases relaxation, instead of
contracture, follows the lesion. This permits of descent of the ribs and
causes the spine to be imperfectly supported. The patient drops the
shoulders and sits with the spine very much arched posteriorly, that is
the. patient is "piled up" instead of sitting erect and supporting the
weight of the trunk on the tuber ischii.

The blood-vessels affected are the veins and arteries passing through
the fourth thoracic foramen, those of the muscles in relation and some
or all of the branches of these vessels.

In addition to these, the thoracic aorta in relation, with its branches
will be affected. The branches involved are, the pericardiac, bronchial,
esophageal, and the fourth intercostal. These arteries are innervated
by branches of the thoracic aortic plexus, which is derived from the
nervi efferentes of the upper thoracic sympathetic ganglia. On this
account, a lesion of the fourth dorsal vertebra will disturb the function
of this plexus and thus affect the amount of blood passing to the above
named parts. The effect on the vessels is one of obstruction, or vaso-
motor inhibition, therefore congestion occurs in most instances; how-
ever, anemia may result.

The parts congested are the spinal muscles, pleura, spinal cord; in
fact all structures in relation are subject to congestion by this lesion.
The spinal vessels are supplied with nerves by the recurrent nerve and
by filaments from the thoracic aortic plexus, which gives rise to fibers
that accompany the intercostal arteries and their branches.

The following nerves are affected, most of them directly, by a lesion
of the fourth thoracic vertebra: Fourth thoracic with its intercostal
or anterior, and posterior divisions, muscular branches .of the above,

APPLIED ANATOMY.

159

PUPILO DILATORS EYE-LIDS
VASO-MOTOR TO HEAD, FACE ARM
SECRETORY TO SWEAT &LANDS ■, '
ACCELERATOR TO HEART
ROTATOFES M

ACCESSORIUS M

1NTE&UMENT OVER BACK ATSPINE0F4-lhT.
ERECTOR SPIN*.

MULTIFIDUS SPIN/S.
LEVATOR COSTARUM

CARDIAC ,
CORONARY ,
PULMONARY,

VASO-MOTOR, ABDOMINAL
VISCERA ANOTOLUN&

Fig. 41 — Showing the fourth thoracic segment with its nerves and their dis-
tribution.

160 APPLIED ANATOMY.

recurrent meningeal, grey and white rami, the fourth thoracic sympa-
thetic ganglion and its branches and the gangliated cord.

As a result of an impairment of the fourth intercostal nerve, the
intercostal muscles, pleura, mamma, fourth rib and its periosteum are
disturbed in some way as to function. The intercostal muscles are most
frequently relaxed, thus respiration is impaired. If the lesion is an
irritative one, the muscles become tender and contractured to a slight
degree, at least they become swollen. The pleura is affected, there
being pain on inspiration or what is more frequently described as a
"catch" or "stitch" in the side.

These painful affections follow such a lesion because (1) the parietal
layer of the pleura receives its sensory innervation from the intercostal
nerve in relation, the nerve being affected by the lesion, and (2) because
the pleural surfaces move on each other in respiration. These surfaces
are swollen, •sometimes inflamed, and the least movement is productive
of excruciating pain.

The mammary gland is involved by this lesion. The character
of the disturbance may vary between a slight pain and a cancerous con-
dition. This nerve, i. e., the fourth intercostal, seems to be sensory,
trophic and possibly secretory to the gland. The effect of the disturb-
ance of the nerve may be pain, lack of development or atrophy and
lessened secretion of milk.

It has not been definitely demonstrated that the mammary gland
has any secretory nerves at all. Clinically, it would appear that secre-
tory nerves supplied the gland and that they came by way of the inter-
costals in relation. This is based on observations of the results of rib
lesions and the effects of their correction. As in other glands, the secre-
tion depends to a large degree on the blood-supply.

Howell says, in discussing the mammary gland: *" Regard-
ing the question of the existence of a secretory nerve, Basch re-
ports that the extirpation of the celiac ganglion or section of the sper-
matic nerve does not prevent the secretion, but causes the appearance
of colostrum corpuscles. Experiments, therefore, as far as they have
been carried, indicate that the gland is under the regulating control of
the central nervous system, either through secretory or vaso-motor
fibers, but that it is essentially an automatic organ. "

*Text-book of Physiology, page 857, 1905.

APPLIED ANATOMY. 161

The trophic effects may often result in ulceration, which simulates
cancer, and in tumefactions of the breast.

The fourth rib is also supplied with trophic impulses by the fourth
intercostal, hence often suffers as a result of lesions involving this nerve.
The writer has seen cases of caries of the rib result from a vertebral le-
sion, the disease being diagnosed as tuberculosis of the rib. The perios-
teum of the rib is of course also supplied by this nerve, this probably
explaining the caries in such cases in which this nerve filament is in-
volved.

Sensation of the fourth interspaces is affected by a lesion involving
the fourth dorsal vertebra. Pain is the most common effect, although
numbness, burning sensation or some other form of perverted sensation
may occur. Complete sensory paralysis is uncommon but is occasionally
met with in cases of marked vertebral lesions.

The posterior division supplies a part of the integument over the
middle part of the thoracic region and the muscles in relation, the in-
ternal branch supplying sensation, while the external branch is princi-
pally motor. This nerve is frequently involved in uterine or other
pelvic disease. Aching between the shoulders is a very common symp-
tom in these cases. I believe that in such cases the muscles of the upper
thoracic region are reflexly put in a contractured state and, like other
muscles, they soon become fatigued and begin to ache. The pathway
of the reflex arc is not well understood. The author presumes that
there is a center in the fourth thoracic segment that controls the activity
of the mammary glands. These glands are parts of the generative
system, hence closely connected in every way with the rest of the genera-
tive organs. On this account, they are subject to reflexes as a result of
pelvic derangement. The muscles ache the more when used. If the
patient should attempt to use the shoulders and arms as in sweeping,
the shoulders ache for some time afterward^. This reflex ache seldom
occurs independently of a lesion of the vertebra or ribs in relation, the
lesion acting as the predisposing cause. If this were not the case every
woman suffering with a congested uterus would have a pain or ache be-
tween the shoulders.

The grey ramus is subject to pressure from a subluxation of the
fourth dorsal vertebra. This pressure is most frequently indirect, that
is through adjacent tissue which is deranged. Sensory and vaso-motor
impulses are carried by this nerve, hence an affect on the spinal cord and

162 APPLIED ANATOMY.

the part of the thoracic wall that is in relation, to which this nerve carries
impulses.

The white rami are also subject to impairment in the above lesion.
The fourth white ramus carries from the fourth dorsal segment to the
fourth thoracic sympathetic ganglion, impulses for the eyes, head and
face, heart, lungs, bronchi and arms; thus disease or weakening of any
or all of these organs and structures may result from a lesion impairing
this white ramus. It also carries afferent impulses from certain of the
viscera, to the spinal cord.

The gangliated cord and the fourth thoracic sympathetic ganglion
are sometimes affected directly by a lesion of the articulations of the
fourth. This ganglion gives rise to the following branches: Filaments
that pass to the thoracic aortic, cardiac, pulmonary and coronary plex-
uses and small branches to the vertebrse and their ligaments. Most of
the impulses passing over these branches originate in the spinal cord,
a few perhaps being formed in the sympathetic ganglia. In either case,
the effect of the lesion would practically be the same; that is, an inter-
ference with the transmission of the impulses to the lungs, heart, vessels
.and vertebra?.

The nerves connecting with the fourth dorsal nerve are the fourth
thoracic ganglion and, through this ganglion, the third and fifth gang-
lia and the solar, pulmonary, cardiac and coronary plexuses.

The parts that are most frequently affected or actually diseased by
this lesion are, the eyelids, optic nerve, retina, ocular muscles, the head,
face, heart, lungs, arm, pleura, chest wall, mamma?, spine, back, spinal
cord, everything in the fourth intervertebral foramen, the. abdominal
vessels and stomach. The eye and its appendages are not often affected
by a lesion so low. In the dog it has been shown experimentally, that
vaso-motor impulses arise in the cord as low as the fourth but clinically
in man this is to be doubted. The fourth thoracic segment contains
clinically, centers for nutrition, sweat, emotions, arm, heart, lungs,
mammae, cilio-spinal, and some describe a center here which when affected,
produces chills. These centers consist of groups of nerve cells that con-
trol the motor, vaso-motor, secretory, trophic and possibly the sensory
impulses to the above named parts of the body. For these centers to
be effective they must be well nourished and in close connection with
the parts supplied, that is the reflex arc must be intact. The activity
of the nerve cells is controlled by the efferent as well as afferent impulses

APPLIED ANATOMY. 163

reaching them and the degree of nourishment furnished them. The
lesion affects these centers by disturbing the nutrition of the cells by
exerting pressure on the vessels that supply and drain this part of the
spinal cord. This disturbs nutrition hence is productive of disorders
of one or more of these centers.

Osteopathically, a lesion of the fourth dorsal is associated with cer-
tain effects that are fairly constant. Named in order of their importance
and frequency we have: malnutrition, functional heart affections and
lung disturbances; other diseases such as pleurisy, spinal cord affections
in which the fourth segment is involved, mastitis and other mammary
diseases, weakness of the muscles in relation and disturbances of the
spinal column such as Pott's disease and curvature sometimes result.

Malnutrition is the most constant effect of a lesion of the fourth
dorsal. The form of lesion most frequent is an anterior condition
characterized by softness, tenderness and a smooth rounded condition
of the tip of the spinous process. The most significant change and sign
is the anterior position. The explanation of the general effect lies in the
fact that the lungs which purify the blood, the heart which propels the
blood, and the stomach and liver which furnish nutrition to the blood,
are all innervated, at least in jaart, by the fourth thoracic segment of the
spinal cord. Malnutrition is usually mostly due to lack of, that is im-
perfect, oxygenation of the blood. Blood to be health}' must have
oxygen. This is furnished the blood b^y the lungs. If the lungs are not
active, the amount of oxygen furnished the lungs is decreased in propor-
tion to the weakening of the lung. On account of this, intercurrent dis-
eases are more fatal. The lungs can not meet the requirements. A per-
son with weak lungs is anemic and malnourished. If such a person con-
tracts disease, the chances of recovery are lessened in proportion to the
weakness of the lungs. The lesion of the fourth thoracic vertebra weak-
ens the lungs by interfering with (1) the circulation to and through the
fourth thoracic segment of the spinal cord in which are located some of
the vaso-motor and trophic centers, and (2) by interfering with the
transmission of these impulses since the intervertebral foramen is less-
ened either directly by change in position of bone, or by ligamentous
thickening. The inrpulses pass over the anterior nerve root into the
common trunk, thence over the white ramus into the ganglion, then out
over the rami efferentes to the pulmonary plexus. Malnutrition is
most marked in the young. There are, of course, other causes such as

rT,A.

Fig. 42.— Showing the deep, short muscles of the back, (after Spalteholz).
Note the direction of the fibers and effect of contracture on position of vertebra)
end of rib.

APPLIED ANATOMY. 165

imperfect respiration and bad air. One writer has stated, and I think
truthfully, that tuberculosis of the lung was "a disease of the lazy,"
meaning that the lungs were not used properly, deep breathing being
too much of an effort.

If the heart is weakened it does not properly propel the blood around
the vascular circuit and the circulation is lessened in rapidity. This
causes impure blood because of imperfect elimination and increased
formation of toxic material. One's vitality is measured by the condi-
tion of the blood. A sluggish circulation implies poor blood, hence a
lowered vitality.

The other cause of malnutrition, that is an interference with ab-
sorption of food, is perhaps not so important as the two named above.
This may occur independently of a lesion of the vertebrae, viz., from
dietetic errors, yet such lesions make it possible for slight indiscretions
of diet to produce marked effects. In all cases of anemia, defects in
development of this part of the vertebral column, and back, shortness
of breath on exertion, in fact in any form of malnutrition, examine care-
fully for a lesion of the fourth dorsal.

The cardiac disturbances are most commonly functional, occasion-
ally organic diseases follow. Arrhythmia is the most frequent of these
effects. The heart beats regularly for a few moments then apparently,
if not in reality, loses a beat. The explanation is that the nerve feed
to the heart that is, the motor impulses do not regularly reach the heart.
A muscle responds to the various changes in the nerve impulses. These
impulses supplying the heart arise in part from centers located in the
fourth thoracic segment. They pass to the heart via the anterior root,
common nerve, white ramus, gangliated cord, thence up to the stellate
and cervical sympathetic nerves, then over the cardiac branches or
directly across by way of the rami efferentes. This lesion affects the
origin of the impulses or the nerve transmitting them. The former is
affected by way of the blood supply to the segment; the latter in the
intervertebral foramen which is lessened in size by the lesion and through
which the nerve fibers pass that carry impulses to the heart. The pres-
sure on the nerves carrying the impulses to the heart is the better ex-
planation.

Palpitation is explained in a similar way. The lesion obstructs the
transmitting of cardiac impulses. The nerve force seems to accumulate
back of the obstruction and finally overcomes it. The heart then re-

166 APPLIED ANATOMY.

sponds to the accumulated impulses. This is soon exhausted and the
heart lessens in rapidity in proportion. Again the cardiac centers may
be unstable from lesions involving them or from impure blood on ac-
count of which the nerve cells are improperly nourished. In exercise,
the heart beats rapidly in order to force blood to the lung for oxygena-
tion as rapidly as it becomes deteriorated from katabolism. Fright
may cause palpitation, if the heart is irritable, as is often the case when
it is weak. Its tone and strength depend on the condition of the centers
and the line of communication reaching from these centers to the heart.
If they are weakened from any cause, and a lesion of the fourth dorsal
is the most common, any exciting cause such as a displaced uterus, dis-
tended stomach, exercise or fright will have the greatest effect on the
weakest organ; in this case, the heart.

Bradycardia is the result of an impairment of the cardiac centers.
This impairment may be from a lesion or from some disease as the pro-
found toxemia from diphtheria. Tachycardia is indicative of a weak,
irritable heart. It seems to be in such a nervous condition that any
exciting cause may markedly increase the pulse rate. The lesion of
the fourth dorsal predisposes the heart to such diseases by interfering
with its nerve mechanism described above, thus leaving it in a weak,
irritable and nervous condition. In cases of Bright's disease the heart
may become very rapid.

The "smothered feeling" is sometimes due to a lesion of the fourth
dorsal but more commonly due to a displacement of the fourth rib on
the left side. Angina pectoris, of which the above is a symptom, is the
result of a similar lesion. Hypertrophy sometimes follows a lesion of
the fourth dorsal which has an irritative effect on the cardiac centers
or nerves. Organic heart troubles in most cases, follow lesions of the
upper thoracic vertebra? or ribs on the left side. Rheumatic fever is
given the credit of producing most cases. It is the exciting cause.
The writer has carried many patients through attacks of acute rheu-
matism without cardiac complications. In these cases care was used
to correct and keep corrected, all lesions that would affect the heart. I
believe that organic heart disease, that is endocarditis, can be prevented
by such treatments, that is by correcting all lesions that would affect
the innervation of the heart. The explanation is that these lesions so
weaken the heart that the fever, with its toxic products, the more readily
affect the valves and thus interfere with the nutrition of the heart muscle.

APPLIED ANATOMY. 167

Some diseases of the heart result from a vaso-motor disturbance of
the nerves of its blood-vessels. The coronary artery and its ramifica-
tions supply the heart. This artery is controlled presumably, by the
coronary plexus, which in turn is governed by centers in the thoracic
spinal cord. The impulses reach the coronary plexus by way of the
cardiac plexus. The vaso-motor supply of the heart has not been definite-
ly demonstrated. A lesion of the fourth dorsal impairs the transmission
of these impulses by lessening the size of the intervertebral foramina.

Remember that the heart is a muscle. Muscle fibers contract when
their nerves are stimulated and relax when inhibited. There must be a
center for control, and there must be a line over which impulses pass
from the center to the muscle. A lesion of the fourth dorsal affects
both. There may be a stimulation or inhibition, at least there will be
a pathological effect from such disturbances of the cardiac nerves and
centers. •

The lungs are weakened by a lesion of the fourth dorsal because
the nerves supplying them pass through the intervertebral foramina.
After the lung is thus weakened any disease to which it is subject, the
more readily sets in; in fact, microbic diseases of the lung would not
occur if the viscus were not first weakened.

Summary. Lesions of the fourth dorsal should be suspected in
malnutrition, heart diseases, lung diseases, mammary affections, atrophy
of one arm, in some cases of stomach disorder, localized pain over this
region; in short, disease of any part innervated by the fourth thoracic
spinal segment.

THE FIFTH THORACIC.

The fifth thoracic vertebra differs slightly from the fourth in that
the spinous process is a little longer, more oblique and more distinctly
hooked or clubbed. The superior facets face almost directly backwards
and are as a rule, plane surfaces. The foramina are partly formed by
these articular processes and the least deviation in position of these
processes would cause a change in size of the foramina; either the lower
or upper foramina are lessened in size. The same remarks that were
made concerning the frequency and cause of lesion of the fourth will
apply to the fifth. Mobility of this part of the spinal column is very
slight. This part acts as a sort of pivot, the movements above, that is
in the upper thoracic and cervical regions, being marked, as are the
movements of the lumbar spine.

168 APPLIED ANATOMY.

Contractured muscles in this area, can scarcely be relieved by physi-
cal exercises on the part of the patient. Such contractures are less
common in the more movable parts of the spinal column. Movement
of the parts tends to relieve such conditions, hence when such occur in
the region of the fifth thoracic, they are not much affected by ordinary
exercises since movement of the spine at this point, is slight.

Lesions of the fifth result ordinarily from one of two causes: Con-
tractured muscles from, thermic or other influences; or from trauma.
The most common form of trauma is a sudden, unexpected bend in this
part of the spine. This sort of injury produces a sprain of the ligaments,
some serous exudation, disturbance of the intervertebral discs, espec-
ially those connecting the articular processes, contracture of muscles
attached and a lessening in size of the intervertebral foramina. This
form is characterized by pain on movement or what is often called, a
stitch in the'back, which in favorable cases gradually disappears. In a
vast majority of cases it furnishes the starting point for diseases of the
spinal cord in this region, the spinal column and the stomach. The supra-
spinous ligament, on account of its position, seems to be affected more
than the other vertebral ligaments. It thickens, softens and remains
tender and compressable for quite a while. After awhile it shortens,
this helping to produce approximation of the vertebra? as in a stiff or
rigid spine.

The commonest lesion of the fifth is an anterior subluxation caused
by a forward rotation of the upper part of the vertebra. This would
cause an approximation of the spines of the fourth and fifth dorsal. From
this it may be inferred that in a case of a break in the spine, the vertebra
immediately above the break is the one at fault unless one part of the
spinal column is turned, twisted or otherwise displaced on the part be-
low. The latter is, in my opinion, by far the most common form of
spinal lesion in which there is irregularity. In treating such conditions,
the part below should be grasped and held firmly while the part above
is used as a lever, thereby restoring normal relation between the two
portions.

The muscles directly involved are the erector and multifidus spina?,
rotatores spina? and the levatores costarum. These muscles in the
typical lesion, become contractured and as a result, their origins and in-
sertions are approximated to a pathological degree. The bony frame-
work becomes warped, as it were; that is, secondary bony lesions form.

APPLIED ANATOMY. 169

These muscles remain tender and can be readily palpated, remaining
cord-like. These contractures interfere with the circulation of blood
through them and through the intervertebral foramina. Congestion or
arterial anemia of the spinal cord follows the latter. In some forms of
lesions the muscles undergo atrophy.

The veins passing out through the fifth intervertebral thoracic
foramen, empty into the intercostal after uniting with the veins that
drain the muscles in relation. The blood then on the left side, usually
passes into the left upper az_ygos veins thence to the heart by way of
the vena azygos major and superior vena cava. The blood from the
right intercostal, passes direciiy into the vena azygos major. These
veins are subject to pressure from enlargement of the lungs, stomach,
intestines and liver. Congestion of the lungs interferes with the pass-
ing of blood through these veins, by exerting pressure directly on them,
especially the left azygi veins, because they cross the bodies of the verte-
brae. In all diseases of the above named viscera in which the size of
the viscus is increased, the patient should lie as much as possible in the
ventral or lateral position. If the ventral position is not assumed at
least daily, congestion of the spinal muscles and particularly the spinal
cord, follows. This in turn coupled with the toxemia resulting from
the disease, often produces a form of paralysis. Post-typhoid paralysis
is a good illustration of paralysis, from in part at least, faulty posture.

The arterial circulation through the parts in relation with the fifth
dorsal is affected by a lesion of this bone. The arteries in relation are
the intercostal and their branches, the principal one being the dorsal,
which divides into the muscular and spinal. The spinal branch is given
off first, hence in muscular contractures, which obstruct the muscular
branch, the blood backs up into the spinal branch, thus congesting the
spinal cord and especially the fifth segment.

The nerves that would be involved by a lesion of the fifth dorsal
are the fifth thoracic, its anterior or intercostal and its posterior branches,
the recurrent meningeal, the grey and white rami communicantes, the
fifth thoracic sympathetic ganglion and its branches and the gangliated
cord.

The nerves that pass through the fifth thoracic intervertebral
foramen are the fifth dorsal and the recurrent meningeal. The trunk of
the fifth dorsal contains fibers that transmit all of the kinds of impulses
peculiar to this region. Motor impulses pass out over this nerve to the

170 APPLIED ANATOMY.

following muscles: Intercostals, levatores costarum, obliquus externus,
rectus abdominis, erector spinae, rotatores spinas and multifidus spinse.
These impulses may be augmented or decreased by the lesion of the fifth
dorsal vertebra. As a result of increase in intensity of impulses, the
movements of the chest, back and abdomen are impaired. The ribs
are pulled upward at the vertebral end, the spinal column curved later-
ally since these muscular contractures are seldom equal on both sides,
and the abdominal wall is made tense. These changes are common but
result oftener as reflexes from visceral disease than directly from the
fifth dorsal lesion. If the impulses are inhibited or interrupted the
above named muscles atrophy to a certain extent, but not very markedly
since this nerve, that is the fifth dorsal, furnishes only a part of the in-
nervation of them. There seems to be in typical cases, a contracture
of a portion of the erector spinae and a relaxation of the rectus abdomi-
nis and oblique muscles.

The common trunk of the fifth dorsal contains fibers over which
pass the accelerator impulses, the nerves being called the cardiac accelera-
tors. Their course is similar to those described under the other upper tho-
racic cardiac accelerators, (which see) . Clinically, these fibers are often in-
volved by a lesion of the fifth dorsal, and a lesion of this vertebra is ex-
pected in most cases of cardiac disturbance.

The pulmonary vessels receive vaso-motor impulses from the fifth
thoracic segment of the spinal cord. These impulses pass out over
fibers contained in the ventral root of the fifth dorsal, the common trunk,
white ramus, ganglion, and the efferent pulmonary. It seems that
these impulses leave the gangliated cord at points above the fifth. If
the lesion interrupts the impulses passing over these fibers, the pul-
monary vessels will dilate. This causes congestion. The circulation
of blood is lessened in rapidity, oxygenation interfered with and sys-
temic as well as local disorder, is the result. If these impulses are aug-
mented there will be constriction of the pulmonary blood-vessels, the
blood pressure is increased and the lung becomes pathologically anemic.
The first is the usual effect, that is congestion, with its tendency to
pneumonia and tuberculosis.

By experiments on the dog, it has been determined that vaso-motor
impulses to the blood-vessels of the arm arise in the fifth dorsal segment
and reach the arm by way of the ventral root, common trunk, anterior
division, white ramus, gangliated cord and the brachial,' or the sub-

APPLIED ANATOMY. 171

clavian plexus. In man we find clinical evidence that proves that the
nerve centers and conducting tracts are similar to, if not identical with, the
above. A lesion of the fifth dorsal will in many cases, cause monoplegia
of the arm. The explanation is that the lesion lessens the size of the
intervertebral foramen through which pass impulses from the center in
the spinal cord to the arm. These impulses are supposed to be trophic
and vaso-motor.

Vaso-motor impulses to the abdominal blood-vessels, arise in the
fifth dorsal segment and reach the blood-vessels by way of the great
splanchnic. The thoracic blood-vessels are also supplied by way of the
thoracic aortic plexus which receives efferent fibers from the upper
thoracic ganglia.

Many sensory impulses are carried by the fibers contained in the
nerve trunk which passes through the fifth dorsal intervertebral foramen.
The integument over the fifth interspace and a portion somewhat below
the spine of the fifth, are supplied with sensation by the fifth dorsal
nerve. The impulses pass to the common trunk by way of the anterior
and posterior divisions, thence over the posterior nerve root into the
spinal cord, most of the impulses passing across to the opposite side of
the cord, thence to the sensorium. Sensory impulses from the pleura,
periosteum, peritoneum, and mammary glands, pass to the sensorium in a
similar way. The sensorium then refers the pain to the seat of the irri-
tation or the supposed source. For example, stimulation of the nerve
trunk or any of the fibers, will cause a pain which is referred to the per-
iphery of the nerve. In lesions of the fifth dorsal or corresponding rib,
the fibers conveying sensory impulses, as mentioned above, are pressed
on but the painful effect is in the periphery instead of at the point of
pressure. From this, it follows that painful affections of the areas de-
scribed above are, in many cases, due to the vertebral and rib lesions.
Anesthesia results if the sensory fibers are inhibited while parasthesia
results if the nerve is stimulated by the lesion. These lesions lessen the
size of th.e intervertebral foramina and the effect is determined by the
amount of pressure from this change in size, and the kinds of fibers in-
volved.

The lungs have a sensory center in the fifth dorsal segment, or rather
sensory impulses from the lungs pass through it on their way to the
sensorium. The impulses pass by the afferent sympathetic fibers to
the gangliated cord thence over the white ramus, posterior root, spinal
cord, etc., to the sensorium.

172 APPLIED ANATOMY.

Clinically it seems to be demonstrated, that sensory impulses pass
from the stomach to this segment. They are in all probability carried
by the great splanchnic nerve. In gastralgia, inhibition at or near the
spine of the fifth dorsal, is often sufficient to relieve temporarily.

The recurrent, is distributed in a way similar to that of the recurrent
nerves described above.

The grey filaments carry impulses from the fifth thoracic ganglion
to the anterior and posterior divisions of the fifth dorsal nerve. The
impulses are mostly efferent in character, the vaso-motor being the most
inrportant.

Sensory impulses from the stomach pass over the white ramus.
Lesions affecting the ramus may cause pain to be referred to the stomach
and other viscera supplied by this segment.

The white ramus of the fifth, carries impulses from the spinal cord
to the fifth thoracic ganglion. The impulses then go up or down in the
gangliated cord or out over the efferent nerve. The impulses carried
by the fifth thoracic white ramus, supply the heart, lungs, arms, stomach,
and abdominal blood-vessels. They vary in character, some being motor,
vaso-motor, secretory, trophic and viscero-inhibitory. The motor sup-
ply, the heart; the vaso-motor the pulmonary and abdominal blood-
vessels; the secretory the gastric glands; the trophic the muscles in re-
lation and those of the arm; the viscero-inhibitory, the stomach.

A lesion of the fifth dorsal, that is a slight displacement or sublux-
ation, will affect the white ramus in most instances. Perversion of
function follows, the particular effect being determined by the fibers
affected and the degree of pressure or other disturbance of them. Pres-
sure on these filaments is the usual cause of disturbance of their function.
The filaments composing the white ramus pass on uninterruptedly from
the spinal cord to the sympathetic ganglion, forming a part of the ven-
tral nerve root, common trunk and anterior division. The foramen
through which these filaments pass is lessened in size by certain forms
of lesions of the fifth thoracic vertebra, therefore the impulses passing
over these filaments would be affected in some way.

The fifth thoracic sympathetic ganglion is adjacent to the fifth dor-
sal vertebra and would be involved in most cases. The effects of dis-
turbance of this ganglion are similar to that from disturbances of the
white ramus, since all the impulses carried by the white ramus pass into,
and most of them through, the corresponding ganglion. Some cells

APPLIED ANATOMY.

173

are located in this ganglion which generate impulses, viz., those carried
by the grey rami. These would be disturbed.

The great splanchnic nerve is the principal branch of this ganglion.
It is formed by the union of roots that branch from the thoracic ganglia
from the fifth to the ninth. Quain says: "The trunk thus constituted,

VASO-MOTOR TOARMANDTOLUN&.

VASOCONSTRICTOR TO PULMON-
ARY VESSELS ANO ARM

SECRETCXYTO SWEAT GLANDS-, \

ACCELERATORS HEART

INTEGUMENT OVER BACK AT SPINE or 51h.

ERECTOR SPINS.

MULTIFIOUS SPINA

LEVATOR
COSTARUM

CORONARY , ,

PULMONARY , )

ESOPHAGEAL.

VASO-MOTOR TO
ABDOMINAL VISCERA

SENSORY. SECRETORY
AND VISCERO-INHIBITOB
TO STOMACH

Fig. 43. — The fifth thoracic segment, with its nerves and their distribution.

174 APPLIED ANATOMY.

descends obliquel}" forward over the bodies of the dorsal vertebra?, and
after perforating the crus of the diaphragm terminates in the upper
part of the semilunar ganglion; some of the fibers may occasionally be
followed to the supra-renal body and the renal plexus. This nerve is
remarkable from its white color and firmness due to it consisting in large
part (four-fifths according to Rudinger) of medullated fibers, which are
continued directly from the spinal nerves; from the highest root they
may be traced upward along the sympathetic cord as far as the third
thoracic ganglion and nerve, or even higher." This nerve gives off
filaments that supply the esophagus, aorta and terminates in the solar
plexus. The impulses passing from the fifth dorsal ganglion over the
upper root forming this nerve go principally to the stomach supplying
it with motor, secretory, vaso-motor, trophic and viscero-inhibitory
impulses. A lesion of the articulations of the fifth dorsal will affect
this nerve-in nearly every instance. In one case there may be a motor
disturbance, in another a secretory or vaso-motor derangement. The
explanation is that in the one case only the part of the nerve carrying
the motor impulses was involved, in the other case the secretory or vaso-
motor fibers were affected.

The great splanchnic nerve has a variety of functions. It conveys
motor impulses to the stomach, therefore stimulation of it increases
peristalsis. It carries vaso-motor impulses to the blood-vessels of the
stomach, liver and intestines and especially the portal vein. Lesions
involving this nerve usually cause a dilatation of these blood-vessels in
that the impulses are inhibited. Congestion of the stomach and liver
is a very constant effect of a lesion of the fifth dorsal. These conditions
lead to many forms of disease. This congestion may at first be arterial
but later on becomes venous. Venous congestion of the stomach causes
an increase in the amount of gastric juice but its quality is impaired.
A catarrhal condition exists. This increased mucous secretion counter-
acts the hydrochloric acid of the stomach and the gastric juice becomes
alkaline. Pepsin acts with difficulty, if at all, in an alkaline medium.
Therefore, the food when ingested is not readily digested and it ferments
in the stomach. This gives rise to lactic acid. The gas, being acid,
gives rise to a burning sensation which is called "heart-burn" since it is
referred to the region of the heart. Dyspepsia in all its varying forms,
results from some lesion interfering with the transmission of impulses
from the spinal cord to the stomach. Errors in diet aggravate the con-

APPLIED ANATOMY.

175

dition and in many cases are alone responsible for the dyspepsia.

A lesion of the fifth dorsal, lessens the size of the foramen through
which pass vaso-motor impulses to the stomach by way of the great
splanchnic nerve.

Some vascular disturbances of the stomach result from abuse of

Fig. 44. — Showing the great splanchnic nerve, left side, with its roots of origin,
the gangliated cord, rami and pulmonary branches. (From photo). The nerves were
colored before taking the photo, r, ramus; p. pulmonary branches; 1, 2, 3, 4, 5,
roots of the great splanchnic nerve, 1. s. lesser splanchnic.

176 APPLIED ANATOMY.

the organ. Errors in diet often cause pathological vascular changes
in the walls of the stomach.

*Landois says: The great splanchnic is the inhibitory nerve for
the intestinal movements, but only so long as the blood in the capillaries
has not become venous and the circulation in the intestine remains un-
disturbed. If the latter condition has arisen, irritation of the splanch-
nic causes increased peristalsis. If arterial blood be introduced, the in-
hibitory action is prolonged." Applying this to effects of lesions dis-
turbing the great splanchnic, a disturbed circulation will necessarily
result , with either a lessened or increased peristalsis. This nerve is also sen-
sory to the stomach and intestines, that is, it is partly afferent and sen-
sory impulses are carried to the spinal cord by it. It is probably a great
deal less sensitive than the cerebro-spinal nerves in relation, hence the
pain is quite frequently referred to the abdominal or thoracic wall, that
is 3 areas supplied by the fifth intercostal nerve.

A portion of the peritoneum is supplied by the great splanchnic.
There is a marked sympathy existing between the abdominal wall and
the viscera covered by it. A blow on the abdomen will cause vaso-
motor paralysis. A painful stimulus applied to the viscus will cause
contracture of the abdominal wall.

A few other branches come from the fifth thoracic ganglion: The
branches to the thoracic aortic plexus and the vertebra; and ligaments.
The gangliated cord is often involved by a lesion of the fifth dorsal.
The passing of impulses in such cases along the sympathetic chain
would be interfered with. This is not indicated by any definite dis-
eased condition but by a general effect on the viscera receiving impulses
that pass along the sympathetic cord.

The fifth dorsal segment of the spinal cord contains certain centers
that have been fairly well determined clinically and experimentally.
The level of the segment is considerably above that of the spine of the
fifth dorsal, but the local effects are most marked at and around the
spinous process, so when reference is made to a center, the external point
or landmark is the spine of the corresponding vertebra. The center for
the nutrition of the body is partly located in this segment. This is ex-
plained above. The motor, vaso-motor and secretory centers for the
stomach are in part located here. This the most important viscus
having almost all its centers in this segment. The liver also has a center

(Text-book of Human Physiology, p. 288).

APPLIED ANATOMY. 177

in this segment but the important centers for it are further down the
spinal cord. The spleen possibly derives some of its innervation from
the fifth dorsal segment. The centers for the accelerator impulses to
the heart are partly located in this segment. The fourth dorsal segment
is the most important, so far as the innervation of the heart is concerned.
Sweat centers for the middle thoracic area are in this segment; motor
and trophic centers for the muscles innervated by the fifth thoracic
nerve are of course, located in this segment.

The structures and viscera most frequently involved by a lesion of
the fifth dorsal are the stomach, liver, pleura, mammary gland, heart, arm,
spinal cord and the muscles of the back in relation. The effect on the
stomach varies with the character of the lesion and the kind of fibers
involved. Dyspepsia is the most common effect on the stomach, of a
lesion of the fifth dorsal vertebra. This is partly explained above under
the head of vaso-motor function of the great splanchnic nerve. Lessen-
ed activity of the muscular fibers, that is dilatation with lessened peri-
stalsis, is also common, especially in the chronic types of dyspepsia. The
various types of dyspepsia, ulceration, heart-burn, gastralgia, gastrop-
tosis, dilatation, nausea and vomiting, boulimia and in fact any stomach
disorder, may follow a lesion of the fifth dorsal. The explanation is, the
lesion lessens the size of the foramen through which pass blood and
lymph vessels to and from the spinal cord (fifth dorsal segment) also
the various nerve filaments over which pass impulses to the stomach
by way of the great splanchnic nerve. These impulses are named under
the function of this nerve.

Vomiting may be due to several causes. The various muscles of
respiration are called into service and the peristalsis of the stomach and
duodenum seems to be reversed. The contraction of the abdominal
muscles, according to Howell* is believed to be the principal factor in
vomiting.

"It was long debated whether the force producing this ejection
comes from a strong contraction of the walls of the stomach itself or
whether it is due mainly to the action of the walls of the abdomen. A
forcible spasmodic contraction of the abdominal muscles takes place,
as may easily be observed by any one upon himself, and it is now believed
that the contraction of these muscles is the principal factor in vomiting.
Magendie found that if the stomach was extirpated and a bladder con-
text-book of Physiology, p. 651, 1905.

178 APPLIED ANATOMY.

taining water was substituted in its place and connected with the esopha-
gus, injection of an emetic caused a typical vomiting movement with
ejection of the contents of the bladder. Gianuzzi showed, on the other
hand, that upon a curarized animal vomiting could not be produced
by an emetic — because, apparently, the muscles of the abdomen were
paralyzed by the curare. "

If the cause lies in the stomach, the vagus furnishes the afferent
path. "The efferent paths of the reflex are found in the motor nerves
innervating the muscles concerned in the vomiting, namely the vagus,
the phrenics and the spinal nerves supplying the abdominal muscles."
Clinically, lesions involving the spinal nerves, the fifth and sixth dorsal,
being the most important, at least predispose to nausea and vomiting.
Morning sickness in pregnancy is made worse by such lesions.

The liver is sometimes affected by a lesion of the fifth dorsal. Ordi-
narily, liver-disorders are associated with lesions of the sixth and seventh
thoracic vertebrae, under the discussion of which its diseases will be con-
sidered. The explanation of why a lesion so high as the fifth would
affect the liver is, that the portal vein as well as the other vessels, are sup-
plied by the splanchnic, and this nerve would be involved by a lesion of
the fifth dorsal, because of its relation to the articulations of the vertebra.

Disorders of the pleura result, in some cases, from some form of
lesion of the fifth dorsal. The explanation is that the fifth intercostal
nerve which supplies in part, the parietal layer of the pleura, is usually
involved by a lesion of the fifth dorsal.

Mammary affections are explained in a similar way, that is, by the
effect of the lesion on the fifth intercostal.

A few of the cardiac accelerator fibers pass out of the fifth dorsal
foramen and many pass through the foramen between the fourth and
fifth dorsal, therefore heart disease follows lesions of the fifth dorsal, if
these fibers are affected by the lesion. Heart and stomach disorders
are often found in the same patient. The common lesion explains this
peculiarity as well as the proximity of the organs.

The upper extremities are often affected by a lesion of the fifth dor-
sal. The important effect is weakness or atrophy. In some cases
complete paralysis follows. The spinal cord is directly involved by
pressure if the subluxation or displacement is marked. Paraplegia is
the sequel to this, it being the result of the transverse myelitis produced
by the subluxation.

APPLIED ANATOMY. 179

Other spinal cord diseases, not depending on direct pressure, come
indirectly from these vertebral lesions. The contour of this portion of
the spine is changed and the median furrow is often widened from atrophy
of this portion of the erector spinas muscle.

Chorea in which the arms are mostly involved, comes in some cases
as a sequel to a lesion at the fifth dorsal. Cutaneous diseases, neuralgia,
"shingles" and in fact any disease of this part of the body, may be the
result directly or indirectly, of a lesion of this vertebra.

Summary. The stomach is the principal viscus supplied by nerves
■coming out of the spinal canal in relation with the fifth dorsal, hence
the most common visceral effect from a lesion of this bone is stomach
disorder. Dietetic errors produce pain and muscular contractures in
this region. Some effect on the stomach can be obtained by palliative
treatment applied to the spine at this point. This effect is measured
by the effect obtained on the medium treated. To get a stimulating
effect on the stomach remove the lesion causing the unnatural inhibi-
tion. To secure an inhibitory effect on the stomach, remove the lesion
causing the increased peristalsis. In either case the lesion produces
the effect through stimulating or otherwise affecting the great splanchnics.
Sometimes, external treatment will cause a direct effect on the stomach,
that is pressure on the spine at the fifth dorsal will lessen peristalsis and
stimulation will increase peristalsis. This effect, if obtained at all, is
at best only temporary, as stated above. If this pressure or stimula-
tion relaxes the muscles or adjusts the spine or ribs, the stomach will be
affected proportionately.

THE SIXTH THORACIC.

The sixth thoracic vertebra is similar in most respects, to the verte-
bras described above. The spinous process is very long and oblique,
reaching to the body of the eighth dorsal. The superior foramina like
those of other thoracic vertebras, are bounded posteriorly by the an-
terior portion of the articular processes, hence any movement of it would
cause some change in size in the foramen. The articular facets are almost
plane surfaces. The transverse processes are directed upward, outward
and backward and bear facets that are quite deep and concave. The
movements of this vertebra are very limited and the remarks applied
to the fifth dorsal, will apply to the sixth.

Lesions of the articulations of this bone are usually very chronic, con-

ISO APPLIED ANATOMY.

sequently, chronic diseases of the stomach and liver follow lesions of this
vertebra. This is because the lesion has been overlooked at or soon
after its occurrence. The usual signs and symptoms of vertebral le-
sions are present. Softening and thickening of the supra-spinous lig-
ament are the most important signs. Tenderness over the spine and
some irregularity are usually present. As is the case of lesions of most
single vertebrae, the bone is anterior more commonly than all other dis-
placements combined.

The ligaments and muscles attached to it are affected if only one
side is involved. A scoliosis quite commonly develops. If anterior,
a lordosis may follow.

The azygi veins are subject to injury from subluxations of the ver-
tebra and from enlargements of adjacent viscera. The lateral spinal
vein is affected in a way similar to that of other lateral spinal veins. Pres-
sure on it c'auses congestion of the areas drained by it: the meninges,
vertebra? and especially the sixth dorsal segment of the spinal cord.

The arteries involved by this lesion are the sixth intercostal and
its branches, and through their nerve supply, the thoracic aorta and
its branches. The intercostal arteries are obstructed, the muscles of
the back contractured and the spinal cord congested.

The intercostal lymphatic vessels are also affected by a vertebral
lesion. The vessels draining the spinal cord pass from it by way of
the intervertebral foramina. From this it can be determined why they
are disturbed in function. Their function is not well understood. Edema
of the part drained seems to be the most constant effect of a disturbance
of the lymph vessel.

The nerves are affected in a way similar to that from other vertebral
lesions. The muscular branches supplying the intercostal, levatores
costarum, obliquus externus, rectus abdominis, and the erector, multi-
fidus and rotatores spinse muscles are at least affected in part. The
most constant effect is on the erector spina? and levatores costarum mus-
cles. The erector spins mass at first contracts but later on undergoes
atrophy; this producing a local widening of the median furrow of the
spine. The levatores costarum, by their contracture, displace the angle
of the ribs upward, this prying or rotating the anterior or sternal end
downward.

The obliquus externus is either relaxed or contractured. In irrita-
tive diseases of the stomach, this muscle becomes contractured and thus

APPLIED. ANATOMY. 181

the abdominal wall becomes tense. The patient yields to this contracture
and consequently, a stooped posture. In non-irritative disorders of the
abdominal organs the muscle becomes relaxed and the viscera descend
from lack of support. The same might be said of the rectus abdominis.

The effects on these muscles are so fairly constant that they are
diagnostic. They are reflex effects and are explained by the proximity
of the cells in the spinal cord that give rise to impulses that supply both
the viscera and the muscles. An irritation of the afferent nerves of the
stomach causes an increased activity of the cells in the sixth dorsal seg-
ment possibly on account of the overflow of impulses, hence congestion.
This soon becomes pathological and the motor cells are affected that
supply the muscles in relation and contracture is the result of the pro-
• longed and unnatural stimulation. In case of relaxation, the disorder
is a chronic one and the nerve cells are in a sense, paralyzed. In the
case of the abdominal muscles, often there are degenerative changes in
the muscle itself that are so marked and extensive, that the fibers are
permanently shortened or lengthened. The lesion may directly affect
both sets of nerves, those innervating the muscles and the viscera, and
thus produce pathological effects in both.

The abdominal muscles protect the delicate structures covered by
them, contracting firmly and quickly from any expected blow directed
against them.

The sensory branches of the sixth thoracic nerve, supply sensation
to the integument over the pit of the stomach, the sixth interspace and
a portion of the integument and tissues at and around the sixth dorsal
spine. In subluxations of the sixth dorsal or other disturbance of it,
such as fracture or Pott's disease involving it, the pain is often referred
to the pit of the stomach. In gastralgia.the greater part of the pain is
in the walls of the stomach while some of it is in the abdominal wall.

This is proven by the fact that the pain is intermittent. The pain
in colic is due directly to the contraction of the viscus. The contrac-
tion is a reflex one and dependent to a great extent on the amount and
character of the contents of, in this case, the stomach. The afferent
nerves are the great splanchnic and the vagus while the efferent, are the
splanchnic and the intercostal. The pain seems to be in the walls of the
stomach and is the result of spasm or contracture of the muscle fibers
composing the wall, this compressing the nerves in the walls. In some
cases possibly the pain is the direct result of a stimulation of the sensory

182 APPLIED ANATOMY.

nerves but I believe this to be the exception especially in gastralgia, or
else the pain would be constant. It is possible to get contraction of the
muscles of the stomach by direct stimulation after all nerve connections
with the spinal cord are severed. This is explained by the presence of
intrinsic ganglia in the walls.

In inflammatory diseases of the stomach, this part of the abdominal
wall, that is the pit of the stomach, is tender. Tenderness on pressure
at the pit of the stomach is almost diagnostic of inflammatory or other
organic disease of the stomach. The explanation is that the same seg-
ment that supplies the stomach, supplies the pit of the stomach and the
pain is referred to the part supplied by the more highly sensory nerves,
the cerebro-spinal. While in other cases, it is due to the inflammation
of the pyloric end.

Sensation to the pleura and peritoneum is also directly furnished
by this sixth dorsal nerve. The cardiac end of the stomach is supplied
with sensation by the sixth nerve, it carrying the impulses to the corre-
sponding segment. The impulses pass from the stomach to the sixth dor-
sal nerve by way of the great splanchnic.

The liver and gall-bladder are also supplied with sensation by this
nerve and the impulses reach it in a similar way. In acute, painful
disturbances of these viscera, the muscles supplied by the same segment
become markedly contractured, particularly the spinal muscles, while
the abdominal wall, as a rule becomes tender and in acute cases, con-
tracted and tense. Hepatic colic is a good illustration of this point.

Pressure over or at the place of emergence from the spinal canal of
the sixth dorsal nerve, may lessen or completely stop the passing of the
sensory impulses from the viscus to the spinal cord, thereby relieving
the pain. Gastralgia and hepatic colic (mild form) can in most cases, be
controlled by such treatment. This treatment is only palliative and
relieves temporarily, if at all. By relaxing the contractured muscles of
the spine, marked effect can be obtained on the affected viscus. Relax-
ation is better secured by adjusting the bony lesion rather than by in-
hibiting the muscle by pressure directly applied to it. The muscular
.contracture is the effect and by relaxing it, although the effect is thus
counteracted yet the cause remains. The subluxation of the sixth dor-
sal, is, in most cases the primary cause of both the visceral and muscular
trouble and by correcting it the effects, unless too chronic, will be and
remain relieved. If a muscle when contractured undergoes structural

APPLIED ANATOMY.

183

SPINAL LIGAMENTS

SEMISPINALS DORS

INTERSPINALS

ROTATOR ES

INTEGUMENT OVER SPINE OF 6th T
MULTIFIDU SPINA
TRANSVERSUS ERECTOR SPINA.

S LEV.COSTARUM

Rf£t§<

PLEXUSES ETC. (SprSEE8thSEG'T7
S SOLAR A. AORTIC C CELIAC

cli ^tW '' Sp SPLENIC TOSPLEEN PANCREASE AND STOMACH

KS,

'&&, % R RENAL TO KIDNEY S R SUPRARENALTO SUP CAPSULE
lfi£,c GGASTRIGTOSTOMAGHANDESOPHAGUS E ESOPHAGLALTOESOPH'S.

H.HEPATICTO LIVER GALL BLDB STOMACH. DUODENUM ANDPANCREAS-
0 DIAPHRAGMATIGTODIAPHRAGN,VENACAVA(RSiDE)ESOPHA&uS(LEFTSIDE)

S.M SUP MESENTERIC TO SMALL INTESTINES CA1CUM
APPENDIX ASCENDINGANDTRANSVE.RSE COLON

I M INF.MESENTERICTODESCENDING ILIAC AND
PELVIC COLON and UPPER PART OF RECTUM

S.G SEMILUNAR GANGLION AG AORTIC-RENAL GANGLION

GRT S.ano=>MS. SPLANCHNICS

TRIANGULARIS-STERNI M

rTO. 45. — The sixth thoracic segment with its nerves and their distribution.

184 APPLIED ANATOMY.

changes that prevent relaxation, stretching of the muscle is to be advised
in such cases.

Vaso-motor impulses to the abdominal blood-vessels pass out over
the sixth dorsal nerve, the white ramus, sixth thoracic ganglion, and
thence to the various vessels by way of the great splanchnic and the
solar plexus. The spinal cord, liver, stomach and small intestines are
especially supplied with vaso-motor impulses by the sixth dorsal seg-
ment. The sixth dorsal ganglion gives origin to one of the roots of the
great splanchnic nerve. This nerve has been discussed in part under
the fifth dorsal segment. It gives off branches to the thoracic aorta and
the oesophagus, before it reaches the solar plexus.

A lesion of the sixth dorsal will affect the spinal cord. The various
centers in the cord may be involved, such as the center for the tone of
muscle, vaso-motor, secretory, viscero-inhibitory, sweat and trophic.
These centers may be involved from direct pressure on the cord or from
changes in size of the foramina which interfere with the nutrition of the
cells. The grey matter in particular, is often affected by lesions occuring
in the young. Anterior polio-myelitis can often be traced to a fall or
other injury in which the spine is involved. These injuries result in a
disturbance of the cells in the anterior horn and the disease known as
infantile paralysis, develops. The explanation of the lesion of the thor-
acic vertebra producing the disease is (l),the nutrition of the cells is eut
off, or (2), the nerve tract connecting the cell with the muscle fibre is
destroyed. The first explanation is the better since in most cases there
are marked vaso-motor changes in the spinal cord. If this congestion
does not result in destruction of nerve cells, a cure is possible, but if the
cells are destroyed whether by congestion or hemorrhage, a cure is scarce-
ly possible. There are in addition to the bony lesions, exciting causes
which act in proportion to the impairment caused by the lesion.

The various columns as well as the cells of the spinal cord, are af-
fected by some forms of lesions of the sixth dorsal. The effect may be
from pressure on the cord itself or from pressure on the vessels that
nourish and supply these columns. Locomotor ataxia and the paraple-
gias are examples. Perhaps not all patients suffering with these forms
of spinal cord disease have lesions of the vertebrae that can be distinctly pal-
pated, but the vast majority of cases result from vertebral lesions, the
sixth dorsal being a common location of the lesion.

In locomotor ataxia, the pressure is exerted directly on the gang-

APPLIED ANATOMY. 1S5

lion on the posterior nerve root or on the blood-vessels that supply it and
the spinal cord. The ganglion is in close relation with the processes that
form the intervertebral foramina and are thus subject to pressure if there
is the slightest deviation. Although this would of itself produce loco-
motor ataxia, yet I believe the better explanation is that the spinal cord
and its nerves are affected through the disturbance of nutrition caused
by these spinal deviations affecting the circulation of the spinal cord and
its branches. Syphilis may have something to do with the production
of the disease but this as yet has not been demonstrated, only surmised.
The toxemia of any disease will make the effect of a spinal lesion on the
spinal cord the more marked. The treatment of syphilis by the internal
administration of the anti-syphilitic remedies such as mercury and the
iodide of potassium is perhaps responsible for the production of the
locomotor ataxia in many cases. Excessive coitus is a very important
cause of locomotor ataxia. * " When sexual impulses force the con-
cerned ganglionic cells too often, and for too long periods of time, they
lose power; and if the state of exhaustion continues without time for
physiological recuperation, degeneration is the final result.''

This condition plus the spinal lesions are responsible for most if
not all cases of tabes dorsalis notwithstanding the statements in the
various texts that syphilis is the only cause.

*von Raitz so well expresses my ideas in regard to the cause of tabes,
that I quote the following: "Injury to the cord, as an etiological fac-
tor of tabes, has of late arrested the attention of unbiased observers,
and there is sufficient evidence to force serious consideration of those
cases whose history points to accidents after which tabetic symptoms
appeared. Injury to the cord may occur without any external evidence, and,
as a matter of fact, seemingly trivial accidents are. at times, followed by
tabes. Severe traumatism to the spine may cause instantaneous partial
or total, transient or permanent paralysis below the level of the injury,
but no symptoms of locomotor ataxia, while a simple fall or sharp twist
of the spinal column, leaving no external evidence of injury to the spine,
and no immediate symptoms referred to the cord, may induce locomotor
ataxia. When, after a fall, symptoms appear gradually, they are not
understood until locomotor disturbances set in; and even then serious
attention is not paid to them, but liniments and antirheumatic remedies
are employed until a competent man makes a diagnosis of tabes. If

*Medical Record, p. 650, 1905.

186 APPLIED ANATOMY.

this physician holds to the syphilis theory, he will, under all circumstances
find that the patient has had syphilis some time ago, no matter whether
he has had symptoms of the disease or not, for, if all evidence fails, the
"benefit of the doubt" covers every lack of information. The fall is
thrown out as an etiological factor as soon as mentioned, because no ex-
planation of how a fall can cause tabes, has as yet, been offered. Some,
however, admit that a fall, while not the cause of the condition, might have
hastened the progress of the disease, which was present before the fall.
How a simple fall can cause injury to the cord and subsequently
tabes is, however, not difficult to understand. We know, when a blood-
vessel is subjected to tension and torsion, it loses its elasticity by over-
stretching or rupture of the muscular fibers of its walls. When a per-
son falls, he will, before the body reaches the ground, try to save him-
self by throwing his weight in the opposite direction. This motion is
carried out with great suddenness and with as much power as the per-
son has at his command. The spine is then bent and twisted at the point
of greatest flexibility. The anatomical relations of the spinal column
allow the greatest freedom of motion in the lumbar spine, and there
the center of gravity of the lower part of the body, in its downward
course is suddenly met by the weight of the upper part of the body in
its opposing direction, thus mitigating the impact of the body with the
ground. To oppose the falling of the body still more forcibly, the arms
are suddenly thrown out in the opposite direction, and according to the
degree of pronation of the upper body, necessary to oppose the fall, a
corresponding bending and twisting of the spinal column takes place,
during which the blood-vessels are stretched and twisted. If the degree
of tension and torsion is greater than the elasticity of the implicated
arterial walls can endure the muscular fibers are damaged and the walls
may, at one or more points, collapse and obliterate. The portion of the cord
concerned will now, sooner or later, suffer for want of nutrition, in propor-
tion to the number or importance of the nutrient arteries involved, and
corresponding symptoms of degeneration become, more or less ap-
parent. The progress of degeneration once started, has a tendency to
progress, unless checked by forced nutrition, which, no doubt, often
enough, takes place in strong individuals. After such injury the spinal
nerve fibers or ganglionic cells, or both, may be affected, as this depends
on where nutrition ceases, and the first symptoms which present them-

APPLIED ANATOMY. 1.S7

selves are disturbances of locomotion. This class furnishes the motor
type of tabes."

This sprain or as we would term it, lesion, may occur in the thor-
acic as well as in the lumbar region. If the disease were due to syphilis
and not dependent on other causes, why is it that only a small per cent,
of syphilitic patients contract the disease? In those that do, we believe
that the antisyphilitie drugs are as much to be blamed for the produc-
tion of the disease as the syphilis itself.

A marked lesion or fracture of the sixth dorsal will cause transverse
myelitis if there is pressure on the spinal cord.

The contour of the spinal column is affected in ninety per cent, of
cases if the lesion occurs before the growth of the spinal column is com-
pleted. These curvatures usually start from a subluxation or strain of a
single articulation and get well under way, before they are noticed. The
articulations of the sixth dorsal furnish a very common starting point
of the trouble. Deviations or sprains of these articulations cause atro-
phy of the muscles on one side and the opposite side proceeds to draw
the spine toward that side and in a year or so a well defined scoliosis is
developed.

Pott's disease may set in as a result of a lesion of the sixth dorsal.
The explanation is that the lesion lessens the resistance, that is, lowers
the vitality of the part, which condition permits of the entrance and
propagation of the micro-organisms peculiar to this disease. Care should
be exercised in the treatment of such a spine not to use much force since
the vertebra? may be badly injured on account of the honey-combed
condition of the body of the bone.

A lesion of the sixth dorsal will cause a disturbance of the ribs artic-
ulating with the transverse processes. The character of the effect is de-
termined by the kind and degree of the vertebral lesion. This is true of
all the thoracic vertebra?. In scoliosis with rotation, a marked bulging
takes place on the convex side with concavity on the opposite side of the
thorax. At first the change in position of the rib produces pain along
the intercostal nerve if the subluxation is a sudden one. If it comes on
gradually, nature adapts herself to the changes and little or no pain is
felt as the rib changes its position.

If the sixth thoracic vertebra is turned toward the right side, the
sixth rib on that side will be forced forward while the corresponding one
on the left will be carried backward. If the vertebra in displaced di-

1S8 APPLIED ANATOMY.

rectly forward, both ribs are carried with it and there in a corresponding
depression of the shafts of the ribs. In this way a differential diagnosis
between a forward displacement of the vertebra and an apparent one,
can be made. If the vertebra is displaced backward, the ribs are carried
with it and the shafts become more prominent. When the part of the

Fig. 46. — Showing effects on disc in lateral subluxation of 5th and 6th thoracic
vertebra. This unequal pressure on the discs is responsible for lateral curvature of
the spinal column. Compare with Figs. 48 and 49.

rib in relation with the transverse process of the vertebra is displaced,
the shaft, hence the anterior part, is changed as to position. Therefore
examine the position of the ribs in making up a diagnosis of the particular
form of vertebral lesion if it is in the thoracic area and remember that the

APPLIED ANATOMY. 189

rib lesion, that is displacement, may be secondary. A lesion of a thor-
acic vertebra will always produce some form of rib lesion but the con-
verse is not necessarily true, that is a rib lesion does not as a rule, pro-
duce a perceptible vertebral lesion.

A lesion of the sixth dorsal, if chronic, invariably affects the stomach
and liver. It may also affect the peritoneum, pleura, diaphragm, pan-
creas, gall-bladder and small intestines. Only the effect on the liver
will be considered at this place. The effect on this organ is primarily
that of congestion. This follows because the innervation of its blood-
vessels comes from the sixth dorsal segment, the impulses reaching the
blood-vessels by way of the splanchnic nerves, solar plexus and hepatic
plexus, and these vaso-motor impulses are obstructed by the lesion.
Almost all liver disturbances start as a congestion. The functions of
the liver are perverted, it becomes heavy and tender, indigestion soon
sets in, followed by many and varied discomforts. Congestion of the
liver increases the amount of formation of bile and seems to lessen ex-
cretion and the patient soon becomes bilious. In passive congestion,
and this is the most common type of pathological congestion, the qualit}'
is impaired with a tendency to a formation of gall stones.

In active congestion of any gland, the quantity of secretion is in-
creased, while the quality is not necessarily affected. In passive con-
gestion there is usually an increased quantity secreted as well as a change
in quality. The secretion after awhile becomes thickened, nasal catarrh
and leucorrhea being the best examples. It is a well known fact that in
colds of the head, there is first a coryza, but afterward the secretion be-
comes thicker as the disease becomes more chronic. In all probability
this is the condition in the liver. That is, in chronic passive conges-
tion the bile is not only increased in amount, but becomes thickened.
The thicker the secretion, the greater the tendency to the formation of
a sediment, which is usually preliminary to the formation of gall stones.

A torpid or sluggish liver seems to be the predisposing cause of gall-
stones, hence the connection between a lesion of the sixth thoracic ver-
tebra and gall-stones. The bile pigment which is increased in amount
by this congestion, is absorbed by the lymphatics, and an attempted
elimination produces jaundice. The other functions are more or less
affected by a lesion of the sixth dorsal because this lesion affects all the
nerves going to the liver, particularly the vaso-motor, trophic, secretory
and sensory. From these effects come jaundice, gall-stones, indiges-

190

APPLIED ANATOMY.

tion, biliousness, malaria, diabetes mellitus, kidney disease and dis-
orders of the bowels and blood.

In jaundice there is excessive secretion of bile, imperfect excretion,
absorption by the lymphatic vessels and an attempt orl the part of the
skin to eliminate the bile pigment. Gall stones result from change in
the character of the bile. An alteration in the composition of the choles-

£■:.

Fig. 47. — Showing spine of boy suffering with Pott's disease,
like enlargement of the 6th dorsal spine. (From photo).

Note the knuckle-

APPLIED ANATOMY. 191

terin, which is supposed to prevent deposit, that is, keep the bile in solu-
tion, and imperfect elimination either from a sluggish condition of the
liver or from obstruction to the bile ducts, acting together, produce gall
stones.

Indigestion may be of two forms as a result of liver disorder, gastric
and intestinal. The former results because of the congestion of the
stomach, which always follows congestion of the liver because all the
blood in the walls of the stomach must pass through the liver before it
reaches the heart. Intestinal indigestion comes from (1) the change
in amount and quality of the bile, this hindering intestinal digestion
since the bile has a great deal to do with this form of digestion, and (2)
from the obstruction to the venous drainage of the small intestine.

Biliousness results from congestion of the liver, as a result of in-
creased secretion of the bile and absorption of it. Nausea and vomiting
occur when the bile reaches the stomach.

Malaria results from an impairment of the quality of the blood
which commonly follows liver disorders, since the liver has to do with
formation of and changes in the blood.' This condition permits the ma-
larial toxines to thrive, or at least prevents destruction, by the blood.

Diabetes mellitus follows a disturbance of the glycogenic function
of the liver. The sugar is thrown directly into the blood and is excreted
by the kidneys. Landois says in speaking of sugar in the blood: "It
occurs a few hours after injury to a particular spot (center for the vaso-
motor nerves for the liver) on the floor of the lower portion of the fourth
ventricle; further after division of the vaso-motor paths in the spinal
cord from above downward to the exit of the nerves for the liver, that is
to the lumbar portion; in the frog, to the fourth vertebra. Division or
paralysis of the vaso-motor conducting paths from the center to the
liver results in glycosuria. According to recent researches by Francois
Franck and Hallion, the vaso-motor nerves of the liver (for the hepatic
artery and the portal vein) arise between the sixth dorsal and second
lumbar nerves, and pass through the communicating branches into the
splanchnic nerves."*

Clinically, the above has been demonstrated and I quote this since
it offers an anatomical explanation of diabetes mellitus.

Lesions affect these nerves, although the effect may not be so marked
as that from section of the nerves as in the experiments from which the

*Landois Human Physiology, p. 313, 1904.

192 APPLIED ANATOMY.

above was determined; nevertheless there is an effect as a result of these
lesions characterized by dryness of the skin, progressive emaciation,
boulimia, thirst, increased secretion of urine which responds to the
sugar tests, sweetish breath and taste in mouth, all of which increase in
intensity until the patient literally starves to death. We recognize
other causes than the one mentioned, that is lesions with the lower thoracic
vertebra?, but they are unimportant when compared with the spinal le-
sions. The vertebrae seem to undergo a change. They become more
prominent and the spinous processes seem clubbed, that is enlarged,
and the change produces a condition in the spinal column that is almost
pathognomonic of the disease.

Kidney diseases follow or complicate liver disorders because of the
change in the urea, it being nature's diuretic, and an increase of waste
matter, thus throwing more work on the kidneys.

Bowel disorders result from the bile changes, there being a change
in amount or quality. Marked odor to the stool is usually due to some
abnormality of the bile, since one of its functions is to prevent putre-
faction.

The blood diseases result because, as stated above, the liver has a
great deal to do with elaboration of the blood.

Lesions of the sixth dorsal, produce these effects, as explained above,
because the various impulses to the liver arise in part in the sixth
dorsal segment, pass over the roots of the sixth dorsal nerves, thence
over the great splanchnic to the liver, and these lesions interfere either
with the center, or the nerves connecting center and liver. These inter-
ferences result mostly from a lessening in size of the intervertebral fora-
men through which nutrition in part, is carried to the spinal centers and
through which all impulses that go from the spinal cord to the liver must
pass. Indirectly the liver may be affected by a lesion impairing the
action of the diaphragm, stomach and small intestines.

Summary. Lesions of the sixth dorsal may produce dyspepsia,
gall-stones, jaundice, pleurisy, peritonitis, gastralgia, intercostal neuralgia,
spinal cord diseases, spinal affections and diaphragmatic disturbances.

THE SEVENTH THORACIC.

The seventh thoracic, differs so little from those described above that
it does not merit separate description. Its spine is on a level with the
inferior angle of the scapula. Motion at this point of the spinal column

APPLIED ANATOMY.

193

is very limited although more marked than that of the upper thoracic
articulations. The movement is mostly restricted by the ribs. As in
the vertebral articulations above, the most frequent movement is an
anterior and posterior one as in respiration. Use is made of this to cor-
rect anterior deviations. The lungs act as a fulcrum, and then when the

Fig. 48. — Showing a swerving of the spine of the sixth to the right and the spine
of the seventh to the left. Compare with Figs. 46 and 49.

194 APPLIED ANATOMY.

spine is flexed and the chest securely braced when the lungs are filled
with air, powerful backward pressure is exerted, and after repeated
attempts, the anterior condition can, in some cases, be overcome. This
anterior condition is common and constitutes a condition hard to re-
lieve. The opposite condition may be present and especially in certain
forms of disease, principally diabetes mellitus.

Sprains of the back take place quite commonly at the articulation
between the seventh and eighth dorsal. This condition is very painful,
movement being almost impossible. The ligaments are partly torn,
congested and thickened. If apparent recovery does take place, an
irregularity will remain, the foramen is lessened in size and a lessening or
complete destruction of mobility results. Many spinal lesions, I refer
to chronic displacements of vertebrae, have a sprain as a starting point.
Several vertebrae are usually involved and a change in contour is the
result.

The blood-vessels passing through the foramina are affected in le-
sions of the seventh. The vein starts in the seventh dorsal segment
and after being reinforced, passes downward and outward through the
corresponding foramen, thence into the intercostal vein.

The arteries branch from the intercostal. The main trunk con-
tinues into the muscles. A branch is given off which passes into the
foramen and being inclosed by the sheath of dura mater that surrounds
the roots of the seventh dorsal nerve, passes obliquely upward to the
corresponding segment, hence carries nutrition to this part of the spinal
cord.

Lesions of the seventh dorsal ordinarily produce pressure on these
vessels. The segment becomes in a measure, congested because the anas-
tomosis is not complete enough to carry blood to and from the cord
without there being any effect. After a while the collateral circulation
may be established, but in the meantime the functions of this segment
are perverted in proportion to the degree of vascular disturbance.

The nerves passing through the intervertebral foramina, with their
branches, are directly affected and the various nerves with which these
connect, are more or less affected indirectly.

The seventh intercostal, supplies the intercostal and abdominal mus-
cles, diaphragm, pleura, peritoneum, the seventh rib and its periosteum,
and. sensation to the pit of the stomach and the seventh interspace. If
the lesion irritates this nerve, in acute cases there will be a, contraction of

APPLIED ANATOMY.

195

the intercostal muscles, or rather an interference with the normal action
of these muscles, since contracture is scarcely possible. The diaphragm
may be affected. Hiccough may develop, which form often ends fa-
tally, or at least runs a course of several days unless stopped by reliev-
ing the irritation to this or other intercostal nerves. The abdominal
muscles contract and cause the patient to assume a stooped posture.
There will be pleurisy and intercostal neuralgia, or there may be neuritis

Fig. 49. — Showing effects on the foramina, between the 6th and 7th, and 7th and
8th thoracic vertebra? in an anterior rotation of the 7th. The articular process is
rotated forward into the lumen of the foramen. Inflammatory deposits fill in the
foramina and fix the vertebrae in their abnormal position. Compare with Figs.
46 and 48.

196 APPLIED ANATOMY.

or shingles. Peritonitis, or pain simulating it, will develop, it being
most intense on the affected side and in the pit of the stomach. Pain
along the course of the nerve is the most common effect, it being the
result of congestion of the nerve although it may be a purely referred
pain. If the lesion inhibits, that is partly paralyzes the nerve,
there will be relaxation in the muscles and numbness in the sen-
sory areas. Contracture of the abdominal muscles, upper part, may
result reflexly from stomach, pancreatic or liver disorder, or a diseased
condition of the small intestines.

Pain in the seventh intercostal nerve may be a referred one from a dis-
ordered condition of viscera innervated by the seventh dorsal segment.
Therefore, liver complaints, stomach disorders and intestinal affections
cause pain, some of which is referred to the seventh intercostal nerve.
The lesion of the seventh dorsal may be responsible for the visceral dis-
order and the referred pain, since the segment may be directly involved
by the lesion.

The posterior division of the seventh dorsal nerve may be irritated
by the lesion. If such is the case the muscles of the back supplied by
this nerve become contractured and pain is present in the region of the
spine of the seventh. Disease of the liver or stomach will also produce
a contracture of these same muscles. Clinically, if the muscles of the
back innervated by the seventh dorsal are contractured, there is in all
probability, liver or stomach disorder. If the lesion inhibits this nerve,
there will be perversion of sensation in this region of the back with re-
laxation of the muscles supplied. Visceral disease, if chronic, will cause
atrophy of some of the spinal muscles. Liver and stomach disorders,
if chronic, cause atrophy of a portion of the erector spina? muscles in re-
lation with the seventh thoracic spine with widening of the median
furrow at that point. Clinically, widening of the median furrow at the
seventh dorsal is diagnostic of chronic liver and stomach disease.. The
converse is not always true since there may be disease of the stomach
without a widening of the median furrow, but this the exception.

It is stated that the anterior and posterior divisions of the spinal
nerve carry vaso-motor, secretory and trophic impulses in addition to
motor and sensory. Thermic impulses are also carried by these nerves.
Coldness of the integument corresponding to the distribution of an inter-
costal nerve is quite common in lesions of the corresponding rib or ver-
tebra, and in certain visceral disorders. Stomach disorders are often

APPLIED AXATOMY.

197

SPINAL LIGAMENTS

SEMISPINALS DORSI
INTERSPINALIS

ROTATORES

INTEGUMENT OVER SPINE OF 71hT.
MULTIHDUS SPINS.
ERECTOR SPINS
LEVATOR COSTARUM

PLEXUSES
A AORTIC C CELIAC

&m,

^o^ SR SUPRARENAL TO CAPSULE R.REN ALTO KIDNEY
SpSPLENICTOSPLEEN PANCREAS ANBSTOMACH/
G GASTRIC-TO STOMACH AND ESOPHAGUS E.ESOPHAGIAL

SM SUP MESENTERIC™ SM. INTESTINES CftCUM
APPENDIX ASCENDINGAND TRANSVERSE COLON

I.M. INr MESENTERIC TOOESCENOING ILIACANO
PELVIC COLON AND UPPER PARTorRECTUM

D. DIAPHRAGMATICTO DIAPHRAGM VENACAVA R SIDE ESOPHAGUS L.S.,

H.HEPATICTO LIVER GALLBLADDER.STOMACH, DUODENUM. PANCREAS'^

SG. SEMILUNAR GANGLIOM A.C. AORTICO-RENAL GANGUOHT,

Gfi S amdSM.S SPLANCHNICS

TRIANGULARIS STERNI M..

Fig. 50. — Showing the seventh thoracic segment of the spinal cord with its
nerves and their distribution.

198 APPLIED ANATOMY.

characterized by a lowered temperature of the integument supplied by
the sixth and seventh intercostal nerves.

Perhaps the explanation is that the vitality of this part of the abdom-
inal or thoracic wall is lowered directly by the lesion or reflexly, by the
gastric disorder. When the nutrition of a part is below par, the blood
stream is slowed and metabolism lessened. In disorders of the stomach,
there is a lowering of the vitality of the parts supplied by the same spinal
segment and the activity of the parts is lessened, hence the lowered
temperature. After all it is a matter of circulation and, in this par-
ticular sort of case, the vitality of the wall is lowered on account of (1),
a central lesion directly involving the part, and (2), a visceral one that
impairs the circulation to that part of the spinal cord that controls the
nutrition of, hence circulation of blood through, the affected area.

Vaso-motor changes in the area supplied by the seventh intercostal,
are not unusual when a lesion of the vertebra or rib, exists. Herpes
zoster, is a type of these disorders. If both intercostal nerves are af-
fected, the patient complains of a constriction around the body corre-
sponding in position to the seventh intercostal nerves. Locomotor
ataxia is a cause, in which case the lesion is a central one. Lesions of the
lower dorsal vertebrae arid ribs are more common and important in the
production of this peculiar constricting pain.

Practically it may be stated that nearly, if not all diseases of the
viscera innervated by the seventh dorsal segment, produce some effect
in the areas supplied by the anterior and posterior divisions of the seventh
dorsal nerve. The explanation is that the impulses set up by the dis-
order, pass to the spinal cord which in turn, in most instances, becomes
congested. This congestion affects the cerebro-spinal nerves derived
from the same segment.

The rami communicantes are more or less affected by a lesion of the
seventh dorsal. If pressed on, the impulses may be lessened or entirely
shut off; and if irritated, they may be increased. The grey rami are
principally efferent and convey as is the case of those above, vaso-motor,
secretory and pilomotor impulses. Undoubtedly, some sensory im-
pulses are transmitted by the giey ramus, consequently irritation of the
seventh grey ramus would cause pain to be referred to the parts sup-
supplied by the great splanchnic and seventh nerves. Inhibition of it
would cause vaso-motor disturbances in the cord and abdominal and
thoracic walls and lessening of sensation in parts supplied by the seventh
thoracic nerves.

APPLIED ANATOMY. 199

If the white rami are affected the various efferent impulses that
normally pass over the great splanchnic nerve will be disturbed in some
way. It is then possible for there to be perverted peristalsis, secretion,
nutrition and blood supply of parts innervated by the nerve filaments
in and composing in part, these white rami. The recurrent meningeal
is in most lesions, affected by direct pressure, hence dilatation of the
spinal blood-vessels takes place if the pressure inhibits instead of stim-
ulates the nerve.

The seventh thoracic sympathetic ganglion is involved directly or
indirectly in all typical lesions of the seventh dorsal. The ganglion lies
in relation with the head of the seventh rib. The rib is partly displaced
in all lesions of the vertebra. The impulses passing to the seventh gang-
lion are carried by filaments that pass through the corresponding inter-
vertebral foramen. This foramen is lessened or otherwise affected by a
lesion of the seventh dorsal. The branches of this ganglion then would
be more or less affected by a lesion of the seventh dorsal. Its branches
are the third root of the great splanchnic and branches to the vertebra
and ligaments. The great splanchnic gives off branches to the thoracic
aortic plexus and the oesophagus before it reaches the solar plexus. If
the nerve is irritated by the lesion the oesophagus and aorta may be con-
stricted since it is at least vaso-motor and possibly motor to the esopha-
gus and vaso-motor to the aorta.

Dysphagia sometimes results from a lesion at the seventh dorsal.
The other functions of the nerve are more or less affected by the lesion.

The bile duct and gall-bladder are relaxed in the chronic lesion hence
tendency to the formation of gall stones because of the incomplete evacua-
tion of the gall-bladder as a result of lessening of the peristalsis. The
sediment may form a concretion, which, on account of its character
and location, is called a gall stone.

The spinal column and cord are affected by this lesion in a way
similar to that from a lesion of the sixth dorsal, which see. Also the
ribs are affected as are other ribs; that is, either a subluxation takes
place or else a strain of theirligaments results from the vertebral lesion.

The liver, stomach, pancreas and the small intestines are the viscera
most frequently diseased by a lesion of the seventh dorsal. They are
affected because (1) a part of their spinal cord centers is located in the
seventh dorsal segment and this segment is invariably disturbed by the
lesion; and (2) the line of communication between these centers and the
viscus is broken or impaired by the lesion.

200 APPLIED ANATOMY.

The structures involved by a lesion of the seventh dorsal are the
peritoneum, pleura, periosteum of the seventh rib and all tissues at-
tached. The explanation is that the nerve supply to these structures
is directly affected by the lesion or else they are affected by contiguity.

The functions of the liver are disturbed by this lesion in a way sim-
ilar to that from the lesion of the sixth dorsal. If the lesion is irritative,
there is increased activity up to a certain point after which fatigue sets
in and the lesion has the opposite effect. There is disturbance of ex-
cretion of bile. It is then retained in the liver, is absorbed by the lym-
phatics and partly excreted by the skin. This gives rise to biliousness,
jaundice, change in character and odor of stool, intestinal indigestion
and constipation, because of the change in character of the bile, the
abnormal place it occupies and the lessening in amount at the nor-
mal place, that is in the intestines. Biliousness follows because of the
toxemia; jaundice, from attempted excretion of the pigment by the skin;
the odor of putrefaction, since the feces undergo a certain amount of de-
composition when the bile is absent; indigestion because bile assists in
the digestion of the fats; and constipation because a lack of bile causes
a lack of secretion of mucous and because the parts are not sufficiently
lubricated.

The glycogenic function is disturbed, this usually resulting in gly-
cosuria. The secretion of urea is altered and kidney diseases develop
in a short time if the disturbance is marked. Metabolism is interfered
with and the food products carried to the liver by the portal vein are
not properly acted on. Most of these effects depend on the vascular
changes in the liver. Sensory disorders of the liver also seem to depend
on the vascular changes since if it is congested, it is tender on pressure.

Any one or all of the these factors are affected by the lesion, hence
the disturbance in function.

Summary. Lesions of the seventh dorsal, cause stomach disorders
such as gastritis, gastroptosis, acidity with eructation of gas, gastralgia,
or even ulcer and cancer, because the nerves controlling the movement,
secretion, nutrition, sensation and the amount of blood, are affected by
the lesion, because they pass through the foramina between the seventh
and eighth dorsal vertebrae. Diseases of the liver follow a lesion of the
seventh dorsal because the amount of blood in it is controlled by the
nerves that are impaired by the lesion, viz., the great splanchnic. These
diseases vary with the character of the lesion and the function affected.

APPLIED ANATOMY.

201

There may be malaria, kidney disease, cirrhosis, gall stones, glyco-
suria, and biliousness with periodic headache. A "sluggish" liver with
its retention and absorption of bile, is the most common effect. Vomiting
is nature's .method of relieving bilious headache. In nearly all chronic
cases of biliousness seen by the writer, a marked anterior condition of
the sixth, seventh or eighth dorsal vertebra was found. The explanation
is that the lesion causes congestion of the liver by dilating the blood-
vessels. There is in all probability, increased secretion of bile and ob-

Fig. 51. — Showing a posterior subluxation of the 7th and Sth thoracic vertebrae
and an anterior condition of the 9th. (From photo). The patient had congestion
of liver.

structed elimination. It then is absorbed and acts as a toxemia. In
hepatic colic the sensory nerves involved are the great splanchnic and
the sixth, seventh and eighth intercostal nerves. Inhibition, in which
marked pressure is exerted against these vertebra; (6, 7 and 8) and the

body is bent backward, will usually relieve the attack. This sort of
treatment lessens the size of the intervertebral foramina thereby inter-
feres with the transmission of the sensory impulses to the sensorium.

202 APPLIED ANATOMY.

Perhaps the effect of this treatment is due in part to the effect on
the vaso-motor nerves that also pass through these foramina. By
moving the vertebra, it may adjust it so that the normal impulses will
again pass through, in which case the treatment is a curative one. Since
most pain is due to pressure from congestion, another explanation of
why such a treatment relieves even in many cases of colic, is that the
circulation through the viscus is bettered, hence the irritation resulting
from pressure and chemical stimulation is lessened.

The pancreas is also involved by a lesion of the seventh dorsal on
account of the resulting disturbance to the great splanchnic nerve, solar
and coeliac plexuses. Glycosuria is one effect of a disturbance of the
pancreas. The small intestine is often involved by this lesion but not
so frequently as by a lesion of the lower thoracic vertebra;. The various
lesions of the seventh dorsal, most frequently produce disease of viscera
by obstructing the foramen through which impulses pass from the spinal
cord centers to the viscera, and through which the corresponding parts
of the spinal cord are nourished and drained.

THE EIGHTH THORACIC.

The eighth dorsal vertebra does not differ materially from the seventh.
The mobility of its articulations is slightly more marked because of the
change in character of the ribs articulating with it. This is demon-
strated best by causing the patient to bend in various directions with
the fixed point at the eighth dorsal.

The most common lesion is the anterior subluxation. Many of
these come from falls backwards against some object, striking at the
eighth dorsal. Extreme flexion may also cause a lesion. Torsion
is the most common condition of all the lesions of the eighth. The effect
is most marked on the side to which the vertebra is turned. Such le-
sions result from a twisting of the body while in extreme flexion or ex-
tension.

The effects vary with the degree, length of standing, cause, condi-
tion of patient and parts affected. The cutaneous sensory effect is man-
ifested by sensory disturbances along the eighth interspace, especially
in that portion of the abdomen supplied by the seventh and eighth dor-
sal nerves, and a portion of the integument in relation with and imme-
diately below the spines of the seventh and eighth dorsal vertebra;. The
usual effect is pain, although there may be anesthesia, coldness of part

APPLIED ANATOMY. 203

or perverted sensation such as formication. These sensory effects vary
with the kinds of lesions. If the lesion is an irritative one, pain will be
the result; if paralytic, anesthesia follows. Not all pains or other sen-
sory disturbances in those areas are due to a lesion of the eight dorsal.
A rib lesion of the same side will cause it. Irritative disease of the eighth
dorsal segment or of viscera supplied by it, will cause sensory disturb-
ances in the areas supplied by the eighth dorsal nerve. Hepatic colic,
intestinal indigestion, liver diseases such as abscess, and occasionally
gastric disturbances will cause pain to be referred to the integument
supplied by the eighth dorsal nerve. The explanation is that the im-
pulses set up by the diseased viscus are carried to the spinal cord (8 d.
segment) over the great splanchnic nerve, thence over the same nerve
tracts that carry impulses from the integument supplied with sensation
by nerve filaments that pass through this segment. The sensorium, in
such cases of referred pain, is mistaken, as to the real source, and ordinarily
refers the impulses to the areas of higher sensibility; or if both visceral
and cutaneous impulses travel over the same column or tract of the
spinal cord, the pain would also be referred to areas that had the greatest
sensory innervation. On this account, lesions of the articulations of the
eighth dorsal may produce sensory disorders that simulate the various
painful affections of viscera supplied by the eighth dorsal segment.

The direct cutaneous sensory effects are due to impingement on or
other disturbance of the common trunk of the eighth dorsal nerve or its
branches. The subluxated bone ordinarily produces direct pressure
on the nerve filaments as they pass through the foramen, at which place
they are in relation with the articular processes of the vertebra. If the
pressure is marked, there will anesthesia; if intermittent, pain or per-
version of sensation. In many cases, especially in mild ones, the pres-
sure is exerted indirectly on the nerve.

Certain structures supplied with sensation by nerves that pass
through the eighth dorsal segment, are affected by a lesion of the eighth
dorsal vertebra. These structures are the peritoneum, pleura, eighth
rib and periosteum, certain muscles, that is muscles supplied by the
eighth dorsal segment, esophagus, and the gall-bladder and ducts. The
explanation is that the sensory impulses, in part if not entirely, from
these structures must pass through the seventh and eighth interverte-
bral foramina which are changed in size by the lesion. Even though
the impulses safely reach the spinal cord, the columns of the cord that

204 APPLIED ANATOMY.

have to do with transmitting sensory impulses, may be affected by the
lesion and consequently there will be some sensory effect in parts sup-
plied. The kind of effect varies, as does any sensory effect, with the kind
and number of impulses and the condition of the cells receiving them.
In the above, pain or hyperesthesia is the rule, hence a lesion of the
eighth dorsal may and often does simulate peritonitis, muscular rheu-
matism and hepatic colic. The explanation of cause and effect is that
the above named structures are innervated in part by the eighth dorsal
segment which controls sensation to them through the eighth intercostal
nerve, posterior division of the eighth dorsal and the great splanchnic
nerve. In such cases it is the rule for the nerve to be congested or in-
flamed. Certain viscera manifest sensory disturbances when the eighth
dorsal vertebra is subluxated, viz., the liver, stomach, small intestines
and possibly the spleen and pancreas. They are affected because their
sensory nerves, that is the branches of the great splanchnic, are in rela-
tion with the eighth dorsal or rather, the filaments that cany impulses
to and from it are in relation and are always affected in typical lesions.
This disturbance in the viscera gives rise to colic, hence in such affect-
ions examine for a vertebral lesion.

The motor effects of a lesion of the eighth dorsal, are manifested in
the structures and viscera supplied by the seventh and eighth dorsal
segments. There may be increased or lessened motion, this depending
on the character and degree of the lesion. In acute cases, the muscles
are contractured; in chronic ones, the opposite condition is the more
common or else there are structural changes in the muscles from which they
become shortened and hardened. The muscles involved are the inter-
costals, levatores costarum, obliqui abdominales, recti and transversales
abdominales, erector, multifidus and rotatores spinsB and the diaphragm.

The intercostal muscles do not become contractured although they
may become quite tender from congestion. This makes respiration
painful, hence difficult. These muscles often atrophy as a result of
the lesion, in which case the respiration is carried on almost entirely
by means of the diaphragm.

The levator costa; muscle, if contractured, will draw up the angle of
the rib; if weakened, Mali permit the angle of the rib to descend. The
muscle will be affected one way or other if the lesion affects its nerve
supply or attachments.

The abdominal muscles are usually symmetrically affected, that is,

APPLIED ANATOMY. 205

there is either a general relaxation or contraction. If the lesion is irrita-
tive, the muscles contract, but if inhibitive, they relax. The condition
of these muscles is a good index to the condition of the viscera covered
by them. In chronic intestinal indigestion, they are usually contrac-
tured; in gastroptosis, enteroptosis and especially in chronic constipa-
tion, they are relaxed. Vertebral lesions are in most cases, responsible
for both the contiactured or relaxed condition and the visceral disorder.

The erector, multindus and rotatores spinae muscles are usually
contractured by a lesion of the eighth dorsal. In cases of malnutrition
they will be relaxed. Their contracture, especially that of the erector
and rotatores spina? muscles, lead to spinal curvatures. If only one side
is involved, a scoliosis with rotation. But on the other hand it must
not be forgotten that curvature comes most frequently from relaxation,
hence these apparently contractured muscles, pull the spine to the op-
posite or convex side.

The function of the diaphragm may be seriously interfered with by
a lesion of the eighth dorsal, because such a lesion often affects the eighth
intercostal which assists in the innervation of the diaphragm. Re-
spiratory disturbances, and the supposed "liver cough" follow.

These muscles named above are supplied by the anterior and posterior
divisions of the eighth dorsal nerve. This nerve is affected by lesions of
the eighth dorsal, because the foramen through which it passes is lessened
in size, or at least, either the seventh or eighth intervertebral foramen
is always affected by a lesion of the eighth dorsal vertebra. This le-
sion also affects the spinal cord, the eighth dorsal segment, especially
the cells that give rise to the filaments that form the nerves supplying
the muscles named above.

The motor and viscero-inliibitor nerves to the stomach are in part,
in relation with the eighth dorsal vertebra and are affected by a sub-
luxation of the vertebra. As a result of this impairment, the peristalsis
of the stomach is perverted. If excessive, ulcers are likely to form since
the stomach attempts to digest itself. There is a sense of hunger usuallv
described as a "gnawing" sensation. If the peristalsis is lessened, diges-
tion is retarded, and fermentation of the food follows. If reversed, vomit-
ing occurs. In ordinary cases of catarrh of the stomach, there is lessened
peristalsis. As to whether this is due to an inhibition of the motor or
stimulation of the inhibitor nerves, there seems to be considerable doubt.
The splanchnic nerve acts as a motor and viscero-inhibitor nerve, hence

206 APPLIED ANATOMY.

the lesion may affect either or both. The effects on the stomach are ex-
plained by the fact that the great splanchnic nerve, which after com-
municating with the vagus supplies the stomach, is disturbed by a le-
sion of the eighth dorsal vertebra. Nearly all the motor impulses pass-
ing over this nerve arise in the spinal cord, pass out over the ventral loot
into the common nerve thence over the white ramus into the gangliated
cord, thence over the efferent or splanchnic nerve to the semi-lunar
ganglion. This line of communication is often broken, or at least crippled,
by the lesion, hence the effect mentioned above.

The motor effect on the small intestines is similar to that on the
stomach, that is, there is increased, perverted or lessened peristalsis,
characterized by diarrhea or griping, vomiting and constipation. The
explanation offered in regard to the motor effects on the stomach will
apply to the small intestines.

A lesion *of the eighth dorsal will also have a motor effect on the
esophagus. Constriction with dysphagia is the common result. The
explanation is that the great splanchnic, sends filaments to the oesophagus
and this nerve is involved in subluxations of the eighth dorsal. Most
disturbances of the esophagus come from lesions affecting the fifth and
sixth roots of the great splanchnic, although a lesion of the eighth dor-
sal may affect it. This connection explains the correlation of forces
in vomiting.

Landois says: "The splanchnic nerve is the motor nerve of the
bile ducts and the gall bladder." Osteopathically, lesions involving
this nerve cause accumulation of bile and gall stones. Inhibition of this
nerve causes relaxation, hence dilatation of the bile ducts Hepatic
colic unless due to an attempted passage of a large calculus, is relieved in
this way, that is by applying pressure at the eighth, extreme extension
of the spine with fixed point at the eighth or by correcting the lesion at
the eighth.

The vaso-motor effect of a lesion of the eighth dorsal is quite marked
on account of the large area innervated and the importance of the blood-
vessels that are supplied by this part of the spinal and gangliated cords.
The abdominal blood-vessels as a whole, are more or less affected. The
vessels of the alimentary tract are innervated by the middle thoracic
area. The superficial blood-vessels in this part of the body are nearly
always involved and special mention should be made of the portal, renal
and splenic vessels. The blood-vessels innervated may be increased

APPLIED ANATOMY. 207

or decreased in size, this being determined by the character of the le-
sion. If it irritates, the blood-vessels will remain small so long as the
stimulation keeps up, but if the lesion inhibits the blood-vessels will
become larger. The first condition is followed by anemia, the second
by congestion. If the constriction is localized there will be no general
rise in blood pressure, but if general, the arterial tension or pressure is
increased.

Dilatation of the superficial arteries occurs in the erythematous
conditions, red neuralgia being a type. Dilatation of the portal vein
causes congestion of the liver, which condition is characterized by a
plethoric, bilious condition. There is a Irypersecretion of bile with ab-
sorption. Constriction of the vein has the opposite effect.

Dilatation of the renal veins is characterized by increase in secre-
tion of urine and later on, by organic disturbances. In interstitial neph-
ritis the opposite condition probably exists. The functions of the spleen
are likewise increased or decreased in a similar way. The abdominal
vessels are affected through the great splanchnic nerve. Landois says:
"Stimulation of the splanchnic nerve causes contraction; its division,
dilatation, of all of the intestinal blood-vessels possessing muscle fibers.
In the latter event enormous accumulation of blood takes place in the
intestinal vessels, so that anemia of other parts of the body results, and
in consequence even death may take place from anemia of the medulla
oblongata." The superficial blood-vessels are affected because their
vaso-motor impulses pass over the grey ramus from the gangliated cord
to the cerebro-spinal nerve, thence to the vessels by way of the inter-
costal nerve and posterior division of the nerve. The nerve tract is
broken or otherwise affected by a subluxation of the eighth dorsal, be-
cause it is in direct relation.

The portal vein is supplied directly by the great splanchnic nerve
which is the vaso-motor nerve to the liver. P'xperimentally, "division
or paralysis of the vaso-motor conducting paths from the center to the
liver, results in glycosuria." A lesion will have a similar effect, if it in-
hibits these impulses.

"The passage as rapidly as possible of large amounts of blood
through the liver acts most favorably upon the secretion." This is
controlled by nerves that are affected by lesions of the eighth dorsal
vertebra. If these nerves are affected, faulty secretion of bile follows,
hence jaundice or other changes.

208 APPLIED ANATOMY.

The renal vessels are affected by a lesion of the eighth dorsal, be-
cause it affects the great splanchnic nerve "which contains the vaso-
motor fibers for the kidney. " If the impulses are inhibited the vessels
dilate. If it is a localized condition, increased secretion of urine follows;
if the rest of the abdominal vaso-motor nerves are paralyzed at the same
time, "the secretion of urine diminishes even to the point of complete
cessation. " The splenic vessels are innervated by the splenic plexus
which ultimately receives its impulses from the great splanchnic nerve,
hence the explanation of effect of the lesion on it has been given above.

The secretory effects of a lesion of the eighth dorsal are manifest
in the amount and quality of sweat, urea, glycogen, gastric juice, succus
entericus, pancreatic juice and the secretions of the spleen. The secre-
tion of the peritoneum should also be considered in the secretory effects
of this lesion.

The amount of sweat secreted seems to depend on things other than
secretory nerves. Landois says: "As in the secretion of saliva, vascu-
lar nerves are principally active in the secretion of sweat in addition to
the true secretory nerves, and most frequently the dilators, as indicated
by the sweating when the skin is reddened." However, the sweat
fibers may be active even though there is anemia. The lesion produces
a disturbance of the sweat glands (1) by affecting the sweat center in
the spinal cord, and (2) by affecting the nerve tracts over which these
impulses travel from the spinal cord to their destination and (3), by
changing the amount and character of the blood supplying the sweat
glands. The center is affected through its blood supply, a venous con-
dition stimulating it to greater activity. The nerve tracts are in the
cerebro-spinal nerve and its branches. This nerve is always more or
less affected by a lesion of the vertebra in relation. The amount of bile
secreted may be increased or decreased as a result of the lesion of the
eighth dorsal. As in the production of sweat, the amount of blood must
be considered. Landois, in speaking of bile secretion, says: "All pro-
cedures that cause contraction of the arteries of the abdomen, such as
irritation of the valve of Vieussens, of the inferior cervical ganglion,
the hepatic nerves, the splanchnic nerve, the spinal cord, whether di-
rectly as by strychnin, or reflexly by irritation of the sensory nerves,
diminish the secretion. " Osteopathically, a lesion of the eighth dorsal
vertebra would have a similar effect because it would irritate the hepatic
nerves, splanchnic nerve and spinal cord, hence the secretory effect.

APPLIED ANATOMY. 209

He further says, "All procedures that produce stagnation of blood in
the hepatic vessels, such as division of the splanchnic nerves, diabetic
puncture, division of the cervical cord, have a like effect."

"Acceleration of the excretion of bile experimentally, follows stimu-
lation of the region of the spinal cord from which the motor nerves (the
splanchnic) are derived that supply the bile ducts and gall-bladder."
The glycogenic function also depends to a large degree, on the vascular
conditions, hence the explanations offered under the head of vaso-motor
effects of the lesion, will apply to the secretory effects on the liver, of a
lesion of the eighth dorsal.

The great splanchnic controls to a large degree the secretions of
the stomach and small intestines. Lesions of the middle thoracic ver-
tebras affect this nerve hence the disturbance in secretion. Catarrh is
the most common effect. Other causes such as thermic changes and
dietetic errors are important. The pancreatic juice is affected in quan-
tity by a lesion of the eighth dorsal, because the great splanchnic is af-
fected by it. Landois says in speaking of the secretion of the pancreatic
juice: "The nerves are derived from the hepatic, splenic and mesen-
teric plexuses, to which the pneumogastric and splanchnic nerves send
branches. The secretion of the gland is excited by stimulation of the
medulla oblongata, of the splenic nerve (feebly) and of the peripheral
stump of the pneumogastric." The pancreas is supposed to secrete a
ferment that destroys or counteracts the sugar in the blood, thus gtycosu-
ria would follow if this ferment were not secreted. This lesion may also
affect the secretion of urine but clinically, the lesion that affects urinary
secretion is lower in the spine and will be considered later.

Nearly, if not all nerves are supposed to exert trophic influences,
thus the trophic effects of a lesion of the eighth dorsal, would be determin-
ed by the nerves involved and the areas innervated. The effect may be
a general one on account of effect on the liver, stomach and pancreas,
but is usually localized in a group of muscles. Some forms of skin
diseases characterized by desquamation, are due to an interference with
the trophic nerve supplying that portion of the integument.

A lesion of the eighth dorsal, affects the spinal column and often is
the starting place of a spinal curvature. As stated above, some of the
spinal muscles are weakened and the opposing muscles draw the spine
toward the sound side. The contour of the ribs is also changed since
they articulate with the vertebrae.

210

APPLIED ANATOMY.

R0TAT0RES SPIN*
SEMISPINALS DOR SI

INTERTRANSVERSAJJ

INTERSPINALS

INTEGUMENT CTMER SPINE OF 8lhT.
MULTIFIDUS 6WNA1
ERECTOR SPINA

LEV. COSTA RUM

PLEXUSES ETC.

S SOLAR C. CELIAC A. AORTIC

W H.HEPATItTO LIVER GALL-BLDR.STOMACH DUODENUM PANCREAS

fe °k G. GASTRIC TO STOMACH ANO ESOPHAGUS E-ESOPHAGIAL

~%% *%* SpSPLENICTO SPLEEN PANCREAS ANO STOMACH
I.M?4

0. DIAPHRAGMATIC TO DIAPHRAGM VENA CAVA R.SIDE ESOPHAGUS L SIDE/

S.M.-SURMESENTERICTO SM.INTESTINES.CfcCUM. APPENDIX, A5C'AWDTRANS.C0L0N^

|,M." INF. MESENTERIC TO DESC. ILIAC ANO PELVIC COLON AND UPPER RECTUM.

Spr.SPERMATIC TO SPERMATIC CORD TESTICLE IN FEMALE THE OVARIAN
TO OVARY BROAD LIGAMENTAND FALLOPIAN TUBE

S.R; SUPRARENALTO SUP CAPSULE R RENALTO KIDNEY

GR. S ANOSM.S. SPLANCHNICS

S.& SEMILUNAR GANGLION

Fig. 52. — Showing the eighth thoracic segment of the spinal cord with its nerves
and their distribution.

APPLIED ANATOMY. 211

The effect on the spinal cord depends on (1) pressure on the blood-
vessels supplying and draining it; (2) pressure on the nerve roots, par-
ticularly the posterior, and (3), pressure directly on the spinal cord.
The first comes as a result of a lessening in size of the intervertebral
foramina, thus directly obstructing the vessels that pass through. The
corresponding segment is affected most, since the blood-vessels pass up
the sheath of dura mater that encloses the corresponding nerves. Pres-
sure on the posterior nerve roots causes ascending degeneration, loco-
motor ataxia possibly being the best illustration of the effects. The
ganglion is most subject to pressure on account of its location. Pressure
on the cord causes transverse myelitis with partial, if not complete par-
alysis of the body below the level of pressure.

Summary. The eighth dorsal is the clinical center for splenic dis-
eases, pancreatic disturbances, gall-stones and intestinal indigestion
that is, lesions of it most constantly produce these effects. Biliary and
intestinal colic, can ordinarily be relieved by inhibition at this point,
the treatment being most effectual if the spine is extended as far as pos-
sible with pressure at this point, that is at the eighth dorsal spine. This
movement lessens the size of the foramina through which the afferent
impulses pass. Backache is common in this region in lesions of the
articulations of the eighth and in kidney, ovarian and intestinal dis-
orders. The prolonged contracture of the spinal muscles in the above
conditions gives rise to backache or in acute cases, to lumbago.

THE NINTH THORACIC.

The ninth thoracic vertebra is slightly larger than the eighth dorsal,
the spine is not as oblique or so hooked. It is classed with the peculiar
vertebrae because it has no demi-facets for articulation with the ribs.
The mobility of its articulations is greater than that of the eighth dorsal,
because of change in character of the ribs. The intervertebral foramina
are formed like those above, by the articular processes and are subject
to change in size by subluxations of the vertebra. The most common
subluxations are torsions and anterior ones. Slight separations such as
"breaks" often occur at one of its articulations, that is between the
eighth and ninth dorsal or between the ninth and tenth dorsal. Such le-
sions ordinarily come from hyperflexion of the spine, especially if force
is exerted while in the stooped position. The lifting of a heavy weight
is often responsible for the separation. The torsion results from an un-

212 APPLIED ANATOMY.

expected twist or turn of the spine. It may at first be diagnosed as
a "crick in the back."

The anterior subluxation is the most important from a pathological
standpoint because of the effect on the foramina, it lessening their
size and compressing the structures that pass through them. In all
acute or recent cases, the ligaments are either stretched or torn in
every pathological case. If torn, they heal slowly and often are
markedly thickened. After a while they contract and approximate the
vertebrae, thus producing a smooth or stiff spine. In most cases they
remain tender and softened, thus indicating by these conditions the
affected vertebra. A separation'or break is not so important as an ap-
proximation. On testing the mobility of the spine, note that it is
greatest at the widened area and lessened or entirely lost at the points
of approximation. As a rule, a separation needs little or no treatment.

All subluxations of the ninth dorsal affect the tissues attached to it.
Some are stretched and irritated, others are relaxed and inhibited. The
connective tissue is affected and the circulation through it obstructed.
The muscles are irritated and soon a contractured condition results.
The muscles then begin to ache or act with difficulty. If the patient
were to assume a stooped posture for a few minutes, it would be difficult
to straighten the spine, the patient complaining of stiffness and an achy
feeling. The principal muscles involved are the erector and multifidus
spinas.

The arteries affected by a subluxation, are the ninth intercostal and
its spinal and muscular branches, the abdominal aorta and its branches
that supply the liver, spleen, stomach, small intestines, pancreas, supra-
renal capsule, ovary and testicle and the kidney.

The intercostal and its branches are affected directly by pressure
either by the displaced vertebra, or by traction on, or contraction of, the
tissues through which the vessels pass. The abdominal aorta and its
branches are affected through their nerve supply, that is, by disturbance
of the splanchnic nerves which cany vaso-motor impulses to these ves-
sels. Direct pressure on an artery lessens the flow of blood through it
by obstructing the lumen. Anastomosis will take place if the arteries
are not of the terminal variety. When its nerve supply is disturbed,
the artery usually becomes larger, hence the rapidity of the flow of blood
is lessened and congestion results. It may become smaller if the lesion
is an irritative one, which is occasionally the condition, especially in
recent cases,

APPLIED ANATOMY. 213

The veins in relation are affected by direct pressure. The veins
correspond to the arteries. The inferior vena cava and its branches
draining, by way of the portal system, the principal abdominal viscera,
are affected through their nerve supply. The most common effect
on the vein is dilatation, this producing congestion. In the case of the
portal vein, congestion of the abdominal viscera results with its disturb-
ances of function.

The nerves affected by this lesion are (1) cerebro-spinal and (2)
sympathetic. The cerebro-spinal affected are the ninth thoracic and
its branches, the ninth intercostal and the posterior division. The sym-
pathetic nerves affected are the gangliated cord, the ninth thoracic gang-
lion and its branches, the great and lesser splanchnic, the rami and the
branches that supply the ligaments, vertebrae, meninges and spinal cord.
Those affected secondarily are the solar plexus and its branches, the
semi-lunar ganglia, and the aortic and renal plexuses with their branches.

The impulses that are carried by these nerves pass through the in-
tervertebral foramina in relation with the ninth dorsal vertebra. At
least two of these foramina are lessened in size by any form of lesion of
the ninth dorsal, therefore the impulses would be impaired. The nerve
cells giving rise to these impulses are nourished and drained by blood that
passes through these foramina, hence a disturbance of these cells in cases
in which the foramina are lessened in size.

The principal abdominal, and some of the pelvic viscera are more
or less disturbed by a lesion of the ninth dorsal. The viscus most fre-
quently and constantly affected is the kidney. This is explained by the
fact that it gets most of its nerve impulses from the ninth dorsal
segment, while the liver, stomach, etc., are innervated mostly by seg-
ments higher in the cord. The kidney is affected then because the le-
sion interrupts the passing of nerve impulses from the spinal cord to it.
These impulses are usually carried by the lesser splanchnic although the
great splanchnic carries some. There is a direct line of communication
between the cord and the kidney although separate names are given to
the different parts of it. The impulses arising in the grey matter of the
ninth dorsal segment, pass over the ventral root, common nerve trunk,
anterior division, white ramus, ninth dorsal ganglion, lesser splanchnic
thence into the aortico-renal ganglion. Sometimes the lesser splanch-
nic furnishes a direct twig to the renal plexus. Pressure at any point
on this line,will disturb the power the nerve has of transmitting impulses,

214

APPLIED ANATOMY.

INTEG. OVER SPINES 9th AND lOfh."

INTERVERTEBRAL DISG

ROTATOR ES

VERT. LI GTS
AND

MENINGES

SEMISPINALS OORSI

ERECTOR SPIN*

Fig. 53. — Showing the ninth thoracic segment of the spinal cord with its^nerves
and their distribution.

AI'1'LIED ANATOMY. 215

hence disturbance of function of the part innervated. In a similar way,
the kidney may be affected by this lesion interfering with the innerva-
tion of its blood-vessels. This nerve supply controls secretion, nutri-
tion, sensation and vaso-motor impulses sent to the blood-vessels of the
kidney. If the lesion is irritative, there will be increased secretion, if the
secretory nerve is involved, pain referred to the kidney or side, and anemia,
if the case is an acute and recent one. Secretion and excretion of urine
seem to depend partly on the secretory nerve, blood pressure, and the
quality and quantity of blood. If the lesion is paralytic, there will be at
first a moderate increase in the amount of urine for a few hours, finally
the action of the kidney becomes entirely suspended and an organic dis-
ease follows.

The suprarenal capsules are affected by a lesion of the ninth dorsal,
because their nerve and blood supply are affected by the lesion. The
nerve impulses that pass to this organ, at least a majority of them, pass
over the lower roots of the splanchnic nerves. These nerves or their
roots, are affected by the lesion. The blood-vessels supplying the supra-
renal capsule are innervated by the solar, phrenic and renal plexuses
which receive most of their impulses from the splanchnic nerves. The
lesion may indirectly cause disease of these organs by causing disease of
other organs, such as the kidney. As to the effect on the body of a lesion
impairing these capsules, little is known. They have to do with the
elaboration of the blood, there being an internal secretion.

The ureter is, or may be affected by a lesion of the ninth dorsal, be-
cause its nerve supply is disturbed. The nerves, motor, sensory and
and vaso-motor, that supply the ureter are derived from the renal plexus
which in turn is formed by the splanchnic nerves. The ninth dorsal
segment contains nerve cells that give rise to filaments that pass directly
to the ureter supplying it with motor, vaso-motor and trophic impulses.
The efferent impulses pass out of the cord over the ventral root, thence
through the intervertebral foramen over the common trunk, then to the
ureter by way of the white ramus, gangliated cord, lesser splanchnic and
renal plexus. The effects will be considered with the study of the tenth
dorsal segment.

The spleen is affected by a lesion of the ninth dorsal because the
ninth segment sends nerve filaments to it. The principal effect of a
lesion involving this nerve seems to be a vaso-motor one. In diseases
characterized by splenic trouble, the lesion often is as low as the ninth

216 APPLIED ANATOMY.

dorsal, although the predominating- spinal center seems to be higher up
in the spinal cord. Schsefer and Moore say that in the dog they found
motor nerves to be present in the third thoracic to the first lumbar in-
clusive. *"The most marked effect was obtained on stimulating the
sixth and eighth dorsal nerves; a very distinct contraction on stimulating
the fifth, ninth and tenth nerves; a slight contraction on stimulating the
third, fourth, eleventh, twelfth and thirteenth thoracic and the first
lumbar nerve." Clinically, it can be proven that a lesion will stimulate
a nerve. A lesion of the ninth dorsal will stimulate the nerves to the
spleen or it may inhibit them, and in most splenic disorders the ninth
dorsal is involved.

The testes and ovaries are involved through their innervation.
This comes almost entirely through the renal plexus and lesser splanch-
nic nerve.

A lesion of the ninth dorsal will interfere with the passing of im-
pulses from the spinal cord to the testicle or ovary since it lessens the
size of the intervertebral foramen. The effects will be considered with
the tenth dorsal segment.

The small intestines are nearly always involved by a lesion of the
ninth dorsal, on account of disturbance of the innervation. Indigestion
is a common effect. This results from the interference with the sensory,
secretory, vaso-motor and motor impulses. Constipation results in
some cases, on account of interference with the peristalsis of the bowel,
it being lessened. Diarrhea, even enteritis, follows if the lesion is an
irritative one. Intussusception may occur.

The liver may be involved by a lesion so low, since its blood supply
is impaired by such a lesion. Also the stomach is sometimes affected
but in such cases the small intestines are also involved, that is, a group
of lesions is present, extending from the fifth to the eleventh dorsal.
The pyloric end of the stomach is said to be most frequently affected
by the lesion.

The principal effect of this lesion (the ninth) is on the vaso-motor
nerves innervating the above named viscera. That the viscus is con-
gested or made anemic by the lesion, needs no proof since it has been so
frequently demonstrated. As to the explanation, it must be through
the vaso-motor nerves or else the congestion would be constant. The
lesion alone is usually not sufficient to produce the vascular effects as
*Note. — Schssfer's Text-book of Phj'siology, p. 643, Vol. II.

APPLIED ANATOMY. 217

we find them. The lesion only weakens, then the error in diet, the ex-
posure during the menstrual period or the overwork or any exciting
cause, will then bring on the attack. It does not necessarily follow that
the lesion produces a pathological congestion or anemia of the viscera
that is constant, because the symptoms are irregular; or that there are
no lesions present during the interval between the attacks, because there
are no apparent indications of them. This applies particularly to ovarian
disorders and sick headaches. As stated above, the lesion plus the ex-
citing cause will invariably bring on an attack, whereas if only one cause
were present, it would take quite a while for the vitality to become so
impaired that an attack would occur, as in the case of a sick headache.

The diseases most commonly associated with a lesion of the ninth
dorsal are Blight's disease, ovarian disease, diabetes mellitus and in-
sipidus, renal colic and in many cases, biliary calculi. The explanation
is that the ninth dorsal segment contains the centers for the above named
viscera and connects with them by a series of nerve strands.

In all cases of megrim, chronic ovarian colic, imperfect secretion
and lessened elimination of urine, and in cases in which there is a pasty,
muddy complexion, it is well to carefully examine the ninth thoracic
vertebra. Usually there is an anterior condition or a marked separa-
tion of the spinous processes of the ninth and tenth. In patients suffer-
ing from a cystic degeneration of the ovaries, invariably lesions were
found in this region in the cases that have come under the writer's ob-
servation.

The lesion either affects the nerve centers in the spinal cord by com-
pressing the spinal vessels, or else it breaks the line of communication
between the spinal segment and the viscus. The effects on the spinal
cord and spinal column are similar to those of lesions of other thoracic
vertebrae.

THE TEXTH THORACIC.

The tenth dorsal vertebra is classed with the peculiar vertebras be-
cause it has an entire costal facet at its upper border and no lower demi-
facet. It approaches the lumbar type of vertebrae in that all the facets
are larger and the spinous process shorter and more nearly horizontal.
The movements of its articulations are more marked than those above,
possibly on account of the character of the ribs articulating with it. Its
lesions are similar to those above and result from similar causes. The
anterior and twisted conditions are most common. The lesion causes

218 APPLIED ANATOMY.

many and varied symptoms. It may have a sensory, motor, vaso-motor,
secretory or trophic effect on viscera. It may cause pressure on adja-
cent structures such as the connective tissue or spinal cord.

A lesion of the tenth dorsal will produce a sensory disturbance in
the small intestines. This disturbance may be hyperesthesia, pares-
thesia or anesthesia. Hyperesthesia occurs in enteritis and colicky con-
ditions which ordinarily come from congestion of the intestinal mucus
membrane. This hyperesthesia is conducive to increased secretion and
excessive peristalsis, hence in typical cases, diarrhea, as in typhoid fever.
The seat of the irritation may be in the mucous membrane but in many
cases the cause lies in the spinal cord, the nerve roots and trunks, or in the
spinal column. The gastric crisis is a well known effect of locomotor
ataxia. The intestinal colic of a baby is another example of effect on
intestines of a lesion in the spinal cord.

The thermic influences cause contracture of the spinal muscles,
which in turn affect the spinal cord and its nerves, especially the nerves
to the stomach and small intestines. The colic is not entirely due to the
stimulation of the sensory nerves by the lesion, whether bony or muscu-
lar, but in part is due to the peristaltic cramping of the bowel. The ex-
planation of the cause (a lesion of the tenth dorsal) and effect (pain in
small intestines) lies either in the fact that the sensory impulses from
the small intestines pass over the superior mesenteric plexus, the lower
part of the solar plexus which receives the lesser splanchnic nerve, the
white ramus, tenth thoracic nerve, posterior root, thence by way of the
spinal cord to the medulla and sensorium, or in the fact, that the motor
innervation of the intestine is by the same route and that the filaments
are also in relation with the foramina of the tenth. Since both kinds of
impulses pass through these foramina, any lesion of the tenth thoracic,
will thus interfere, in some way, with these nerve filaments and conse-
quently, sensory disturbances follow.

A lesion of the vertebra may irritate the sensory nerves in relation
thus setting up impulses that would be referred to the small intestine or
tenth dorsal nerve, their supposed source. Inhibition at the tenth
dorsal, may stop the passing of impulses to the sensorium, hence relief
would follow. Extreme extension of the spine with fulcrum or fixed
point at the eleventh dorsal, is the best way in which to apply this treat-
ment. The subluxated vertebra may interfere with a part of the im-
pulses, hence a perverted sensation. Again, this lesion may entirely

Al'PLIED ANATOMY.

219

EG. OVER SPINES OF ICKTi

INTERVERTEBRAL DISC
ROTATORES

SEMISPINALS OORSl

ERECTOR SPINA!

Fig. 54. — Showing the tenth thoracic segment of the spinal cord with its
nerves and their distribution.

220 APPLIED ANATOMY.

cut off the sensory line of communication, hence sensory paralysis of
the small intestines. Peristalsis of the small intestines, depends to a
very marked extent on normal activity of the sensory nerves supplying
them. Normally the presence of food in the small intestine stimulates
the sensory nerves, thereby setting up impulses that are carried to the
spinal cord which, in turn, transfers them to the efferent nerves, thereby
causing peristalsis of the small intestine, in other words it is a reflex
process. A lesion of the tenth dorsal will interfere with this process,
hence lessened peristalsis. From this comes indigestion and constipa-
tion.

According to Head, the liver and gall-bladder are supplied with sen-
sation, in part, by the tenth dorsal nerve. The explanation is that the
lesser splanchnic nerve carries impulses to and from the ceeliac plexus
which innervates the liver and gall-bladder by way of the hepatic, which
is a branch or division of the celiac. The effects of such a disturbance
have been considered above.

Pain in the kidney may result from a lesion of the tenth dorsal, since
the lesser splanchnic nerve, which conveys the sensory impulses from
it, is involved by a subluxation of this vertebra. An irritation of this
nerve then, would produce pain that would be referred to the kidney.
Pain in the ureter also comes from this lesion and is explained in a sim-
ilar way. Such pain is called renal colic and most frequently comes
from the passing of gravel. In some cases it comes from a lesion of the
lower thoracic vertebra? and the effect is often quite marked, in fact I
have seen cases in which the pain from such a lesion was as marked as
from the passing of an ordinary calculus. Inhibition at the tenth dor-
sal in such cases, will cause dilatation of the ureter because it lessens the
pain, hence lessens the reflex muscular contractions, or else the inhibition
directly lessens the amount of motor impulses passing to the ureter.
Inhibition at this point breaks the circuit or stops or lessens the number
and intensity of the sensory impulses, hence the sensorium is not aware
of the real condition.

According to Head, the tenth dorsal nerve contains sensory fibers
for the prostate gland. Clinically, this seems to be the exception, the
sensory centers being lower in the spinal cord. Accepting the statement
as being true, the possible route would be the lesser splanchnics, sper-
matic plexus and prostatic plexus.

The testicle is supplied with sensation in part by the tenth dorsal

APPLIED ANATOMY. 221

nerve, that is nerve filaments having their origin in the cells of the
tenth dorsal ganglion pass directly to the testicle by way of the lesser
splanchnic, renal plexus and spermatic plexus which are afferent as well
as efferent in function. If these nerves are stimulated by the lesion,
pain will be referred to the testicle. In pain or aching of the testicle, in-
hibition at the tenth dorsal may relieve since the impulses pass by way
of the tenth thoracic segment on their way to the sensorium. Anes-
thesia or a loss of sensibility is more common and follows a paralytic
lesion of the tenth dorsal, that is one that entirely obstructs the passing
of sensory impulses beyond the point of obstruction.

In the female the analagous organ, the ovary, is affected in a similar
way. It is not uncommon for a lesion of the lower dorsal vertebra
to produce ovarian colic. Contractures of muscles in relation with the
tenth dorsal will also produce the ovarian cramp. The explanation is
that the lesion affects, that is irritates the sensory nerves leading from
the ovary to the spinal cord, that is the lesser splanchnic, which contains
these sensory filaments. The point of irritation is usually in the com-
mon nerve trunk which is in relation with the intervertebral foramen.

The fundus of the uterus is also supplied with sensation by the
ovarian plexus, hence some sensory disturbance would follow injury to
this plexus. If the nerves were irritated by the lesion, there would be
pain in the fundus which would be fairly constant but made worse by in-
creased peristalsis. The effects of this disturbance would be painful
menstruation. If the sensory impulses were inhibited, difficult menstrua-
tion and parturition would follow since each is a reflex process. These
will be discussed later on.

The pancreas would be involved through its sensory nerve supply,
this probably coming from the cceliac plexus. Deaver says that the
lesser splanchnic goes directly to this plexus, hence the explanation of
the sensory effects, is made easy.

A lesion of the tenth dorsal will produce a cutaneous sensory effect
in the integument supplied by the tenth dorsal nerve through its anterior
and posterior divisions. There may be hyperesthesia, perversion of
sensation or anesthesia. In most cases the pain from this lesion is re-
ferred to a point external to and below the umbilicus. Disturbances
of the viscera and structures innervated by the tenth dorsal segment,
are often characterized by pain in the tenth intercostal nerve. This is
especially true of intestinal, kidney, ureter, ovarian and some uterine
diseases.

222 APPLIED ANATOMY.

The peritoneum in relation with the tenth nerve, the tenth rib and
its periosteum, the fascia and muscles in relation, are supplied with sen-
sation by the tenth dorsal ganglion, consequently would be affected in
some way by the lesion. Backache in this region is the result of con-
tracture of the muscles in relation, this producing irritation of the sen
sory nerve supplying the muscles.

A lesion of the tenth dorsal vertebra will produce a motor effect in
the viscera and organs mentioned under the above head since nearly if
not all nerves are mixed nerves. A lesion affecting one part of the nerve
will in all likelihood, affect other parts; that is, if the sensory filaments are
involved, the motor filaments will also be affected. The peristalsis of the
small intestines may be lessened or increased by a lesion of the tenth
dorsal since it may inhibit or stimulate the motor supply. The gall-
bladder and bile ducts are affected by this lesion, but possibly not so
readily as by a lesion a little higher in the cord, The ureter is also af-
fected through its motor supply, there being a disturbance of peristalsis.
In a similar way the motor supply of the testes and ovaries, prostate
gland and uterus may be altered in some way by the lesion since the
impulses pass over the lesser splanchnic, which nerve is nearly always
affected by an ordinary lesion. The spleen is similarly involved, that
is, its movements or rhythm are interfered with by the lesion.

The muscles innervated by the tenth dorsal segment are affected by
a lesion of the articulations of the tenth dorsal vertebra. The effect on
the muscles may be one of relaxation or contracture. If the lesion is
an irritative one, contracture will follow, if paralytic, relaxation will
result. The muscles involved directly by a lesion of the tenth dorsal are
the intercostales, levatores costarum, serratus posticus inferior, obliqui,
transversales and recti abdominales, erector, multifidus and rotatores
spins and the diaphragm. The effects of relaxation and contracture of
these muscles have been considered above.

A lesion of the tenth dorsal will produce a vaso-motor effect on ves-
sels innervated by the nerves that are in relation with the vertebra.
The blood-vessels involved are the tenth intercostal and its branches,
renal, ovarian, and spermatic, celiac axis with its branches, the splenic,
gastric and hepatic, superior mesenteric and the vena azygi veins. The
effect is either one of constriction or of dilatation. In most instances
dilatation takes place, or at least is the chronic effect of the lesion, on the
vessel. If the intercostal vessels are dilated, the circulation through the

APPLIED ANATOMY. 223

muscles of the back, abdominal wall, parietal layer of the peritoneum
and, most important of all, the circulation of the tenth dorsal segment
is impaired. The last leads to passive congestion of the cord with mal-
nutrition of the nerve cells of this segment. As a result, it is possible
for every nerve derived from this segment to become diseased. The ef-
fect on the visceral nerves seems to be most marked in those that sup-
ply the small intestine and ovary.

In cases of disturbances of activity of the ovary, kidney and small
intestine, the trouble may be in the spinal center, its nutrition being in-
volved by the lesion causing dilatation of the blood-vessels. Conges-
tion of the spinal cord, if passive, in such cases, tends to lessen activity
of the nerve cells in the segment involved.

The renal vessels are involved because the lesser splanchnic nerve
is affected by the lesion, and this nerve carries vaso-motor impulses to
the vessels of the kidney. Inhibition will at first produce an increased
secretion of urine on account of the congestion, but later on lessened secre-
tion results. Stimulation of the vaso-motor nerve will lessen the size of
the renal vessels hence will lessen secretion. Most diseases of the kidney
are of vaso-motor origin, that is the vessels are dilated and the circula-
tion lessened in rapidity, hence a lowering of the vitality of the blood and
of the part, in proportion to the degree of dilatation of the vessels and
slowing of the blood-stream.

The ovarian blood-vessels are very often affected by a lesion of the
tenth dorsal. If the vaso-motor impulses are inhibited, congestion of
the ovary follows. Congestion of the ovary is attended by dysmenor-
rhea, disturbed ovulation, pain in the iliac fossa on the same side, back-
ache, sense of weight, and finally leads to inflammation. Mammary dis-
orders, as well as disturbances of the sexual function, follow or ac-
company the congestion. A constriction of the ovarian blood-vessels
causes anemia of the ovary which, if kept up for any great length of time,
causes atrophy with softening. The infantile ovary results most fre-
quently from an injury to the spine from the ninth to the twelfth dorsal,
which affects the ovary through the vaso-motor nerves; that is, the devel-
opment is arrested or else the nourishment is disturbed. The lesion of
the tenth dorsal, produces these effects by producing pressure, either on
the filaments that go to form the lesser splanchnic nerve, or on the
blood-vessels that nourish the tenth dorsal segment.

In the male analogous conditions may arise; that is congestion and

224 APPLIED ANATOMY.

anemia of the testicle. The most common and important effect on the
testicle is varicocele. In this disease the vaso-motor nerves are inhi-
bited by the lesion, and as a result, the spermatic veins dilate. If this
condition remains for a while it is called varicocele. There are other
causes of dilatation of these veins which are important and classed as
exciting ones and probably the most potent cause of all is repeated, un-
gratified sexual desire.

The superior mesenteric vessels are quite frequently affected by a
lesion of the tenth dorsal, judging from the effects in the parts supplied
by this artery in cases in which there is present this lesion. If the le-
sion inhibits the nerves to these blood-vessels, congestion takes place
with altered and increased secretion. Catarrh of the intestine is a com-
mon type. Intestinal indigestion is a sequel. Typhoid fever is another
disease which has for a predisposing cause congestion of the intestine,
from lesions inhibiting the vaso-motor as well as other nerves supplying
the bowel. If the lesion stimulates the vaso-motor nerves, anemia of
the bowel results but this is only a temporary effect since prolonged stim-
ulation leads to inhibition. In anemia, the secretions are lessened and
peristalsis impaired.

The pancreatic blood-vessels are affected in a similar way; that is,
they are dilated when the lesion inhibits, and lessened in size when the
lesion is irritative. Dilatation causes increased secretion at least for
a while; after it becomes chronic, the quality of the blood may be so im-
paired that secretion is altered or lessened.

The splenic, hepatic and gastric vessels may be affected since the
lesser splanchnic nerve passes into the celiac plexus and this plexus
supplies the above named vessels. The lesser splanchnic as stated
above, is affected by the lesion of the tenth dorsal, and this nerve conveys
vaso-motor impulses to the celiac plexus.

The azygi veins are supplied in this region by branches from the
solar plexus. The lesser splanchnic nerves in all probability, carry im-
pulses to the parts of the veins in relation with this segment.

A lesion of the tenth dorsal will have a secretory effect on organs
that secrete and are supplied by the lesser splanchnic nerve. The most
important organs affected are the small intestines, testes, ovaries, kid-
neys, pancreas, supra-renal capsules and probably the liver, spleen and
stomach. Secretion does not depend entirely on the vaso-motor nerves
but in part (I do not know how much) on the so-called secretory

APPLIED ANATOMY. 225

nerves. Stimulation of these secretory nerves increases the amount of
secretion; inhibition lessens it. The lesser splanchnic is supposed to
have in it secretory filaments. Lesions stimulate or inhibit.

A lesion of the tenth dorsal may stimulate or inhibit tht; tenth dor-
sal nerve. The tenth dorsal nerve supplies the integument in relation
with secretory impulses to the sweat and sebaceous glands, hence disturb-
ance of these glands in lesions of the tenth dorsal.

All nerves are more or less trophic in character. A lesion of the
tenth dorsal will produce trophic effects in parts supplied by the nerves
having their origin in the tenth dorsal segment. The effect is most
marked in the muscles of the back. At first marked contracture
takes place; later on, atrophy, as is evidenced by the widening of- the
median furrow of the spine.

The adjacent tissues and structures are also affected by the lesion.
We would mention in particular the spinal ligaments, fascia and spinal
cord. The effect may come from traction or pressure on the tissues in
relation. The effect varies with tissues involved and the amount of
traction or pressure. Pressure on the spinal cord produces myelitis.

Summary. A lesion of the tenth dorsal will affect the lesser splanch-
nic and the tenth dorsal nerves. The splanchnic conveys sensory,
motor, vaso-motor, secretory and trophic impulses to the kidney, ureter,
ovaries and testes, fundus of uterus and prostate gland, stomach, liver,
spleen and pancreas. The cerebro-spinal nerves supply the integument,
muscles and fascia. Almost any disease of the above mentioned parts,
follows a lesion of the articulations of the tenth, since the lesion interferes
with the nerves, blood-vessels, spinal cord and all tissues in relation.

THE ELEVENTH THORACIC.

The eleventh dorsal vertebra is also classed as one of the peculiar
vertebrae. Morris says: "The eleventh has a large body resembling
a lumbar vertebra. The rib facets are on the pedicles and they are
complete and of large size The transverse processes are short, show
evidence of becoming broken up into three parts, and have no facets for
the tubercles of the eleventh pair of ribs. In many mammals the spines
of the anterior vertebras are directed backward and those of the pos-
terior directed forward, while in the center of the column there is one
spine vertical. The latter is called the anti-clinial vertebra and indi-
cates the point at which the thoracic begin to assume the character of

226 APPLIED ANATOMY.

lumbar vertebrae. In man the eleventh thoracic is the anti-clinal ver-
tebra. "

The mobility of its articulations is quite marked since the ribs do
not articulate with the transverse processes. The intervertebral discs
are thicker and possibly more elastic, judging from the increased mo-
bility. The vertebra is often subluxated, due, I believe, to its position,
it being located at the junction of a movable portion, the lumbar verte-
bras, with a comparatively immovable portion, the thoracic vertebras.
It is subject to lesions similar in degree and character to those mentioned
above, the approximation or separation being very common, if not the
most frequent. If this vertebra alone is involved, the subluxation most
frequent is an anterior rotation of the vertebra, affecting the articula-
tions above and below.

The integument supplied by the eleventh dorsal nerve is affected
by a lesion.of the eleventh dorsal, because of impairment of the nerve
supply. This nerve is supposed to carry sweat impulses to the integu-
ment of the eleventh interspace and to that in the lower thoracic and
upper lumbar regions. Stimulation of the nerve usually increases the
amount of sweat since its secretion is determined by secretory rather
than vaso-motor nerves. Localized sweating in the lower thoracic
region is not uncommon and is suggestive of a nervous condition or
bowel disorder such as constipation. Lessened secretion of sweat re-
sults if the sweat centers are made less active by the lesion or if the
eleventh thoracic is inhibited, thereby impairing the passing of secre-
tory impulses to the skin. This condition is spoken of by Landois who
says: "It has been observed in circumscribed areas of the skin as one
of the phenomena of certain tropho-neuroses as, for instance, unilateral
atrophy of the face, and in paralyzed parts. In some of these cases
there may be paralysis of the nerves in question or of their spinal centers. "

The trophic condition of the skin is controlled to a great extent, by
nerves called the trophic nerves. In case of the spinal nerves the trophic
nerve is only a part of it, not a separate distinct nerve trunk, but com-
posed of filaments enclosed in a common sheath. Church says: "The
significance of abnormal variations in the nutritional conditions of a
part is at once apparent when it is recalled that the growth and nourish-
ment of all the structures of the body are presided over by trophic cen-
ters acting through peripheral nerves."

For the proper nutrition of skin, muscle, nerve and bone, the integ-
rity of the trophic center, of its peripheral nerves, and their terminals,

APPLIED ANATOMY.

227

is essential. In other words, the anterior spinal cell and its polar pro-
longation in the efferent nerve, the lower neuron, can not be injured
or destroyed without correspondingly impairing the function of nutri-
tion in its area of distribution. Lesions of the vertebra affect both the
trophic center and its peripheral path, thus dystrophies of the skin fol-

Fig. 55. — Showing an anterior condition of the 10th and 11th thoracic verte-
brae, b; c. muscular contracture The patient had some kidney disorder. (From
photo).

low. These lesions affect the trophic center through its nutrition and
the peripheral path by pressure on the nerve, usually at its exit from
the spinal canal.

A lesion of the eleventh dorsal will affect a localized portion of the

228 APPLIED ANATOMY.

skin principally on account of effect on the peripheral tract, the eleventh
thoracic nerve and its branches. These trophic disturbances are char-
acterized by a thickened, dry, scaly epidermis and in some cases a glossy
condition. In other cases, pimples or even boils develop. The lesion
may so affect the superficial nerves that an inflammation or neuritis
may develop, herpes zoster being an example. In milder cases the le-
sion produces a superficial or cutaneous tenderness. In many of these
cases there are no inflammatory indications but the slightest touch
produces intense pain. In such cases the lesion affects the spinal cord,
its meninges, or in some cases, the trunk of the spinal nerve. In other
cases the lesion affects the viscera supplied by the eleventh dorsal seg-
ment, and if irritative, the pain is referred to the cerebro-spinal nerves
and is felt in the integument of superficial tissues. Inflammatory dis-
turbances of the ovary, small intestine, vermiform appendix, ureter,
cecum and 'the peritoneum in relation with these structures, will cause
pain to be referred to the areas innervated by the eleventh thoracic
spinal nerves.

The muscles of the back and abdomen, the intercostals and the dia-
phragm will be affected by a lesion of the eleventh dorsal. In the case
of the spinal and abdominal muscles, they will be. contractured or re-
laxed; contractured if the lesion is irritative, relaxed if inhibitory. The
intercostal muscles also, in all likelihood, become contractured but they
are so flat and short that the condition can not be readily detected.
Contractured conditions of the spinal muscles produce (1) backache,
(2) vascular disturbances of the spinal cord and (3) curvature of the
spine. Relaxation of these muscles produces weakness of the spinal
column. Relaxation of the abdominal muscles produces enteroptosis.
If the diaphragm is affected, and it frequently is, respiration is disturbed,
usually becoming difficult.

The peritoneum is affected by a lesion of the eleventh dorsal. Its
secretion is disturbed, usually lessened. If increased, ascites develops;
if lessened, pain on movement of parts. In some, the lesion produces
a pain that is referred to the abdominal wall and peritoneum. Peri-
tonitis develops if the lesion is irritative, since the blood-vessels of the
peritoneum would be affected by the lesion. Relaxation of the vis-
ceral layer of the peritoneum followed by enteroptosis, occurs in par-
alytic lesions.

The ligaments of the ribs and vertebra are affected by a lesion of

APPLIED ANATOMY.

229

MULTtriDUS SPIN*
INTERSPINALS ROTATOR ES

INTE&.OVER PdT051h L

ERECTOR SPIN*.

LEVATOR
COSTARUM

Fig. 56. — The eleventh thoracic segment of the spinal cord, with its branches and
their distribution.

230 APPLIED ANATOMY.

the eleventh dorsal, because their innervation is disturbed. This is also
true of the periosteum. The ligaments of the vertebra are either stretch-
ed or broken by the lesion. At any rate they always thicken and prob-
ably always partly fill the intervertebral foramina. In acute cases the
ligaments become very tender and remain so for quite a while if not
properly treated. The vertebral joints are sprained in a way similar
to that of other joints and the effects are also very similar.

The spinal cord is affected by the lesion either directly, as by pressure,
or indirectly through impairment of its circulation. Pressure on the
spinal cord at this point would produce paraplegia and loss of control of
the various centers at points lower down in the cord. If pressure pro-
duces complete transverse myelitis, atonic paraplegia follows; but if not
complete, spastic paraplegia results. Interference with the circulation
to the cord- of course produces various effects which depend on cells
affected, amount and degree of disturbance and length of standing of
lesion. The spinal cord is also affected by ascending degeneration from
injury of or pressure on, the posterior nerve roots. These ganglia are
in the foramina and a very slight deviation of the vertebra would pro-
duce pressure on them, this producing degeneration. The effect seems
to be a sensory one, there being a loss, to a certain degree, of tactile sen-
sation.

The spinal column is weakened by a subluxation of any of its ver-
tebrae. A lesion of the eleventh dorsal, causes a weakness of the small
of the back and the patient is unable to undergo much exercise without
marked discomfort in this area. Spinal curvatures often start from a
subluxation of the eleventh dorsal, in fact, I doubt that pathological
curvatures start from any other cause than a subluxation of a vertebra.
Lumbago, often results from a lesion of the eleventh dorsal, but most
often results from a lesion lower in the spinal column. The explanation
is that the movement of the spinal articulations is lost or markedly
lessened on account of the subluxation of the vertebra or a sprain of its
ligaments.

The viscera most commonly affected by this lesion are the small
intestines, cecum and vermiform appendix, ovary and testicle, kidney,
spleen, ureter, prostate, uterus, epididymus, Fallopian tubes, and supra-
renal capsule.

The small intestines are affected because their nerve and blood sup-
ply are disturbed by the lesion. The lesser splanchnic carries sensory,

Fig. 57. — Showing the nerve supply of the abdominal viscera. The liver has been
drawn back, exposing the gall-bladder. Enteroptosis produces a
stretching of these nerves.

232 APPLIED ANATOMY.

motor, secretory, vaso-motor and possibly trophic fibers to the small
intestines. This nerve is affected because the filaments composing it
are subject to compression by the subluxated vertebra while they are
in the intervertebral foramen.

Howell in speaking of the function of the sympathetic innervation
of the small intestine says: "The fibers received from the sympathetic
chain give mainly an inhibitory effect when stimulated, although some
motor fibers apparently may take this path. Bechterew and Mislawski
state that the sympathetic fibers for the small intestine emerge from the
spinal cord as medullated fibers in the sixth dorsal to the first lumbar
spinal nerves, (or lower-bunch) and pass to the sympathetic chain in
the splanchnic nerves and thence to the semilunar plexus. "

Clinically, it seems that these impulses to the small intestine pass
to it by way'of the ninth, tenth and eleventh spinal nerves, that is. these
segments have more to do with the innervation of the small intestine
than any other. This has been determined, to a great extent, by ob-
serving the effects of lesions is this region on the intestine; it being found
that a lesion affecting this part disturbs the intestine most.

From this lesion there would result pain, as in enteralgia; disturbed
peristalsis, as in diarrhea; constipation and invagination; increased or
lessened secretion, as in catarrhal enteritis and constipation; congestion,
as in enteritis and ulceration.

Enteralgia can be relieved by inhibition at the eleventh dorsal spine,
It can be cured in most instances, by correction of lesion of the tenth
or eleventh dorsal vertebra.

The cecum is affected through disturbances of its blood and nerve
supply. Its nerve supply is from the superior mesenteric plexus which
is derived from the lower part of the solar plexus into which part, the
lesser splanchnic nerve enters. This nerve controls the blood-vessels
supplying the cecum, also its sensory, motor, secretory and trophic im-
pulses. The cecum marks the junction of the large and small intestines.
It is quite large and has leading from it the vermiform appendix. Its
function is similar to that of the rest of the large bowel, that is, to serve
as a sort of reservoir in which desiccation of the fecal matter may take
place. A lesion of the eleventh dorsal will, through the nerve supply,
alter and affect its peristalsis, secretion, sensation and amount of blood.
Constipation with impaction of the cecum is the result.- From this
develops a change of position from the increased weight, that is the cecum

APPLIED ANATOMY. 233

prolapses. This causes congestion and stagnation of the blood and is
the starting point of many abdominal disorders. The impaction soon
weakens or paralyzes the valve closing the lumen of the appendix so that
it can neither prevent the passing of particles of fecal matter into the
appendix, nor expel them after they enter. The contents of the ap-
pendix then undergo fermentation, possibly putrefaction, and soon the
patient has appendicitis. The lesion of the eleventh dorsal vertebra is
the predisposing cause, the particles of partly digested food, the ex-
citing cause. The lesion inhibits the passing of sensory, motor and sec-
tory impulses, hence a deadened condition of the bowel results. These
nerve impulses arise in the spinal cord and reach the cecum by way of
the ventral root, common trunk, anterior division, white ramus, sympa-
thetic ganglion, lesser splanchnic, solar plexus (lower portion) and super-
ior mesenteric plexus. If the lesion is irritative, there may be excessive
peristalsis, hence flux, or diarrhea in mild cases. Invagination may re-
sult and the small intestine be partly drawn into the cecum.

Inflammatory conditions occur if the vaso-motor nerves are inhibited
to such a degree that the blood-vessels remain engorged. In typhoid
fever, the predisposing cause is a lesion in the lower thoracic area, which
weakens the part, principally through the trophic and vaso-motor dis-
turbances, after which the bacillus, the exciting and immediate causes
the more readily attacks the part. The lesion is often at the articula-
tions of the eleventh dorsal, affecting the lesser splanchnic, which carries
trophic and vaso-motor impulses to Peyer's patches of the small
intestines. The trouble may at first be a secretory or motor one; that
is, there is lessened peristalsis and finally constipation. A lessened secre-
tion of succus entericus is responsible for many cases of constipation.
Constipation is indicative of a lowering of the vitality of the parts, which
is mainly responsible for the fever. If the intestines are normal, the
ingestion of food or water in which there are typhoid bacilli will have
no deleterious effect, but if the vitality of the parts is lowered by a le-
sion which interferes with the passing of trophic, vaso-motor, motor or
secretory impulses, the microbe peculiar to typhoid fever will find a fa-
vorable nidus for propagation, and typhoid fever will result.

The kidneys are affected by this lesion because the lesser splanch-
nic nerve conveys the various nerve impulses from the spinal cord to the
kidney. As explained above, this nerve, either the trunk or the fila-
ments forming it, is in relation with the articulations of the vertebra and

234 APPLIED ANATOMY.

the slightest deviation of the vertebra will produce pressure on it. lhe
ureter is affected for the same reason.

According to Head, the eleventh dorsal has to do with the sensory
innervation of the bladder, as in "overdistension and ineffectual con-
traction. " The nerve pathway must be the lesser splanchnic and the
aortic plexus.

The prostate gland is also affected by this lesion; since the nerve
impulses reach it in a way similar to those of the bladder. The lesion
interferes with it in some way, hence the effects.

The testes and epididymus are also involved by this lesion. The
impulses controlling them are carried by the lesser splanchnic to the
renal, thence over the spermatic. The nutrition, amount of blood, sen-
sation and motion are controlled by this nerve, hence almost any patholo-
gical condition of these parts may result from the lesion. A poorly
developed or badly nourished small, tender, soft testicle is the most
common effect. Varicocele is also common. Sterility is not an unusual
effect.

The ovaries are affected in a similar way; also the fundus of the
uterus and the Fallopian tubes through their nerve supply, the ovarian
plexus. Motor, sensory, vaso-motor, secretory or trophic effects re-
sult from the lesion, hence imperfect or too marked contraction, painful
contraction, congestion, leucorrhea or softening of the uterus, especially
the fundus, may result. These effects on the uterus have been noted
clinically.

Lesions of the eleventh dorsal are most commonly associated with
kidney, ovarian and intestinal disorders. These disorders are best rep-
resented by albuminuria, ovarian inflammation, and intestinal indiges-
tion and constipation.

THE TWELFTH THORACIC.

The twelfth dorsal vertebra is a transitional vertebra, marking the
change from the thoracic to the lumbar type. In appearance, it very
much resembles the lumbar vertebrae in that all the parts are large,
the spinous process short, thick and almost horizontal. The superior
facets face almost directly back while the inferior, instead of looking for-
ward, are turned outward to articulate with the superior facets of the
first lumbar which face inward. As is the case with the eleventh dorsal,
the ribs do not articulate with the transverse processes, hence the mo-
bility of both the vertebrae and ribs is greater on this account.

APPLIED ANATOMY.

235

The transverse process is rudimentary and is usually divided into
three parts. There is a single facet on the body for articulation with the
head of the twelfth rib, hence the vertebra is different from those above.
The mobility of the articulation between the twelfth dorsal and first lum-
bar is quite marked in the normal subject but this articulation is often
the seat of hypermobility. A "break" is the most common form of
lesion. By this term is meant a separation of the spinous processes.
It is sometimes pathological but in most cases is not. It occurs oftenest

CRUS OF DIAPHRAGM

EXT. ARCUATE LIG'T.

LIVER

KIDNEY

QUADRATUS
LUMBORUM

Fig. 58. — Showing the relation of the kidneys to the ribs and quadratus lum-
borum muscles. Pressure immediately below the twelfth rib near the vertebral end
is productive of pain in most disorders of the kidney or pelvic organs.

236 APPLIED ANATOMY.

at this articulation on account of the change in character of the vertebrae
and because this part of the spine bears the greatest part of the strain
in lifting. The mobility, which is normally quite marked, is also in part,
responsible for the separation. Unless there is approximation of the
vertebras above or below, the break causes little trouble other than
weakness of the spine since the foramina are increased rather than de-
creased in size on account of the stretching of the ligaments. In many
subjects the separation and hypermobility are only compensatory and
in such cases it is a mistake to attempt reduction of the supposed sub-
luxation.

The articulations of the twelfth dorsal are subject to the usual verte-
bral lesions such as would result from rotation, approximation, anterior
and posterior deviations of the vertebras in relation. The effects vary
with the degree of the lesion, length of standing, that is the extent to
which nature has overcome the disturbance, the structures pressed on
and also their condition. In addition, the degree of the effect is meas-
ured in part, by the condition of the viscus or other structures depending
on the twelfth dorsal segment for nutrition and nerve supply. For ex-
ample, if the function of the testicle were abused, a very trivial lesion, one
that would ordinarily have no effect, would at once affect the function of
the organ, disturbing it the more.

The effects of a lesion of the articulations of the twelfth dorsal ver-
tebra may then be classified under five heads: sensory, motor, vaso-
motor, secretory and trophic.

The sensory effects may be conveniently divided into effect on the
integument, on viscera and on other structures. The integument de-
pending on the nerves in relation with the twelfth thoracic vertebra
for sensation, is that over the crest of the ilium, the upper part of the
gluteal region and as low as the trochanter, over the pubes and a part of
the tip of the penis. It is rather odd that few, if. an}', sensory branches
supplying the integument in the middle and upper lumbar regions come
from the lumbar nerves, but from the lower thoracic, principally the
tenth and eleventh. These areas may be anesthetic or hyperesthetic
from the above lesion or they may be reflexly affected, that is pain may
be referred to the skin over this area from disease of viscera supplied by
the same spinal segment as for instance, the ovary. If the subluxation
or lesion inhibits the passing of the sensory impulses, anesthesia or
numbness would result. In acute or recent subluxations, an irritation

APPLIED ANATOMY. 237

exists producing pain in all or a part of the above described area. Con-
versely, pain in this area is indicative of a lesion of the twelfth dorsal, or
rib on the same side. In some forms of female disorders, especially if
the ovaries are involved, the patient often describes a pain as passing or
running over the crest of the ilium. This is a referred pain. The ex-
planation is that the sensory or afferent impulses arising from the dis^
eased condition, are carried to the spinal cord, the twelfth dorsal segment,
by way of the ovarian and renal plexuses, thence to the sensorium by
the same tract that carries impulses from the integument. The sen-
sorium mistakes the source of the impulses and wrongly refers them to
the cutaneous nerve supplying the crest of the ilium, that is the twelfth
dorsal or subcostal nerve.

The renal plexus is not entirely distributed to the kidney. A part
forms the ovarian, or rather the impulses from the spinal and gangliated
cord pass directly through the renal to the ovarian plexus and these
uerves carrying the impulses have little, if anything, to do with the sup-
ply of the kidney. According to Head, the viscera supplied with sensa-
tion by the twelfth dorsal segment or rather the viscera whose, sensory
impulses pass through this segment on their way to the sensorium are
the kidneys and ureter, intestines as low as the rectum, urinary bladder,
prostate, testes and epididymus, uterus and its appendages. The im-
pulses from the kidneys and ureter, pass to the cord by way of the least
splanchnic. The intestines are supplied by the mesenteric plexuses
which send to and receive impulses from, the lower dorsal and lumbar
portions of the spinal cord. The genitalia connect with the spinal cord
by way of the ovarian or spermatic, and uterine plexuses.

A lesion of the twelfth dorsal articulations may produce pain in the
various organs and viscera mentioned above, but more commonly the
pain is referred to the areas supplied with sensation by the twelfth dor-
sal nerve which is derived from the same source as is the sensory innerva-
tion of the viscera. The lesion more commonly inhibits the passing of
impulses to the spinal cord, hence the parts will not readily respond to a
stimulation or an irritation. On account of this, the peristalsis of the
viscera supplied by the twelfth dorsal segment is seriously interfered
with since sensation to a great degree controls peristalsis. In the case
of the large bowel constipation follows. How common a condition it is
for the abdomen of a patient to feel as if it were paralyzed, and we base
our prognosis in many cases on the degree of weakness and relaxation.

238

APPLIED ANATOMY.

I NTEG. OVCR LUMBAR REGION

INTEG. over CREST
OF ILIUM

OBLIQUE
PYRAMIDALIS OVER TROCHANTER

Fig. 59. — The twelfth segment of the thoracic spina] cord, with its nerves and
their distribution.

APPLIED ANATOMY. 239

If the cecum is involved, appendicitis results in many cases. As
stated before, if the irritability of the appendix is lessened, the particles
of fecal matter which get into the appendix fail to stimulate the sensory
nerves supplying it, because these nerves are partly or completely par-
alyzed by the lesion. Peristalsis of the appendix, as well as that of the
other parts of the intestinal tract, is governed by the irritability of the
mucous membrane lining it, that is peristalsis is, to a great extent, a re-
flex process. The fecal matter stimulates the sensory nerves of the
bowels. The impulses thus generated pass to the spinal cord and are
there transferred to the efferent nerve cells and the result is, that motor
impulses are sent to the bowel. Any lesion breaking or crippling this
reflex arc, will lessen peristalsis of the bowel. Anything stimulating any
of the parts forming this arc will, in all likelihood, increase the peristalsis.

A lesion of the twelfth dorsal vertebra will impair the passing of
sensory impulses to the spinal cord, hence paralysis follows if the obstruc-
tion is complete, numbness, if partial. From this arises constipation,
appendicitis and any other disease dependent on a lessened peristalsis.

Micturition is also a reflex process and the condition of the sensory
nerves supplying the bladder is an important consideration. A lesion
of the twelfth dorsal will affect the sensory innervation. It may
stimulate it, causing frequent micturition, or it may deaden the sensi-
bility, causing imperfect micturition or retention of urine. Although
the center for micturition is a few segments lower in the spinal cord,
according to Head the twelfth dorsal nerve controls the sensory in-
nervation of the bladder. Clinically, it is found that micturition is often
affected by a lesion of the twelfth dorsal.

The testes and ovaries are supplied with sensation by the spermatic
and ovarian plexuses, hence would be involved by lesions affecting these
nerves. Nearly all the internal genitalia receive impulses from as high
in the spinal cord as the twelfth dorsal segment, and accordingly, would
be involved.

The adjacent muscles and those forming the abdominal wall, also
receive sensation from the twelfth dorsal. False or pseudo-appendicitis,
is often due to a lesion of the articulations of the twelfth dorsal, this
causing pain in the iliac fossa by affecting the eleventh and twelfth dor-
sal nerves.

The lesion at the twelfth dorsal will produce a motor effect on mus-
cles, tissues and viscera. The muscles affected are those supplied by the

240 APPLIED ANATOMY.

twelfth dorsal nerve; the abdominal and back muscles, the quadratus
lumborum and in most instances, the diaphragm. These muscles may
be contractured or relaxed. The effects on these muscles, of a lesion
disturbing their innervation have been considered with the exception of
that of the quadratus lumborum. This muscle, if relaxed, will permit
of the drawing upwards of the twelfth rib, that is it becomes displaced
upward under the eleventh rib. If the muscle is contractured it will draw
the twelfth rib down. In replacing or setting the twelfth rib, the con-
dition of this muscle must be considered, because it determines to a
great extent, the position of the rib. Contracture of these muscles pro-
duces an ache in the region of the small of the back. This is because of
the fatigue.

There may be a motor effect on the small and large intestines, kid-
ney and ureter and the internal genitalia. This is explained by the fact
that the lesser and least splanchnic nerves carry impulses to the above
named viscera and structures and these nerves, or the filaments going
to form them, are always more or less affected by the lesion. These
splanchnic nerves usually pass through plexuses but the nerve filaments
that spring from the cells in the grey matter of the spinal cord eventually
reach their destination, that is, the impulses originated in the cell, are
carried directly to their destination. The lesion interrupts this connec-
tion or else stimulates the nerves, thereby increasing the amount and
number of its impulses. According to Qnain, the circular muscle fibers
of the rectum are supplied by the lower thoracic segments. From this,
rectal disorders may follow a lesion of the twelfth dorsal.

This lesion will, through the vaso-motor nerves, affect the inter-
costal, renal, ovarian and spermatic, mesenteric and iliac blood-vessels.
The abdominal aorta, inferior vena cava and the agyzi veins are also
affected by the lesion, through their nerve supply. The effects of con-
striction and dilatation on these blood-vessels have been considered
above. Suffice it to say that congestion of the twelfth dorsal segment,
the muscles of the back, the intestines, ovaries and testes and the kid-
neys are common effects. The diseases most frequently caused by these
vasomiotor disturbances are hyperemia with hemorrhage in the spinal
cord, catarrh of the bowels, inflammation of the ovary or testicle, var-
icocele and nephritis.

The secretory effects are most marked in the integument, intestines,
kidne3*s, ovaries and testes. The first has been considered, there being

APPLIED ANATOMY. 241

hyperidrosis or anidrosis. The succus entericus may be lessened or in-
creased in amount. If markedly lessened, constipation results; if in-
creased, diarrhea. These effects, or at least some variation of them, are
fairly common. The explanation is that the lesion affects the lesser and
least splanchnic nerves which carry secretory impulses to the intestines.
Experimentally, stimulation of this nerve increases secretion in the in-
testines, inhibition lessens it. In this, the vaso-motor element must also
be considered. The lesion at the twelfth dorsal articulation may do
either, hence if the lesion is substituted for the electric or chemical agent
ordinarily used, any standard work of physiology contains the explana-
tion. Clinically, it is known that the lesion may be a paralytic or irrita-
tive one. hence the possibility of the substitution. This lesion may
affect the secretion of urine through the renal splanchnic nerve.

The ovaries have an internal secretion which in all probability, is
controlled by a secretory nerve, if it is like other glands. The secretion
of the testicle is likewise under the control of a secretory nerve, although
the amount and character of the blood enters largely into the process.
The cells controlling these secretory impulses are located in the spinal
cord, the twelfth dorsal segment containing some. They connect with
the organs by way of the ovarian or spermatic plexus of nerves.

The trophic effects vary in different cases. Clinically, the ovaries,
testes and uterus are most frequently involved. The muscles are weak-
ened, from which curvatures develop. In short, any part depending
on the twelfth dorsal segment for its nerve supply, may be affected
and the usual effect is that of malnutrition.

THE FIRST LUMBAR.

The first lumbar vertebra, is a good type of the lumbar vertebra
which are the largest of the movable vertebra?. The body is kidney-
shaped, that is the transverse diameter is considerably greater than the
antero-posterior. The notches in the pedicles are deeper than those
of the dorsal vertebra?, thus making the intervertebral foramina larger.
The spinous process is short, large and thin, resembling a spatula in shape.
It points in nearly a horizontal direction and its edges are slightly thick-
ened. The transverse processes are smaller and more slender than those
of the thoracic vertebra?. They are directed outward and slightly
backward. The articular processes are quite large and the facets deep.
The superior facets face backward and inward and are concave. The

242

APPLIED ANATOMY.

inferior face in the opposite direction and are not so widely separated as
the superior, since they are embraced by the superior facets of the ver-
tebra below. The mammillary processes surmount the articular and

TRANS. PROC

Fig. 60. — A lumbar vertebra.

consist of an elongated oval tubercle. They correspond to the superior
tubercles on the transverse processes of the lower thoracic vertebrae.
The vertebral or spinal foramina are triangular and larger than in the dor-
sal region.

The intervertebral disc is quite thick at this point and is slightly
thicker in front than posteriorly, this causing the anterior curve in this
region. The curves of the spinal column depend more on the

THICKNESS AND ELASTICITY OF THE INTERVERTEBRAL DISCS THAN ON THE

size of the bodies of the vertebra. The disc is particularly liable
to compression in the lumbar region on account of the strain and super-
imposed weight of the body.

The mobility of the articulations of the first lumbar is very well
marked, all movements being represented. Hypermobility is quite
common at the articulation between the twelfth dorsal and first lumbar.
Strains of the articulations of the first lumbar are quite common, partly
on account of the free mobility and partly on account of the position of
the vertebra, its articulations bearing the brunt of the muscular exer-
tions of this area.

The ligaments in this region are thicker and stronger than those
above and are more subject to irritation by which they are shortened and
still further thickened. The muscles of the back are also better developed,
while to the body of the vertebra are attached the psoas magnus muscles.
These muscles, when contractured, impair to a great extent; the mobility

APPLIED ANATOMY.

243

CRT GANGLIATED CORD OF SYMPATHETIC

FOURTH LUMBAR VERTEBRA

ABDOMINAL AORTIC PLEXUS

INF MESENTERIC PLEXUS

LUMBAR GANGLIA

HYPOGASTRIC
PLEXUS

LADDER

f'LEXUS
VESICAL PLEXUS
RECTUM

NERVES OFTHE RECTUM
PROSTATIC PLEXUS
UUHSALN.OrPENIS

Fig. 61. — Showing nerves of the male pelvic organs, (after Spalteholz).

244 APPLIED ANATOMY.

of the part and approximate the vertebrae, thus lessening the size of the
intervertebral foramina. These foramina transmit veins, arteries, lym-
phatics and nerves.

The veins drain the first lumbar segment in particular, and the spinal
cord and its coverings in general. On removing the posterior arches
of the lumbar and thoracic vertebras and slitting the coverings of the
cord and nerve roots, these vessels in a well injected cadaver, can be
readily outlined. The veins follow, or rather accompany the corres-
ponding nerves, and are enclosed by the sheath of dura mater which
surrounds the nerve root. A lessening of the size of the first lumbar
intervertebral foramen, compresses the vein and some circulatory dis-
turbance follows. Judging from clinical evidence, the effect is most
marked in the corresponding segment. The congestion may at first
be an irritative one, that is the nerve cells may be stimulated by this
venous congestion, hence increased activity in parts innervated by this
segment. The after effect, is, I believe, always that of lessening the
activity of the cell, and diseases characterized by a lack of vitality or
activity of the parts is the result. Constipation is a good example.
The venous blood then passing through the first lumbar intervertebral
foramen, comes mostly from the first lumbar segment and adjacent areas,
and passes into the lumbar veins and then into the azygi veins.

The arteries that pass through the first lumbar foramen are branches
of the lumbar. Their course is similar to that of the veins, that is they
pass up the sheath which encloses the nerve roots and into the corres-
ponding segment of the spinal cord. A lesion of this articulation will
cause pressure on this artery, and arterial anemia of the parts supplied
by it will result. The degree of anemia is governed by the extent of the
anastomosis and amount of pressure. This anemia is not the ordinary
form, — since the same pressure or obstruction causes a retention of the
venous blood — but an arterial form of anemia, since the arterial blood
is obstructed. The effect is similar to, if not identical with, that de-
scribed above since the vein is always compressed and affected more
than the artery on account of the character of its walls.

The nerve trunks and filaments affected by this lesion are the ilio-
inguinal, ilio-hypogastric, genito-crural, recurrent meningeal and the
filaments that go to form the efferent branches of the first lumbar sym-
pathetic ganglion, viz., branches to the renal plexus, aortic plexus and
the small branches that supply the vertebra? and ligaments. The le-

APPLIED ANATOMY.

245

Fig. 62. — The lumbar portion of the sympathetic gangliated cord and lumbar
plexus. (After Cunningham). I. M. P. inferior mesenteric plexus; A. pi. aortic
plexus; S. M. P. superior mesenteric plexus; R. pi. renal plexus; S. R. C. suprarenal
capsule; Va. vagus; Grt. S. great splanchnic; Sy. sympathetic gangliated cord; 11T,
12 T, 1 L, 2 L, 3 L, 4 L, 5 L, anterior divisions of spinal nerves; Q, nerves to quadra-
tus lumborum; I. H. ilio-hypogastric; I. I. ilio-inguinal; G. C. genito-crural; E. C. ex-
ternal cutaneous; A. C. anterior crural; A. 0. accessory obturator; 0. obturator; 4,
5, lumbo-sacral cord; H. pi. lrypogastric plex,us.

246 APPLIED ANATOMY.

sion may irritate the nerves in the foramen, hence a temporary increase
in activity of parts supplied, but more commonly the lesion inhibits, to a
certain extent, the passing of the nerve impulses, which is followed by a
lessening of activity or functioning of the nerve and parts involved.

The ilio-inguinal is one of the anterior divisions of the first lumbar
nerve. The anterior divisions form the lumbar plexus of nerves but
each nerve seems to retain its individuality, that is it passes through the
lumbar plexus with few communications. This nerve sometimes re-
ceives a filament from the last dorsal nerve and communicates with the
ilio-hypogastric. It perforates the psoas magnus muscle, passes in re-
lation with the quadratus lumborum and lies behind the kidney. It
crosses the iliacus and pierces the transversalis near the crest of the ilium,
supplying it and the internal oblique muscle. It then passes through
the inguinal canal emerging at the external abdominal ring. It gives
off muscular branches to the transversalis, internal oblique, rectus ab-
dominis and the dartos. The condition of the dartos is indicative of
the condition of the testicle. If relaxed, it shows a weakened condition
but if the rugae are firm, it is suggestive of a healthy testicle. The con-
dition of the dartos is controlled in a great measure by this nerve. Ac-
cording to Cunningham, the ilio-inguinal nerve gives off cutaneous
branches "which innervate the skin (1) of the anterior abdominal wall
over the symphysis pubis, (2) of the thigh over the upper and inner part
of Scarpa's triangle, and (3) of the upper part of the scrotum, and root
and dorsum of the penis (of the mons Veneris and labium ma jus in the
female)". A lesion of the articulations of the first lumbar, will affect
this nerve hence there may be sensory disturbances in the above men-
tioned areas, pain being the usual form of disturbance. Many a case
of pruritus vulvae and pain in the external genitalia, is due to a sublux-
ation of the first lumbar vertebra. The explanation is that the lesion
stimulates some or all of the filaments forming this nerve and as a re-
sult, impulses arise that are carried over the usual paths to the sensorium,
but there is a mistake as to the source and the pain is referred to the
periphery of the nerve, the accustomed place. This nerve may be af-
fected by a strain of the psoas muscle or by a lesion that produces con-
tracture of it.

The ilio-hypogastric nerve also comes from the first lumbar segment,
often in common with the ilio-inguinal, and its course is about the same,
it piercing the psoas and transversalis muscles. It follows the crest

Fig. 63. — Showing the posterior abdominal wall with its muscles and nerves
(After Cunningham). V. O. vena caval opening; C. tend, central tendon; A. ligt.
arcuate ligament; 12th R. twelfth rib; L. F. lumbar fascia; I. H. ilio-hypogastric n.;
L. vis & sym. lumbar vessels and symphathetic n.; I. I. ilio-inguinal n.; O. d. b. deep
branch of obturator n.; E. O. esophageal opening; D. lc. left crus of diaphragm;
A. L. adductor longus; A. B. adductor brevis; G. gracilis. Note the relation of the
lumbar nerves to the psoas muscle.

248 APPLIED ANATOMY.

of the ilium, running between the transversalis and internal oblique mus-
cles and near the anterior superior spine, divides into an iliac and hypo-
gastric branch.

The iliac branch is supposed to correspond to the lateral cutaneous
branch of an intercostal nerve. It pierces the internal oblique muscle
thus becoming cutaneous, and supplies the skin over the upper and outer
side of the buttock behind the distribution of the lateral cutaneous
branch of the last thoracic nerve. The hypogastric branch passes for-
ward and, piercing the internal oblique, supplies the integument over the
hypogastrium. The ilio-hypogastric nerve supplies the internal and ex-
ternal oblique, transversalis and rectus abdominis.

The ilio-inguinal and ilio-hypogastric nerves are often the seat of
referred pain. Renal colic causes pain in the areas supplied by the
ilio-inguinal nerve. The possible explanation is that the same segment
(first lumbar)"supplies both, and that irritation to the sensory nerves of
the kidney and ureter will produce both a motor and sensory effect in the
parts supplied by the cerebro-spinal nerves which comes from the same
spinal segment. Ovarian colic will have a similar effect. vStimulation
of the pudendum will affect the ovary possibly directly, or at least in-
directly, through the general effect on the sexual apparatus.

The genito-crural nerve is also affected by a lesion of the first lum-
bar articulations. It pierces the psoas muscle, passes down in relation
with the external iliac vessels and behind the ureter and near Poupart's
ligament, it divides into two unequal nerves, the genital and crural
branches. Its function and distribution will be considered under dis-
cussion of the second lumbar segment since the greater part of the nerve
comes from the second.

The posterior division of the first lumbar nerve divides into the usual
internal and external branches. The internal ends in the multifidus
spinas muscle. The external enters the subcutaneous tissue, crosses the
crest of the ilium, and, with the second and third, form the superior
clunii nerves. This branch supplies the integument of the gluteal re-
gion.

According to Quain the first lumbar ganglion sends a nerve to the
renal plexus. The impulses passing over this nerve originate in the
spinal cord, the first lumbar segment. In other words, the filaments
that go to make up this nerve are prolongations from cells located in
spinal cord. These filaments pass through the intervertebral foramen,

Al'PLIEl) ANATOMY. 2'1'J

forming a part of the trunk of the common nerve, the first lumbar.

A lesion of the first lumbar articulation will lessen the size of this
foramen thus interfering with (1), the nerve by pressure on it, or (2)
the blood-vessels carrying nutrition to the cells that give rise to the
nerve filaments. This nerve (renal branch of the first lumbar ganglion) ,
carries motor, vaso-motor, and trophic impulses to the kidney and ureter
and possibly sensory impulses from the kidney and ureter to the spinal
cord.

The principal efferent branches of the first lumbar ganglion go to the
aortic and hypogastric plexuses. The aortic or intermesenteric plexus
(plexus aorticus abdominalis) placed along the abdominal aorta, occupies
the interval between the origins of the superior and inferior mesenteric
arteries. It consists, for the most part, of two lateral cords which are
connected above with the semilunar ganglia and renal plexuses and ex-
tend downward on the sides of the aorta, meeting in several communi-
cating branches over the front of the vessel. The cords receive branches
from some of the lumbar ganglia and at the points where they join, there
are often small, ganglionic enlargements which are more distinct in the
infant. Several filaments pass to the root of the inferior mesenteric
artery to form the plexus on that vessel, and in connection with these is
the inferior mesenteric ganglion placed below the origin of the artery.
"The aortic plexus furnishes the inferior mesenteric plexus and part
of the spermatic, gives some filaments to the lower vena cava, and ends
below in the hypogastric plexus. " (Quain.) The cells giving origin
to these different nerve fibers are for the most part, located in the spinal
cord and as in the case of the renal branch, the impulses pass over the
filaments that form a part of the ventral root and common nerve trunk.
A lesion of the first lumbar articulation will affect these filaments in a
way similar to those forming the renal branch described above. The
aortic plexus is motor to the intestines, this part especially supplying
the cecum and ascending colon. It also supplies the ovary and testicle
and, possibly, all the structures supplied by the hypogastric plexus, viz.,
the uterus, vagina, prostate and rectum. It is in -part vaso-motor to
the abdominal aorta, inferior vena cava, mesenteric vessels, ovarian and
spermatic vessels, vesical, hemorrhoidal, uterine and possibly the va-
ginal vessels. The lesion usually intercepts the impulses, or at least
lessens them, hence dilatation of the vessels is the common sequel.
From congestion many forms of disease may arise. This plexus is also

250

APPLIED ANATOMY.

MULTIFIDUS SPIN*. ERECTOR SPINK.
TRANSVERSUS SPIN,
SUP CLUhlJM

CUTANEOUS FROM MIDLINE ABOVE CREST
OF ILIUM DOWNTO BELOW (7R.TROCHANTER

CONNECTS WITH 12th T.

A.. LUMBAR I

$lfe»|l^rSU LABIA MAJUS PELVIC FLOOR

Pr.

CUTUS. ABOVE PUBIS, SCARPA'S

ABO'L WALL ABOVE PUBIS

TTtANSVERSALIS
ABDOMINIS

MUSCLES OF ABDOMEN

Fig. 64. — The first lumbar segment of the spinal cord with its nerves and their
distribution.

APPLIED ANATOMY. 251

secretory to the above parts, hence secretion will necessarily be impaired
by the lesion, if it affects this plexus, and it usually does. The left strand
of fibers almost entirely forms the inferior mesenteric plexus. Thus
lesions affecting the foramina on the left side, are the more important so far
as the effects on the bowel are concerned.

The first lumbar sympathetic ganglion also furnished filaments to
the first lumbar vertebra and its ligaments. An impairment of these
nerves results in a weakened spinal column. In other cases, the spine
becomes rigid from contracture of these ligaments. Caries of the ver-
tebra? is also a sequel to a lesion affecting these nerves.

The recurrent meningeal nerve is, like the other recurrent nerves,
formed by filaments from the cerebro-spinal and sympathetic nerves.
It is vaso-motor to the spinal cord, first lumbar segment, and the menin-
ges. The nerve passes through the intervertebral foramen and thus is
subject to pressure when the vertebrae forming this foramen are sublux-
ated. As a result, anemia or congestion of the parts supplied, is the
result.

The disorders most common are lumbago, affections of the kidney,
such as gravel, albuminuria and Bright's diseases, and bowel disorders such
as constipation, diarrhea and flux. Bladder disturbances are also fre-
quent when this lesion exists. Quain states that this segment furnishes
nerves that are motor to the uterus, bladder and circular muscle fibers
of the rectum; vaso-motor to the abdominal vessels and vessels of the
penis and lower limbs.

THE SECOND LUMBAR.

The second lumbar vertebra is a typical one, so needs no separate
description. Its size varies with the degree of muscular, and the
general osseous development of the patient. Its articular facets
are large and the articulations strong and apparently secure, on account
of the depth of the facets. If this were not the case, lesions would be
more common than they are, on account of the lumbar vertebra? not
being reinforced by the ribs. Notwithstanding this, lesions are quite
common. The approximation of adjacent vertebrae is one of the most
common. A posterior condition is also common but does not cause so
much trouble in proportion to the degree of irregularity as do other le-
sions, as for example, an anterior condition. Whenever this bone is
moved beyond the physiological range of motion, the tissues attached to

252 ' APPLIED ANATOMY.

it are either stretched or broken. The articular facets, in spines in which
there has been a forcible and abnormal flexion or extension, are moved
abnormally far or separated so that the function of the joint is impaired.

The tissues involved are the periosteum, peritoneum, muscles, lig-
aments and the fascia attached to the vertebra. The effects of the le-
sion may be confined to those tissues attached to the vertebra and would
be similar to those from sprain of any joint, such as edema and tender-
ness with pain on attempt to use it. The intervertebral foramen would
be lessened in size partly by change in position of the parts forming it
and partly by the thickened ligaments in relation. The effects on the
veins and arteries are very similar to those of a lesion of the first lumbar
on the vessels in relation with it, and these have been considered above.

The nerves that are formed from filaments passing through the sec-
ond intervertebral foramen and would be affected by the lesion, are the
genito-crurarj external cutaneous, anterior crural, obturator, recurrent
meningeal, posterior division of the second lumbar nerve and the nervi
efferentes which branch from the second lumbar ganglion, viz., branches
to the aortic and hypogastric plexuses and to the second lumbar vertebra
and its ligaments.

The genito-crural nerve, soon after emerging from its foramen,
enters the psoas muscle and after passing through it into the psoas fascia,
divides near Poupart's ligament, into the genital and crural branches.
The genital branch passes across the iliac vessels into the inguinal
canal, entering it at the internal abdominal ring. It traverses this
canal in company with the spermatic cord and supplies the iliac artery,
cremaster muscle, integument of the scrotum and a part of the skin of
the thigh in relation. In the female, it accompanies the round ligament to
its destination and is also supposed to send' some motor filaments to it.
The crural branch passes under Poupart's ligament into the thigh and
becomes cutaneous by passing through the saphenous opening. It
supplies the skin over Scarpa's triangle not supplied by the ilio-inguinal
and, communicating with the middle cutaneous of the anterior crural,
sends some filaments to the femoral artery.

The lesion of the second lumbar articulation will stimulate or in-
hibit the impulses that should normally pass over this nerve. If they
are inhibited, there will be impairment or loss of sensation in the skin
over the upper and inner part of the thigh and the skin of the scrotum.
The scrotum will not respond to cutaneous stimulation, it becomes re-

AVl'LIED ANATOMY.

253

INTEGUMENTOVER UPPER LUMBAR

*e>/>&

iffiajS LON&US

wlLB/ adductors brevis

MAGNUS QUAO.
HIPANDKNEE-
TO BALLOFGRTTOE
INT'G INNER LEGANDPOOT-

1NTEG0VER
OUTERTHIGHTOKNEE

SARTORIU5M.

MID.CUTANEOUS

PATELLA PLEXUS

INT. CUTANEOUS

Fig. 65. — The second lumbar segment of the spinal cord with its nerves and
their distribution.

254 APPLIED ANATOMY.

laxed and the testicle is no longer held in its proper place but becomes
pendulous. The cremasteric reflex dejDends to a great extent on the
condition of the cutaneous nerves, and in this condition it would be
lessened or lost. If the nerve were stimulated by the lesion, there would
be hyperesthesia or pain in the above areas.

This nerve is often the seat of pain referred from the ureter as in
renal colic. The explanation is that the impulses generated by the
calculus stimulating the sensory nerves lining the ureter, are carried to
the second lumbar segment, thence to the sensorium over the same
pathway as are the impulses from the genito-crural nerve and thus the
sensorium is mistaken in part at least, as to the location of the painful
stimulus. The pain is referred to the inner side of the thigh or scrotum,
sometimes the penis, and retraction of the testicle is generally present..

This nerve supplies motor impulses to only one muscle, the cre-
master. This muscle is named from its function, that of suspending the
testicle. It is regarded as a detached portion of the internal oblique and
is formed into several loops that enclose the testicle and lower part of
the spermatic cord. It arises from the middle portion of Poupart's liga-
ment and is inserted into the spine of the pubic bone and the fascia in
relation. The cremaster muscle is peculiar in that its fibers are separate
thus forming a series of loops. Its function is to draw the testicle up-
ward and its contraction is involuntary. It can be stimulated to con-
traction by irritation of the adjacent skin. The height of the testicle
is ordinarily an indication of its strength. A pendulous testicle is a weak
one, while one that is held quite closely to the pubic bone, is usually in
a healthy condition. The cremaster muscle supports the testicle, hence
the condition of it is a guide to the condition of the testicle. In short,
if the cremasteric reflex is lessened or lost and if the testicle is pendulous,
there is loss of sexual strength.

The femoral artery may be affected by the lesion since it is inner-
vated in part, by the genito-crural nerve which is affected by the lesion,
because of the relation of its roots to the articulation.

The external cutaneous nerve passes through the psoas magnus
muscle, crosses the iliacus, passes under Poupart's ligament and becomes
cutaneous immediately below the anterior superior spine. It divides
into an anterior and a posterior branch. The anterior is the larger and
supplies the integument on the outer side of the thigh almost to
the knee. The posterior branch supplies the lower part of the buttock

APPLIED ANATOMY. 255

and the upper part of the outer aspect of the thigh. It is entirely sen-
sory, hence the lesion of the second lumbar articulations will, if it affects
this nerve, produce numbness or pain in the above areas.

The anterior crural and obturator nerves may be affected by the le-
sion. The effects will be considered under the discussion of the third
and fourth lumbar. The posterior division of the second lumbar nerve
supplies in part, the muscles of the back in relation and in conjunction
with the first and third, supplies sensation to a part of the integument
in the middle lumbar region.

The branches of the second lumbar ganglion contribute to form the
aortic plexus which in turn, helps to make up the ovarian, inferior mesen-
teric and hypogastric plexuses. According to McClellan, the hypogastric
plexus receives some filaments directly from the lumbar ganglia. These
plexuses control the vaso-motor impulses to the bladder, vas deferens,
round ligament, rectum, intestines and the uterus. They are, in all
probability, sensory, secretory, vaso-motor and trophic to the genitalia
and the lower intestinal tract. These plexuses are affected by the le-
sion of the second lumbar, because the subluxated bone presses on or
otherwise disturbs the impulses from the spinal cord that supply them.
These impulses pass over filaments that connect the organs and struc-
tures named above. These nerve filaments pass through the inter-
vertebral foramen and this foramen is practically always lessened in
size, by the lesion. As a result of the lesion, there may be congestion of
the genitalia on account of inhibition of vaso-motor impulses. There
may be anemia if the lesion causes prolonged stimulation. Tumefac-
tions of the uterus result in some cases in consequence of the congestion.
The continued congestion leads to deposits. The rigid lumbar spine is
the most common of all bony lesions producing tumors of the uterus.
The tumor is the result of the disordered innervation of the uterus, from
the rigidity. The large colon may become diseased from vaso-motor
disturbances. If the vessels are dilated, diarrhea may result, or in ex-
treme cases, bloody flux. These conditions result from impairment of
the lower bowel, hence the lesion is usually in the middle and lower lum-
bar regions.

If the nutrient nerve to the round ligament is impaired, the ligament
relaxes and the uterus, no longer firmly held in anteversion, becomes
retrodeviated from any exciting cause. If the ligament is stimulated the
patient will complain of a drawing or pulling sensation along the course
of the ligament.

256 APPLIED ANATOMY.

The bladder is affected because the motor supply is intercepted or
otherwise affected by the lesion. This is because the nerve filaments
pass through the intervertebral foramina in relation with the affected
vertebra, the second lumbar. The muscle fibers relax if the lesion is
paralytic, contract if it is irritative, hence the condition called vesical
tenesmus. The uterus is also affected in a similar way.

The rectum receives motor impulses from this segment by way of
the aortic or hypogastric and hemorrhoidal plexuses. It also receives
vaso-motor impulses in the same way. There may be relaxation or con-
traction, or if the vaso-motor filaments are disturbed, hemorrhoids may
result.

This segment contains three centers, the functions of which have
been quite clearly demonstrated experimentally and clinically, viz.,
defecation, micturition and parturition. A center consists of a group of
cells that transfers afferent to efferent impulses. To do this there must
be an afferent nerve which keeps the center informed as to the condition
of the part, a center or group of cells to receive the afferent impulses,
and an efferent nerve by which the center can send impulses to the part.
Defecation is a reflex phenomenon, hence there must be a stimulus, a sen-
sory nerve to receive and transmit the impulses, a center to receive the
impulses and a motor nerve to transmit the impulses to the muscles in
relation with the part stimulated. In defecation the stimulus is the
presence of fecal matter in the rectum. Ordinarily, the rectum is empty
except at a time just prior to defecation. When it is impacted or en-
gorged, constipation exists. I have partly determined this in the female
by hundreds of vaginal examinations. The sensory or afferent nerves
are branches of the hemorrhoidal and the inferior mesenteric plexus.
The efferent nerves are also a part of these plexuses. In order then that
defecation be normal, the sensory nerves must be of normal irritability,
the line of communication between the bowel and the center, and the
center and the bowel, unbroken, and the center properly nourished. The
afferent and efferent impulses pass through the second lumbar foramen
over the common nerve trunk. Therefore, a lesion at this articulation
may produce constipation by (1), pressing on the afferent nerve thus
interfering with the impulses that arise from the pressure of accumulated
feces; (2), by pressing on the efferent nerve, hence the motor impulses
do not reach the bowel; and (3), by interfering with the nutrition of the
center, thus making it less active and less susceptible to the afferent

APPLIED ANATOMY. 257

impulses, that is the afferent impulses reach the center but the cells do
not respond to the stimulation, hence no efferent impulses are generated
although the pathway is unobstructed. It must be borne in mind that
all the afferent impulses do not reach the defecation center by wajr of the
sensory nerves connecting directly with the second lumbar segment, but
that some reach it by the first, third, fourth, and possibly the fifth.
After reaching the spinal cord, the impulses may travel through several
segments, usually from below upward, so that constipation may fee. and
usually is produced by lesions at and below the second lumbar vertebra.
The osteopathic treatment removes these obstructions by restoring the
foramina to normal size, thus relieving pressure on the nerves and blood-
vessels. A palliative effect may be obtained by artificially stimulating
the sensory nerves lining the bowel, thus increasing the number and in-
tensity of the impulses that are normally transmitted to the defecation
center. These impulses may be increased to such an extent that they
will overcome slight obstructions and awaken an inactive center, so long
as the stimulation is applied. This may be accomplished by the use^of
certain drugs which directly stimulate the nerves, or indirectly through
increase of secretion of bile and succus entericus; by the introduction of
water into the bowel, which stimulates the sensory nerves; or by mechani-
cal stimulation, as in dilating the rectum. All these treatments are
palliative in that they do not remove the cause. After continued use.
they lose their power of stimulation and a change has to be made, and
the constipation is made the worse by such treatments.

The opposite condition (diarrhea) may result from this lesion, if it
stimulates (l),the afferent nerve as it passes through the foramen, (2),
the center, through increasing the amount of arterial blood, and (3),
the efferent impulses by stimulation of the motor nerve while it is in
relation with the vertebra. The usual palliative treatment for this con-
dition is inhibition applied to the lumbar area of the spine. The best
way to give this treatment is to extend" the spine over the hand or knee
applied to the second, third or fourth lumbar spine. This lessens the
size of the foramina, therefore shuts off (l),the amount of afferent im-
pulses, (2), the nutrition of the center, it then becoming less active, and
(3), by inhibiting the motor or efferent impulses. To cure this condition
the irritation must be removed permanently, which is accomplished by
correcting the lesion that causes the irritation. The other palliative
measures often resorted to are (1), drugs which deaden the sensory nerves

258 APPLIED ANATOMY.

supplying the bowel, and (2), foods that have little residue, such as
cheese and boiled milk. These do not remove causes, hence soon be-
come of no value even as palliative measures. The lesion may so affect
the bowel that the peristalsis is so increased that tenesmus, eversion of
the bowel and discharge of blood may follow. In such cases the sen-
sory nerves are more sensitive, the center more active and the motor
impulses markedly increased in number and intensity.

The micturition center, also located in this segment, may be affected
by the lesion. Micturition is also a reflex process, the accumulation of
urine in the bladder furnishing the stimulus, the vesical plexus the af-
ferent and efferent nerves. When the amount of urine reaches a cer-
tain point and the pressure a certain degree, the center is so informed
and the bladder wall contracts, while the sphincter vesicae relaxes. The
lesions, as in constipation, may (1), lessen the irritability of the sensory
nerves innervating the mucous membrane of the bladder, principally the
trigone; (2), inhibit the activity of the center; (3) , interfere with the pass-
ing of motor impulses to the bladder or (4) , interfere with the nutrition
of the muscle fibers of the bladder wall. In such cases the bladder be-
comes distended with urine and finally the sphincter muscle is overcome,
allowing the urine to dribble away. If the lesion is an irritative one, the
nerves or center, taking part in the reflex phenomenon, are stimulated
and frequent micturition results. In persistent and bad cases, tenes-
mus or spasm of the bladder results. The bladder is empty but con-
traction continues until it becomes quite painful. The sacral nerves
may have something to do with some of these cases hence the lesion
may be lower in the spine or pelvic bones. Inhibition at the second lum-
bar will often relieve vesical tenesmus. This lesion may also produce
cystitis and possibly calculi, on account of incomplete evacuation of the
bladder from weakness. Cystitis results from retention of urine and
from vaso-motor disturbances. Bed-wetting in children may also come
from this lesion. The brain ordinarily exerts an inhibitory influence
on the spinal centers but in enuresis this connection may be impaired by
the lesion. A better explanation is that the lesion irritates the micturi-
tion center. This center should be in a state of rest during sleep but the
lesion keeps it irritated so that a little urine will set up impulses strong
enough to affect and bring into activity the already irritable micturition
center. Inhibition at the second lumbar just before retiring will, in most
ceases, prevent the bed-wetting for that night. If only the inhibition

APPLIED ANATOMY. 259

is given it will have to be repeated every evening. This treatment seems
to temporarily overcome the effect of the lesion, that is the irritation is
in a measure counteracted. To cure the case the cause of the irritation
must be removed or counteracted and this is accomplished by correct-
ing the lesion. Children often outgrow the disorder because in time the
lesion ceases to exert an irritating influence., or nature succeeds in over-
coming or repairing the injury.

The parturition center, so-called from the role it plays in parturi-
tion, is also located in the second lumbar segment. It is as much of
a menstruation center as it is a parturition center, for it controls the
contraction of the longitudinal, and possibly the circular, muscle fibers
of the uterus. In parturition, which is a reflex process, the stimulus
is the fetus in utero, the afferent nerves the filaments composing a part
of the ovarian and uterine plexuses. The efferent impulses are carried
over other filaments of the same plexuses. If the lesion stimulates the
center or its nerves, to any marked extent, abortion may result. If
by a treatment the afferent or efferent nerves or the center are stimulated
very much, contraction of the uterus to such an extent that pregnancy
may be terminated, is possible but uncommon. During labor, stimula-
tion of these nerves increases the intensity and frequency of the uterine
contractions. Inhibition has the opposite effect. A lesion of the sec-
ond lumbar may disturb parturition by (1), affecting the afferent im-
pulses; (2), by affecting the center; (3), by impairing the activity of the
efferent nerve or (4), by affecting the nutrition of the muscle fibers of
the uterus. The usual effect is lessened activity, that is the lesion in-
hibits the function of the center and inertia uteri in some form or degree,
is the result. The explanation is that the center is on the inside of the
spinal canal and the uterus is in the abdominal cavity and the nerve fila-
ments connecting them must pass through the intervertebral foramina.
In the case of a lesion, these filaments are affected hence their
•conducting power is lessened; or else the lesion disturbs the nutrition of
the parturition center, thus making it less susceptible to the impulses
carried to it by the sensory nerves. In all such cases, labor can be made
■comparatively easy by antepartum treatment. This treatment con-
sists of correcting all lumbar lesions whether a single vertebra is affected
•or the lesion consists of a stiffening of the articulations. These lesions
make labor hard, as mentioned above, by interfering with the reflex
process. Labor is made easier by osteopathic antepartum treatment

260 APPLIED ANATOMY.

since by it lesions of the spine are corrected, thus relieving and removing
obstructions to (l),the afferent impulses, (2), to the blood supply and
drainage of the parturition center, restoring it to normal activity,
and (3), to the efferent nerve fibers. These results are accomplished to
a great extent, if not entirely, by increasing the size of the intervertebral
foramina, or rather by restoring them to their natural size. In some
cases this is hard to do, in others impossible, on account of the per-
manent or chronic changes in the thickness of the intervertebral discs
and the thickening of the spinal ligaments in relation with the foramen.
In the treatment of pregnant cases, precaution should be taken not to
treat too hard, that is do not stimulate the uterus too much or too
suddenly, or abortion may result. In cases in which abortion is likely
to occur, the treatment is especially indicated and that in the lumbar
area, but be careful how you give it. The writer knows from experience
that good, thorough treatment applied to the lumbar spine for the
purpose of restoring normal mobility to every articulation is of great
value in making labor easy and in preventing complications and sequellse
depending on a weakened uterus, such as postpartum hemorrhage
and subinvolution.

The menstrual function is also disordered by this lesion affecting the
center or its nerves. It is the motor center for the uterus hence any
disorder of the uterus, especially the fundus and body, may be the re-
sult of a lesion of the second lumbar articulation. Dysmenorrhea is the
most common. This results because the lesion affects the afferent or
efferent nerves, hence there is imperfect contraction. In the case of
menstruation, the menstrual flow is the stimulus; the rest of the reflex
arc is the same as that for parturition. The lesion may stimulate the
center or any part of its nerves, causing excessive contraction or "cramps. ' '
The irritation may continue for several days after the discharge ceases
causing post-menstrual pain. It may occur at the mid-intermenstrual
period, hence the intermenstrual pain. The lesion may inhibit the center
or its nerves. Blood will then accumulate in the uterus and undergo
coagulation. The afferent impulses are lessened, as are the efferent, and
the uterus with difficulty expels the menstrual flow. The explanation
is about the same as that given under parturition, that is the lesion
lessens the size of the intervertebral foramina, hence interferes with the
passing of blood and nerve impulses through them on account of which,
the center is crippled as are the connections with the uterus disturbed.

APPLIED ANATOMY. 261

Almost any disorder of the lower bowel and pelvic organs may re-
sult from a subluxation of the second lumbar vertebra because nearly,
if not all, depend to a great extent, for their nutrition, secretion, blood,
sensation and motion upon their nervous connection with the lumbar
spinal cord, and the second lumbar segment is in all probability the most
important part. This connection is partly broken by a lesion of the
second lumbar, because a great many filaments pass through the foramina
in relation and these are always affected by a subluxation.

Lumbago quite often comes from subluxation of the second lumbar,
because it affects the innervation of the spinal muscles, the sensory in-
nervation of the joint and the mobility of the joint is either lost or mo-
tion in it, causes pain. Like any dislocated bone, the ligaments become
tender, and this alone will prevent movement on account of pain. In
chronic cases, the effect depends on the degree of irritation of the sen-
sory nerves, or on the muscular changes brought about as a result of the
lesion, and on the changes in the articulation itself. The ordinary
"stitch" in the back is commonly directly due to a subluxation of a ver^
tebra, usually a lumbar.

This lesion will weaken the spinal column, leading to curvatures or
in mild cases, to simply an ache or weakness of the back. The spinal
cord or rather its prolongation, ma}' be compressed by a dislocation of
the vertebra. A subluxation of the second, will affect the corresponding
segment with impairment of function of every part, relying for its in-
innervation, upon this segment or any segment below it. If a trans-
verse myelitis takes place paralysis of the parts below would follow.

THE THIRD LUMBAR.

The third lumbar vertebra is quite large and all its prominences well
developed for the attachment of muscles. It differs little from the first
and second. Its movements are fairly well marked in the normal sub-
ject but in the aged and in cases in which the spine is in any way dis-
eased, the movements are impaired. The transverse processes are
longer than those above. Lesions of two articulations may take place,
that is the vertebra may be slipped on both its inferior and superior artic-
ulations, but this form of lesion is not so common as the one in which
one articulation is involved, that is one part of the spinal column is
twisted or otherwise displaced on the lower segment.

The ligaments in this region are thicker and stronger and the facets

262 APPLIED ANATOMY.

deeper than above. It takes more force to dislocate or even sprain a
lumbar articulation than a thoracic or cervical, but the lumbar region
is subject to many times more strain than any other part of the spinal
column and on this account. a sprain or subluxation of a lumbar vertebra,
occurs almost as often as that of a cervical and more frequently than that
of a thoracic.

A lesion of the third lumbar articulation will produce effects on the
adjacent structures similar to that from a lesion of the second lumbar.
The ligaments will at first be thickened, congested and tender, later on
they contract and an approximation, with a thinning of the discs is the
result. This always lessens the mobility hence we speak of it as a smooth
spine. The muscles and other tissues attached to it are also affected.

The most important of these muscles are the multifidus spina;,
erector spina; and the psoas magnus. An irritative lesion of the third,
will cause contracture of one or more of these muscles. If of the mul-
tifidus spinse, the spine will be drawn to the side of contracture on ac-
count of the way the tendinous fibers are inserted and on account of their
length, they being very short. If of the erector spina?, extension of the
spine becomes imperfect or difficult and the spine is swerved toward the
affected side. If of the psoas magnus, flexion of the thighs on the ab-
domen or of the spine become difficult and the patient walks with a
stoop and a stiffened gait. If the lesion is a paralytic one, the effect is
one of relaxation and weakness. The various movements of this part
of the spine become impaired and the patient has a weak back. Par-
alysis of one of the spinal muscles permits the unopposed muscle on the
opposite side to draw the spine to that side and change of contour, often
to the degree of a curvature, is the result.

The veins and arteries passing through the formina are obstructed,
and the parts drained by the veins and those supplied with arterial
blood by the arteries disturbed, the spinal cord being the most im-
portant.

The nerves affected by this lesion are the anterior crural, obturator,
external cutaneous, accessory obturator, posterior division of third lum-
bar, aortic and hypogastric plexuses with their branches, the gangliated
cord, recurrent nerve, rami communicantes, and branches to the ver-
tebra and its ligaments.

The anterior crural is the largest of the nerves of the lumbar plexus.
It is formed principally from the third lumbar segment, although fila-

APPLIED ANATOMY. 263

ments from the fourth lumbar, and the second and sometimes the first
lumbar, joint the root from the third, to form the nerve. It pierces the
psoas magnus muscle. Deaver says that in psoas abscess "it is left in-
tact, although the muscle may be entirely removed by necrosis. " Many
a pain and ache in the lower limbs is due to disease or contracture of
this muscle affecting this nerve which pierces it. The nerve passes out
under Poupart's ligament, below which it becomes somewhat flattened
out and divides into two parts, one that is principally cutaneous and
one that is almost entirely motor. Before it emerges from the abdomen,
it gives off muscular branches to the iliacus, some filaments to the femoral
artery, and some anatomists claim that some fibers pass from this nerve,
in company with the nutrient artery, to the femur. The middle cutane-
ous supplies sensory filaments to the front of the thigh and inner side of
the patella. The internal cutaneous supplies sensation to the integu-
ment of the anterior and inner portion of the thigh, outer side of the
knee, inner side of the calf of the leg and foot. It also supplies the pecti-
neus muscle. The sartorius is supplied by the middle cutaneous; the
rectus femoris and hip-joint by filaments from other branches of the
anterior crural.

These branches to the hip-joint and the femur are of importance in
cases of malnutrition, such as tuberculosis of the joint or possibly in cases
of arrected or improper development of the joint or bone. Lesions of
the third lumbar articulation interfere with the nutrition of the hip-
joint and the femur through effects on this nerve and are responsible
for many cases of arrested development and disease of the hip-joint. In
the treatment of tubercular disorders of the hip-joint and of the femur,
the lumbar spinal treatment is more important than any other, since it is
the rule for a lesion to be present there in such cases. In fact, the cure
depends on this treatment since by it the cause of the disease is removed.
In all cases of dislocation of the hip, treatment applied to this region is
often very helpful in restoring strength and nutrition to the parts, through
removing pressure on, and other disturbances of, the anterior crural
nerve.

The branches which supply the vastus externus and internus, also
supply the knee-joint. The long saphenous, so named from its length
and relation to the vein of the same name, supplies sensation to the in-
tegument over the knee-cap and inner side of the calf of the leg and
foot. A lesion of the third lumbar articulation would affect this nerve

264

APPLIED ANATOMY.

MULTIfTOUS SPINK. ERECTOR SPINft. INTE&. OVER UP LUMBAR
LATISSIMUS DORSI

VERT.

V».*«8f r REC.FEMOR1S

>C '.ON&US^BREVIS/ VAST EXT

gracilis/ UAST. INT.

INTE&.INNERSIOEOFLEGTO
BALL OF GR. TOE

INT.CUTA'S.

5ARTORIUS

MID.CUTA'S.

LOWER y4tti.
OFFRONTOFTHI&H
LEX.
CRUREUS AND SUBCRUREUS

HIPANDKNEEJT. INNERTHIGH

Fig. 66 — The third lumbar segment of the spinal cord, with its nerves and
their distribution.

APPLIED ANATOMY. 265

by producing pressure on the roots forming it, by interfering with the
nutrition of the cells or by causing contracture of tissues pierced by the
nerve. If the lesion stimulates the nerve, there will be pain in the parts
supplied with sensation by it, viz., the hip-joint, knee-joint, integument
over the anterior and inner side of the thigh, leg and foot. Pain in the
knee may be the result of a lesion of the third lumbar articulation or
hip. The common reflex pain in case of dislocated hip or of coxitis, is
pain in the knee. The explanation is that the irritation applied to one
part may, and does cause pain to be referred to another, on account of
which errors in diagnosis have been made.

The muscles of the front of the thigh become contractured as a
result of an irritative lesion of the third lumbar and the condition is
■often diagnosed as "rheumatism" of the muscles. The femoral artery
becomes smaller in cases in which such lesions exist, and the lower
limb is not well nourished. The branches to the hip-joint, femur and
muscles are also nutrient. If the lesion inhibits the function of this
nerve, there will be weakness of the limb, malnutrition of the hip-joint,
numbness of the integument and atrophy, with a weakening of the mus-
cles, neuralgia, rheumatism, weakness, edema, malnutrition and de-
formities of the lower limb. In spastic paraplegia, the dragging of the
toe is due in part, to impairment of this nerve and partly to inability to
flex the ankle. The patient leans forward in order to be able to take a
step on account of inability to flex the thigh. In this way, the line of
gravity is brought anterior to the base.

The obturator nerve also comes principally from this segment. It
pierces the psoas muscle, and emerges from the pelvis through the thyroid
■or obturator foramen. While in the foramen, it divides into an anterior
and posterior branch. The anterior, supplies the hip-joint, the gracilis
.and adductor longus muscles and the femoral artery. According to
Hilton, this nerve passes in relation with the sacro-iliac synchondrosis
and sends a filament to the articulation. From this it is then possible
for a lesion of the articulations of the third lumbar vertebra to produce
pain in the hip, synchondrosis, and spasm or contracture of the adductor
muscles

The posterior division supplies the remaining adductors and the
knee-joint, and occasionally supplies the integument over the inner side
of the thigh. In spastic paraplegia there is often spasm of the adduc-
tors and the patient has the cross-legged progression. The lesion af-

266 APPLIED ANATOMY.

fects this nerve either at its origin, or at the foramen through which its
roots make their exit. A dislocated or diseased hip, as in the case of
the anterior crural nerve, will most commonly produce more pain at or
in the knee-joint than in the hip-joint. In some female disorders, the
adductors become contractured and there is also pain on inner side of
the thigh. This is in the form of a cramp in the average case. In
hysteria, these muscles are often involved. They are sometimes in-
jured in parturition, falls by which the limbs are abnormally separated
and, Deaver says, by horseback riding. They contract in dislocation of
the hip. In congenital dislocations of the hip these muscles have to
be stretched to a very marked extent or else forcibly broken under
anesthesia (as practiced by Lorenz) before reduction is possible. In any
ordinary case of dislocation of the hip, these muscles are often affected
and, in addition to the glutei, must be considered as important factors
in the treatment of such a disorder. In thyroid dislocations of the hip,
the head of the femur may press directly against this nerve. The author
saw a case of this sort in which there was constant pain, almost excru-
ciating, in the areas supplied by the obturator. A slight change in posi-
tion would give immediate and complete relief, while pressure in the
opposite direction increased the pain. This nerve may be the seat of
pain referred from organs innervated by the same segment, the uterus
and ovaries being at fault in most cases. The real cause may be the sub-
luxated lumbar vertebra. Hilton says, "Tracing the trunk of the nerve
we find it associated with many internal and external parts. As-
suming the obturator to be the seat of pain on the inner side of the knee
and within the knee-joint, it is plain that this may depend upon disease
within the vertebral canal or it may depend upon some diseased condi-
tion of a vertebra near which the nerve lies. It passes over the sacro-
iliac articulations, and when that joint is inflamed and swollen, as some-
times happens, patients complain of pain within the knee and on the inner
side. I have known patients to complain of pain in the inner side of the
knee when the disease was not in the hip-joint." He also cites cases of
psoas abscess, fecal impaction of sigmoid, and other disorders of the
large bowel at this point, affecting this nerve. These points entirely
agree with the osteopathic explanations, since similar cases have been
seen. The kinds of cases seen have been those in which the diseased
condition of the vertebra near which the nerve lay, consisted of a sprain
or other form of lesion of the joint, subluxation being common. The

APPLIED ANATOMY. 267

writer had a case of synovitis of the knee-joint with marked pain and
edema, which was the result of a subluxated innominate on the same
side and a retrodeviated uterus. These conditions were overcome and
the knee disturbances were entirely relieved.

A lesion of the third lumbar articulation will produce similar effects
by pressing on the roots of origin of the obturator nerve while they are
in the foramina. In cases of pain in the lower limb, it is advisable to
begin at the seat of pain and examine the articulations and parts from
below upward with which the nerve is in relation. In most cases the
trouble will be found to be in the spine.

The posterior division of the third lumbar, unites with that of the
first and second and help to form the superior clunii nerve. It supplies
some cutaneous filaments to the gluteal region, but most of the branches
are muscular. A lesion of the articulations of the third lumbar will
produce contracture of the lumbar spinal muscles. These muscles are
supplied with sensation by the same nerves that supply them with mo-
tion and nutrition, or at least by branches of them. The same nerve
that supplies sensation to these muscles at this level does not supply the
integument over the muscle. Backache, when reflex from uterine or
other pelvic disorder, is, ordinarily the result of reflex contracture of the
the muscles. The impulses are carried to the lumbar spinal cord by the
uterine, and hypogastric nerves; the cord becomes congested, or at least
abnormal impulses arise that result in contracture of muscles supplied
by this segment. If the integument over the lumbar spine is tender,
that is, if there is cutaneous hyperesthesia, the eleventh and twelfth
thoracic nerves are most commonly involved and the trouble is uniformly
a disorder of the ovary or kidney. In a reflex backache in which there
is no hyperesthesia of the skin, the trouble is most commonly in the
uterus and the ache is due to the congestion and contracture of the spinal
muscles in that region. In the first case the explanation is that the
eleventh and twelfth dorsal segments are involved, and it would not be
likely that the third lumbar segment and its sensory branches would be
involved, unless there were other disorders, that is disorders of viscera
supplied by this segment. The ovarian plexus gets nearly all of its im-
pulses from the lower thoracic; the uterine from the lumbar. A lesion
of the third lumbar articulation may produce both contracture of the
lumbar spinal muscles and uterine disease.

The external cutaneous nerve has been considered.

268 APPLIED ANATOMY.

The accessory obturator nerve is often absent but is of importance
when present, because it sends an articular branch to the hip-joint.

The sympathetic gangliated cord is seldom affected directly by a
lesion of the third lumbar, but often indirectly. The nervi efferentes of
the third lumbar ganglion consists of branches to the aortic and hypo-
gastric plexuses. This ganglion (third lumbar) receives its motor power
from the spinal cord but the route over which the impulses travel seems
to be doubtful. Quain says: "White rami communicantes are not
furnished by all the spinal nerves. According to Gaskell, by whose in-
vestigations the fundamental constitution of the sympathetic and its
relations to the cerebro-spinal nerves were first made clear, they are
found in the dog from the second dorsal to the second lumbar nerves in-
clusive; but Langley has shown that in the dog and cat, white rami com-
municantes are given off by the spinal nerves from the first dorsal to the
fourth lumbar, and in the rabbit from the first dorsal to the fifth lumbar
inclusive. " In man it is most probable that they exist throughout the
entire thoracic and lumbar regions if any reliance can be placed on clin-
ical indications, and we will treat the subject from that viewpoint. The
impulses then that pass into the third lumbar ganglion, come from the
spinal cord by way of the white ramus, and in all probability, many of
these efferent impulses pass on through the ganglion, with little or no
interruption, into the nervi efferentes helping to form the aortic and
hypogastric plexuses.

The aortic plexus supplies the inferior vena cava and contains nerve
fibers that go to form the inferior mesenteric, hypogastric and ovarian
or spermatic plexuses. The inferior mesenteric is formed almost en-
tirely from the left aortic plexus. The impulses, therefore, that pass to
it from the spinal cord must pass out through the foramina on the left
side. On this account, a lesion in which the foramina on the left
were affected, would produce bowel disorders in preference to other dis-
turbances, assuming the impulses come from the left side, which fact
seems to be borne out in clinical observations. A subluxation to the
right, would affect the uterus more than the bowel. Inhibition applied
to the left side of the spine of the third lumbar vertebra, will have a more
marked effect on diarrhea than a similar treatment applied to the right
side.

The inferior mesenteric plexus transmits, motor, vaso-motor, secre-

*Quain's Anatomy, Vol. III. pt. II, p. 359.

APPLIED ANATOMY. 269

tory, sensory and trophic impulses to and from the spinal cord and the
lower bowel. If the lesion obstructs this line of communication to such
an extent that these impulses are checked or stopped, there would be, as
an effect, lessened peristalsis, congestion, disturbed secretion, loss of
irritability, and malnutrition of the rectum, and the descending and sig-
moid colon. Constipation, hemorrhoids, ulcers and prolapsus are the
most common sequella?. If the lesion irritated these filaments, there
would be increased peristalsis, anemia, secretory disturbances, secretion
usually being lessened, pain, and possibly some trophic effect if the condi-
tion becomes chronic. It is seldom that a lesion will affect all of the fila-
ments, hence only one or two of the above named functions of this plexus
are usually involved by the lesion. These nerves, especially the sensory
and motor, in all probability connect with the defecation center. I
believe that there is a direct line of communication between the lumbar
segments of the spinal cord and the bowel and that impulses pass over
this line to and from the spinal cord. Also these impulses are carried
over nerve filaments that pass through the lumbar intervertebral for-
amina. A lesion of the third lumbar articulation produces disorders of
the lower bowel by affecting the size of the foramen, this interfering with
the line of communication, or disturbing the nutrition of the cells from
which the impulses arise.

It seems from clinical observation that few, if any, impulses pass
from the third lumbar segment to the ovary. Although the ovarian
plexus is derived in part from the aortic, I believe that the filaments come
from a point higher up the cord. Clinically, we find the lesions which
affect the ovary or testicle are several vertebrae higher, viz., the tenth,
eleventh and twelfth dorsal, and sometimes the first lumbar.

The hypogastric plexus may be affected through the aortic, since it
is formed in part by the aortic, or it may be affected by the lesion directly
interfering with the impulses that pass from the spinal cord to the plexus;
that is, some of the nervi efferentes of the third lumbar ganglion. From
the hypogastric plexus are derived, through the pelvic, the hemorrhoidal;
vesical; uterine; vaginal and prostatic plexuses. This means that
nerve cells in the grey matter of the spinal cord give rise to nerve fila-
ments that pass, with little or no interruption in the normal case, to
these various plexuses, or rather through them to the viscus or organ.
The sacral nerves send branches into the above named plexuses and
must be considered when the effects of a lesion are to be determined.

270 APPLIED ANATOMY.

The hemorrhoidal plexus supplies the rectum with vaso-motor, .
motor, secretory and sensory impulses. These impulses, as mentioned
above, are derived from the spinal cord, pass out over the ventral root
into the common nerve trunk, thence over the white ramus into the
third lumbar ganglion, then over the efferent branch into the hypo-
gastric, pelvic and hemorrhoidal plexuses. The sympathetic ganglion
perhaps alters in some way these impulses, as is the function of a gang-
lion. A lesion of the third lumbar vertebral articulation will interfere
with this line of communication. As a result there may be. hemorrhoids,
diarrhea, ulceration of rectum, proctitis, prolapsus or, in fact, any dis-
ease of the part that would result from an interference with the vaso-
motor, motor, secretory, sensory or trophic nerve supply.

The vesical plexus derives its impulses from the same source, in a
similar way.. This plexus supplies the bladder, ureter, vas deferens,
vesicle seminales and testicle. From this it is readily seen that almost
any disorder of these parts, may result from a lesion impairing their
innervation. If the nerves to the bladder are involved, there may be
retention of urine, enuresis, frequent micturition, incomplete evacuation,
dribbling of urine, cystitis, calculi, pain and tenesmus. If the ureter is
diseased, there may be hydronephrosis, hematuria, colic or strangury.
If the nerves to the vas deferens are affected, its function is perverted,
that is, the secretion of the testicle is not properly transmitted to the
seminal vesicles. If some of the nerve filaments supplying these seminal
vesicles are disturbed, there may be retention of the semen, passing of
semen from any strain, or emissions, usually nocturnal, although they
may be diurnal. If the lesion is an irritative one, the nerves supplying
the receptacles of the semen are made more irritable and involuntary
evacuation of their contents takes place from any exciting cause, an
erotic dream being the most potent and common.

If the lesion is paralytic, that is if it inhibits these impulses, there
results a condition called spermatorrhea. This disorder is characterized
by the passing of semen in small quantities during micturition or defe-
cation. In such cases the seminal vesicles are weak and any increase of
abdominal or pelvic pressure, may overcome the resistance offered by the
sphincter and a part of the contents escape. These vesicles are in rela-
tion with the rectum, and in constipation the pressure of the impaction
is directly against them, this tending to cause a weakening of their walls.
The straining at stool with the downward pressure also tends to cause

APPLIED ANATOMY. 271

evacuation of the vesicle. If the part is weakened by the lesion inter-
fering with its innervation, these causes act with greater effect. Abuses
will also weaken them and should be considered in the treatment of their
disorders.

The testicle may be affected by a lesion of the third lumbar through
the vesical and pelvic plexuses but clinically the lesions are higher up
the spinal column.

The uterine plexus is also affected by a lesion of the third lumbar.
The reason for it is that the impulses supplying it come from the lumbar
spinal cord and some of them pass out from the cord through the for-
amina in relation with this vertebra. The principal functon of this
plexus is vaso-motor and motor to the uterus. It is also secretory,
trophic and sensory. This has been determined from clinical observations
rather than from experiments on animals. A lesion of the third lumbar
may produce anemia or hyperemia or congestion. Congestion is in-
dicated by leucorrhea, backache and sense of weight, aching of limbs,
menstrual disorders and possibly catarrh or inflammation. If the
motor nerves are stimulated, contraction to a painful degree is the re-
sult; if inhibited, relaxation of the muscle fibers is the sequel. On ac-
count of these motor disturbances there may be dysmenorrhea, inertia
uteri, subinvolution, uterine colic and superin volution. The secretory
nerves of the uterus may be disturbed independently of the other nerve
filaments, but this is the exception. The sensory nerves to the uterus
may be stimulated or inhibited by the lesion, thus there may be as a con-
sequence, pain, with increased peristalsis or numbness with lessened per-
istalsis. The movements, that in the peristalsis, of the uterus, like other
organs that have a rhythmical movement, are controlled to a great ex-
tent by the condition of the sensory nerves, that is peristalsis is usually
a reflex phenomenon.

Fibroid tumors may follow irritation to the trophic nerves to the
muscle fibers of the uterus, thus causing a hypertrophy of its muscle tissue,
but this I believe is unusual. Repeated congestion of the organ is
probably the most important cause. The vaginal plexus also receives
a few filaments from the third lumbar segment by way of the hypogastric
and pelvic plexuses. I believe that most of its impulses are derived
from points lower, judging from clinical indications.

The prostatic plexus is analogous to the uterine and is formed from
filaments from the same source. The impulses pass out over the ventral

272 APPLIED ANATOMY.

root, white ramus, third lumbar ganglion, hypogastric plexus and pelvic
plexus. They are vaso-motor, motor, sensory, secretory, and possibly
trophic. The vaso-motor effect is that of constriction or dilatation of
the blood-vessels. Constriction results in anemia, dilatation in conges-
tion. Congestion increases the secretion of the prostate and often pro-
duces prostatorrhea. This condition is often confused with spermator-
rhea. A mucus discharge during defecation or at the completion of the
act of micturition, is most commonly prostatorrhea. Congestion may
produce reflex effects similar in character to those from uterine con-
gestion, viz., backache and headache. There seems to be an increase in
the temperature of the integument of the top of the head in such cases,
this possibly having something to do with alopecia, the increased tem-
perature tending to dry the roots of the hair in relation. The gland is
more of a muscle than a gland and its function is to expel by its contrac-
tion, what urine may in be the lower part of the bladder and urethra and
during orgasm, the semen. If the muscle fibers are weakened, mic-
turition is imperfect and often there is no orgasm. If weakened by a
lesion inhibiting its motor nerve supply, this function is impaired in
proportion to the degree of disturbance; marked weakness of this gland
accompanies some forms of impotence. If the lesion is irritative, the
patient experiences pain in micturition, and micturition is established
only after several moments of straining. This is also characteristic of
hypertrophy from any cause but is especially marked in enlargement
from excessive venery or specific urethritis that has extended beyond
the triangular ligament, to the prostate. The sensory effects are usually
indicated by frequent micturition. The secretory nerves may also be
impaired by the lesion, there being a lessened or increased amount of
secretion. These various effects are determined more by the amount of
venery than by any one thing else. Abuse of the organ plus a lesion, will
in every case produce some or all of the conditions named above, hyper-
trophy being the most important on account of its frequency.

A lesion of the third lumbar articulation affects the prostate (1) by
breaking or otherwise impairing the line of communication between the
third lumbar segment and the gland ; and (2) by interfering with the nu-
trition of the nerve cells that give rise to and control the impulses that
pass to the gland. The lesion usually does one of the above by direct
pressure on (1) the nerve trunk which contains the nerve filaments men-
tioned above, or (2) by direct pressure on the blood-vessels that supply
or drain the third lumbar segment.

APPLIED ANATOMY. 273

The recurrent meningeal nerve is affected in a way similar to that
of the recurrent nerves mentioned above, and the effect of the interfer-
ence with its function is about the same.

The gangliated cord itself may be affected directly by the lesion
through tightening of the tissues or enlargement of viscera, thus causing
pressure on it. It is so located in this region that an enlarged viscus
may produce direct pressure on it, if the patient is in the dorsal posture.
In four footed animals, nature has so arranged that the gangliated cord
and its branches and connections, the spinal blood-vessels and the azygi
and -lumbar veins, are free from pressure on account of posture. This
should serve as a hint as to the cause of certain diseases characterized
or accompanied by disturbances of these structures, also the treatment
for them. Pressure on the sympathetic cord will produce effects in
viscera and structures supplied with nerve force by way of this cord.
At the third lumbar, the pelvic viscera and the lower bowel are most in-
volved.

The effect on the spinal cord or cauda equina, like most other ef-
fects, varies with the degree of the lesion and the condition of it. If the
subluxation is so marked that pressure is exerted on the cauda equina at
this point, degeneration with paraplegia follows. In such cases the
paralysis affects the lower limbs, bowel, bladder and, to a certain ex-
tent, the pelvic viscera. The limbs undergo atrophy and are cold even
in warm weather. Deformities sometimes develop. In the case of the
bladder, there is a dripping of urine on account of paralysis of the vesical
sphincter. The bowels are paralyzed to such an extent that there is
constipation in an aggravated form. The sexual organs are commonly
involved, impotence being an effect. The circulation to this part of the
cord is also affected.

The spinal column is weakened at the point of lesion. In some in-
stances it may only be a "crick" in the back, or in others the patient may
be prostrated. Curvature develops in some, caries of the vertebra? in
others. In every case of a true lesion of the third lumbar articulation,
the articular facets are not in perfect apposition so that the function of
the joint is disturbed in proportion to the degree of displacement and
effects on the attached tissues, principally the ligaments. In some
cases an apparent anchylosis develops and nature compensates for this
loss of motion by increasing mobility at some other point, usually at the
articulation between the thoracic and lumbar regions.

274 APPLIED ANATOMT.

A lesion of the third lumbar is most frequently associated with
lumbago, backache, disorders of the lower bowel, pelvic organs and dis-
turbances of the lower limb, principally motor and sensory.

THE FOURTH LUMBAR.

The fourth lumbar vertebra is slightly larger than the third. The
body is distinctly reniform in shape. The transverse processes are
frequently very much elongated while in other cases,they are rudimentary.
They give attachment to the ilio-lumbar ligaments which are in turn
affected in practically all subluxations of the vertebra. The spinous
process is heavy and in old and muscular subjects, there are often found
facets for articulation with the process above and below. The inter-
vertebral disc is very thick and markedly elastic, yet on account of its
position, it bearing the superimposed weight of the body, it is often
flattened and non-elastic. There is quite pronounced movement of its
articulations which is lessened as the patient becomes older, in sedentary
occupations and in cases in which there are lesions in this region. The
lesions of the articulations of this vertebra are common, most of them
coming from sprains of the back. It is decidedly unusual for a com-
plete dislocation to occur at the articulations of the fourth lumbar on
account of the depth of its articular facets and the strength of the spinal
ligaments. Sprains of the spine often occur at this point on account of
its position, it being a point at which the_strain is very great as in lifting,
or in any muscular effort in which the spinal column is used. An un-
expected torsion, a mis-step, extreme flexion, rotation or extension will
cause a rupture of some of the fibers composing the spinal ligaments. A
sprain results if the movement of the articulation is beyond the physio-
logical range. Every articulation has a certain definite range of move-
ment and the ligaments of the joint limit this movement. A sudden or
forceful twist whereby the movement is abnormal in extent, partly
dislocates the articular surfaces and injuries the ligament. This causes
an irritation, tenderness, a thickening, lessened movement and the usual
symptoms and signs of a lesion or subluxation of the vertebra. Most
of these sprains or lesions come from torsion or extreme flexion, hence
the deviation of the vertebra which is judged, to a great extent by the
position of the spinous process, is to one side or posterior.

These lesions produce varied effects on adjacent and distant struc-
tures. In acute or recent cases, the local effect is the most pronounced,

APPLIED ANATOMY. 275

but in chronic cases, the secondary or distant effect is most marked.
These effects may be motor, sensory, vaso-motor, secretory, or trophic,
depending on the degree of the lesion and the kind of nerve filaments
and number of blood-vessels affected by the lesion. Since the fourth
lumbar foramen is formed in part by the ilio-lumbar ligament, it follows
that any subluxation of the fourth lumbar vertebra, would affect the size
of this foramen if this ligament were injured, which is the condition in
the average case.

The motor effect may be that of a weakening or relaxation; con-
tracture or hypertonicity. The muscles on the inner and anterior as-
pect of the thigh may be involved by a lesion of the fourth lumbar. If
the lesion is paralytic, relaxation with weakness of the muscles in this
area is the result. Locomotion is interfered with since the patient with
difficulty, if at all, is able to lift the limb, that is flex the thigh, thus the
patient to overcome this, leans forward to carry the line of gravity be-
yond the base. Spastic paraplegia furnishes a type of such disorder.
If the adductors are relaxed and weakened, adduction is impaired in
proportion to the degree of relaxation. This is not a common effect.
If the lesion is irritative the thigh is flexed on the abdomen, and adducted.
Straightening of the limbs and, abduction are impossible or very painful
and hard to perform. Deformities of the lower limbs sometimes result.
In some cases there are spasms of these groups of muscles. Continued
contraction produces pain, sometimes a cramping of the muscles of the
thigh. The sartorius muscle, by its contraction, interferes with the
venous drainage of the limbs and varicosities result from the obstruc-
tion thus caused. It crosses the thigh immediately below the saphenous
opening and its contraction if prolonged, obstructs to a certain extent,
the lumen of the veins in relation. These effect0 on the muscles result
from inhibition or stimulation of the anterior crural and obturator nerves.
These nerves have part of their origin in the fourth lumbar segment, and
the roots originating in the fourth lumbar, form a part of the cauda equina
and pass out at the fourth lumbar intervertebral foramen. This foramen
-or the one between the third and fourth lumbar, is always lessened by
a subluxation of the fourth lumbar, hence the effect on these nerves.

Most contractures, I believe, result from disturbances of the vas-
cular supply of the cells in the spinal cord. These cells are located in
the anterior horns of the grey matter and control the tone of muscles
innervated by the nerve filaments having their origin in these cells. A
.stimulation of the cells would result in hypertonicity.

276 APPLIED ANATOMY.

The gluteus medius and minimus are innervated by this segment.
If their nerves are inhibited, adduction of the hip-joint, rotation of the
thigh inwards and approximation of crest of ilium and great trochanter,
are difficult or impossible. Morris says: "In walking, if it were not
for the powerful contraction of the gluteus medius and its associated
muscles, the gluteus minimus and tensor vaginae femoris, the pelvis
would not be held firmly upon the upper part of the thigh when one leg
is upon the ground and the other is advanced in the forward step. In
fast walking the rotatory action of the muscle comes into play, for not
only does the gluteus medius, of the limb which is resting upon the ground
support the pelvis by drawing downward the crest of the ilium, but, by
drawing backward the front portion of that crest, it throws forward the
opposite side of the pelvis and increases the length of the stride. " A
lesion of the fpurth lumbar, will impair these movements since it dis-
turbs the nerves innervating the above named muscles. This lesion
will also affect the quadratus femoris muscle. This muscle is a strong
external rotator of the femur, which function would be perverted by the
lesion. Some of the muscles of the back of the leg are innervated by
the fourth lumbar segment, also those of the front and outer side of the
leg. Impairment of these muscles may be directly due to the lumbar
lesion. Contracture, as in cramping of the muscle, is not unusual, while
weakness is quite common. Infantile paralysis and its effects on mus-
cles will be considered under trophic effects of this lesion.

The muscles of the back supplied by the posterior division of the
fourth lumbar nerve are also relaxed, or more commonly, contractured,
as a result of the lesion. A relaxation usually means hypermobility with
pronounced weakness of the spine at this point. A curvature results in
approximation of the vertebra?, impairment of circulation through the
muscle and the spinal cord, stiffness of spine, hence lessened mobility,
tenderness in and over the muscles, and later on, deformities of the spinal
column, that is, curvatures. These muscles, the multifidus, erector and
rotatores spina?, are connected by filaments with nerve cells in the fourth
lumbar segment. A lesion of the fourth lumbar articulation interferes
with this line of communication, hence the effect. It does little, if any
good, to treat the effect, that is to try to relax or contract the muscles
by direct manipulation of them, unless there is structural shortening,
since their condition is the effect. Adjust the vertebra and the effect
will disappear.

APPLIED ANATOMY. 277

The uterus and Fallopian tubes, especially the former, are supplied
with motor impulses by way of the uterine and ovarian plexuses of nerves.
These motor impulses in all probability, come almost entirely from the
spinal cord, although some may be derived entirely from the sympa-
thetic gangliated cord. In the grey matter of the fourth lumbar, as
well as in the segments above it, are located cells that control and give rise
to motor impulses that pass to the uterus, principally by way of the ven-
tral root of the fourth lumbar nerve, common trunk of this nerve, ramus
communicans to the gangliated cord, then by way of thenervusefferens,
to the hypogastric and uterine plexuses. These impulses, like others,
may be inhibited or stimulated. If inhibited, the uterine muscle fibers
relax. The size of the uterine blood-vessels is controlled to a great ex-
tent, by the condition of the muscle fibers of the uterus; that is, a certain
amount of tone or contraction is necessary to the proper functioning of
the blood-vessels. As a result of this relaxation the blood-vessels en-
large and congestion immediately occurs. Parturition and menstrua-
tion are difficult on account of this muscular weakening. If the motor
impulses of the uterus are stimulated, the uterine muscle fibers contract,
often to a painful degree as is illustrated by some forms of dysmenorrhea
and post-menstrual pain. Even after the menstrual flow has been en-
tirely expelled, this irritation from the lesion continues and uterine con-
tractions continue, hence the pain. The menstrual flow is usually
scant, since the contraction of the uterus lessens the amount of blood in
the uterus.

The peristalsis of the Fallopian tube is lessened by, a lesion that in-
hibits the impulses, while it is increased to a painful degree, in cases in
which the lesion is irritative.

Some of the motor impulses to the vagina may pass from the spinal
cord (fourth lumbar segment) by way of the hypogastric, pelvic and
vaginal plexuses, but I believe that most, if not all of them come from
the sacral segments. A few cases of motor disturbances of the vagina
have come under my care in which the lesions were undoubtedly in the
lumbar area. The vaginal walls become relaxed if the motor impulses
are shut off or even inhibited. This results in a large, patulous vagina
with obliteration of the ruga?. If the motor impulses are increased in
number or intensity, the muscle fibers of the vaginal walls contract.
Vaginismus is the best example of this effect.

In the male, the muscle fibers of the prostate may be affected by a

278 APPLIED ANATOMY.

lesion of the fourth lumbar in a way similar to that from a lesion of the
third lumbar, which has been considered above.

The vas deferens is supplied with motor impulses by the fourth lum-
bar segment. Landois in speaking of ejaculation says, "The center
(Budge's genito-spinal center) is situated at the level of the fourth lum-
bar vertebra in rabbits. The motor fibers of the vasa deferentia are de-
rived from the fourth and fifth lumbar nerves which enter the sympa-
thetic and finally pass thence to the vasa deferentia. " From clinical
observation in man it seems that the center is the same as that men-
tioned above, viz., fourth and fifth lumbar. The peristalsis of the vas
deferens is affected by a lesion of the fourth lumbar. The functions of
this vessel are to convey the secretion of the testicle to the seminal ves-
icles and to assist in ejaculation. These functions are impaired, because
the peristalsis is decreased or increased to a pathological degree.

The seminal vesicles are also affected by a lesion of the fourth lum-
bar.

The rectum and lower bowel are often affected by a lesion of the
fourth lumbar. The effect is due rather to a disturbance of the secre-
tory, sensory, vaso-motor and motor, than to a disturbance merely of
the motor nerve. This lesion is most often found in diarrhea. It may
stimulate the motor nerve thereby increasing the peristalsis, or it may af-
fect the secretory, vaso-motor or sensory impulses. Peristalsis of the lower
bowel is governed by motor impulses from the lumbar spinal cord, the
fourth lumbar segment being very important. If the lesion is irrita-
tive, peristalsis will be increased; if inhibitive it will be lessened. In-
hibition applied to the fourth lumbar vertebra, or a great deal better
still, a correction of the subluxations in the lumbar region, will relieve
and cure flux and kindred disorders in practically all curable cases. The
explanation is that the lesion irritates the motor or other nerves to the
bowel and by correcting the displacement or subluxation of the bone,
this irritative effect is lessened or entirely relieved. The nerves carrying
these impulses are the hypogastric, pelvic and hemorrhoidal plexuses. If
the lesion inhibits the impulses, constipation with relaxation of the mus-
cle fibers in the lower bowel will result.

The bladder may also be affected by the lesion. The effects are
similar to those from other lumbar" lesions and have been considered.

A lesion of the fourth lumbar may produce sensory disturbances in
the skin of the lower limb, muscles innervated by the fourth lumbar seg-

APPLIED ANATOMY. 279

ment, the pelvic viscera and certain articulations. The cutaneous ef-
fects of a lesion of the fourth lumbar articulation are manifested by pain
or anesthesia, partial or complete, in the integument on the anterior
portion of the thigh, inner and outer sides of the leg, inner side of foot
and over a part of the gluteal region. If the lesion is irritative, there will
be pain; if inhibitive, numbness. Many a pain in the lower limbs is due
to a lumbar lesion. The explanation is that the anterior crural, and obtur-
ator nerve sand lumbo-sacral cord, supply the limb with sensory impulses,
or rather the sensory or efferent impulses from the lower limb pass through
these nerves. These nerves are more or less involved by a lesion of the
fourth lumbar, because some of their roots pass through the interverte-
bral foramina in relation with the fourth lumbar articulation.

The muscles supplied with motion by the anterior crural, obtura-
tor, anterior tibial and posterior division of the fourth lumbar nerve,
are also supplied with sensation by the same nerves. The lesion may pro-
duce a numbness in them but more commonly a pain or ache. This
painful condition simulates what is ordinarily called muscular rheumatism
and is often confused with it. The sensory innervation of a muscle is
not nearly so great as the cutaneous nerve supply, since sensory nerves
principally supply the superficial structures to better insure protection
of the organism. Aching of the limbs is often due to a lumbar lesion.
This lesion irritates the sensory filaments of the nerves passing through
the fourth lumbar segment and the impulses resulting, are referred by the
sensorium to the limb, the supposed source. In acute pain in the mus-
cles of the legs, the trouble is nearly always in the spine; in aches of the
lower limb the cause may be in the spine or it may be the result of im-
pure blood in the muscle itself. In cases of unusual activity of a muscle,
there is excessive katabolism and this acts as a chemical irritation to the
sensory nerves supplying the muscle. In back-ache in the lower lum-
bar region, the cause may be" in the spine, which condition directly stim-
ulates the nerve supply of the spinal muscles, this producing contracture.
Often the lesion affects the viscus, which disturbance in turn causes re-
flex contracture of the spinal muscles, and nearly all contractured
muscles are tender and subject to ache. Aching of the lower lumbar
region is indicative of (1) lesion of the lower lumbar or (2) pelvic dis-
order of the uterus in the female, and prostatic disorder in the male.

According to Head's chart no viscera are supplied with sensation by
the fourth lumbar segment, but clinically there are indications that this

280 APPLIED ANATOMY.

segment controls in part, the sensory innervation of the bowel, bladder
and pelvic genitalia. The writer has had many opportunities to test this
in'cases of pain in these organs, and has often found that a slight twist of
the 'fourth lumbar vertebra produces pain in the above mentioned parts
and that a correction of the lesion brings relief.

The fourth lumbar segment controls the sensory nerves supplying
the hip-, knee- and ankle-joints, the sacro-iliac synchondrosis and perhaps
the articulations of the foot. Pain in the hip-joint is often due to a
lesion of the fourth lumbar articulation since it will irritate the anterior
crural and obturator nerves, both of which send filaments to the hip-
joint. The impulses arising from this irritation are carried by the same
pathway that those from the hip-joint pass and the sensorium is mis-
taken as to their source. This lesion produces symptoms that are often
mistaken for those from injury to or dislocation of the hip, knee, ankle
or innominate. In painful conditions of the knee-joint, the cause is
often in the spine. Most cases of pain in the knee-joint are due to dis-
ease or dislocation of the femur, but occasionally the lumbar region is
responsible.

Pain in the lower limb, lower bowel, and generative organs, is often
the result of a lumbar lesion, and a lesion of the fourth lumbar articu-
lation is the most important one of the lumbar lesions.

The blood-vessels innervated by the fourth lumbar segment and
the lumbar gangliated cord are more or less disturbed by this lesion.
They are either lessened or increased in size, the first producing anemia,
the second, congestion. The cutaneous blood-vessels are often disturbed.
This disturbance may be indicated by coldness of the part or a conges-
tion, this increasing the surface temperature and changing the color to
a vivid pink or it may be mottled. The areas involved are the gluteal,
and part of the thigh. The cutaneous circulation through these areas is
poor in comparison to that of other areas of the body, hence the fre-
quency of boils on the buttocks and the lowered temperature which is so
common. These blood-vessels are supplied with vaso-motor impulses
derived from the fourth lumbar ganglion; some probably coming from
the segment, they passing out over the ventral root, common nerve and
posterior division of the fourth lumbar nerve. The spinal blood-ves-
sels are affected by this lesion since they are innervated by the fourth
lumbar segment by way of the recurrent meningeal nerve. The effects
of a lesion on this nerve have been considered.

APPLIED ANATOMY.

2S1

The pelvic blood-vessels are affected by this lesion through a dis-
turbance of the hypogastric and pelvic plexuses with their branches and
communications. The blood-vessels most affected are the uterine and
hemorrhoidal. Anemia or congestion may follow, it depending on
whether the vaso-motor nerves are stimulated or inhibited by the lesion.

The vessels of the lower limb are also affected by the lesion through

'common iliac
arteryamdvein

INT. PUDIC
ART. ANDVE1

VENOUS PLEXUS

Fig. 67. — Showing the veins of the female pelvic organs. Note their number
and tortuosity. Displacements of the uterus or enteroptosis readily obstruct these
veins and thus lead to congestion (after Spalteholz).

disturbance of the crural nerve and the plexus around the iliac arteries.
These plexuses are formed by branches from the spinal cord. Anemia
of^the limb results if the blood-vessels are constricted; congestion,
if^they become dilated. Varicose veins sometimes result from a lesion
of the fourth lumbar, because it inhibits the passing of impulses to the

282

APPLIED ANATOMY.

veins of the limb. There is usually some exciting cause which further
dilates the veins, such as standing on the feet for long periods, enteropto-
sis or pelvic enlargements. The primary and predisposing causes are
in the spinal column. All parts below the occiput must connect with
the spinal cord if it is to functionate properly. . The moment this con-
nection is broken, the function of the part is affected and soon it becomes
the prey of disease. Nature has arranged for compensation if the in-

gJfillMK

BODY OF THE
\C PANCREAS

£_ INF. MESENTERIC-
V~ ' VEIN

MID COLIC VEIN

RIGHT COLIC
VEINANOARTERY

VEIN AND ARTERY

OFTHEVERMIFORM

APPENDIX

Fig. 68. — Showing the veins of the intestines.

2S3 APPLIED ANATOMY.

jury is not too great; that is impulses may pass over other nerves in rela-
tion and connected with, the affected part. A lesion of the fourth lum-
bar, breaks the connection existing between the spinal cord and the blood-
vessels of the lower limb. At first the circulation through the limb is
slowed; this is accompanied by aching of the limb, or it may become cold.
If only the superficial vessels are affected, varicosities result. The ex-
planation is that the vaso-motor impulses to these vessels pass out from
the spinal cord over nerve filaments that pass through the intervertebral
foramina in relation with the fourth lumbar, and in lesions of this artic-
ulation, the foramen is always lessened in size from change in position
of the bone or by deposits from injur}' to ligaments.

Secretory disorders resulting from a lesion of the fourth lumbar
are most commonly indicated by catarrh of bowel, uterus and bladder
and excessive perspiration of lower limbs. These disorders, particularly
the catarrhal ones, are due to a great extent, to the vaso-motor disturb-
ances but in addition the secretory nerves are also involved, this making
the effect more marked. Lack of sweat or excessive perspiration of
the lower limbs is sometimes encountered and can be traced to spinal
lesions, the fourth lumbar being an important one.

The trophic disorders are most marked in the lower limb and con-
sist of malnutrition with atrophy. The nutrition of a part depends on
amount and character of the blood supply and ability of the part to select
from this blood, food that is nourishing. The trophic nerve is supposed
to be a separate nerve filament which has the function of controlling this
selective process. The trophic nerve cells are in the anterior horns of
the grey matter of the spinal cord. Like other cells, these must have
nerve filaments connecting them with the parts innervated. If this line of
communication is broken or impaired, the part suffers, or if the cells are
affected, a similar result follows. Infantile paralysis is a type in which
the trophic cells are impaired or destroyed. If destroyed, the paralysis
resulting from it is incurable; but if their function is only suspended a
cure may be effected. It is advisable to treat the case for a while in order
to ascertain which kind it is, since the diagnosis can not very well be made
in any other way. The lesion is responsible for many cases of both forms
because it disturbs the nutrition of the nerve cells or produces a conges-
tion so severe that hemorrhage results.

The hip-joint is especially affected in lesions of the fourth lumbar,
which disturb the nutrition of the lower limb. As a result, the ligaments

Fig. 69. — Showing the azygi veins and their tributaries. I. J., internal jugu-
lar; E. J., external jugular; S., subclavian; S. V., superior vena cava; A., azygos
major; I. V., inferior vena cava; A. L., anterior lumbar; I., iliac; L. A., left lower
azygos; V., vertebral; A. V., anterior vertebral.

APPLIED ANATOMY. 285

become stretched and weakened, permitting the head of the bone to
drop part way out of the acetabulum. This is especially true of anterior
polio-myelitis and has given rise to many errors in diagnosis, as the con-
dition resembles a dislocated femur. In congenital dislocations, the lack
of development of the acetabulum and leg can be overcome to a marked
extent, by spinal treatment applied at or near the fourth lumbar. In
most cases of dislocated hip, some form of spinal lesion is present, the
correction of which constitutes a preliminary treatment prior to the
reduction of the dislocation. In hip-joint disease, the predisposing
cause is the spinal lesion which interferes with the nutrition of the hip-
joint, then the trauma or dislocation the more readily results in disease.
If the vitality is lowered to a certain degree, the tubercle bacilli if present,
become active and tuberculosis of the hip is the result. Most, if not all,
of these trophic impulses that supply the hip-joint pass by way of the
obturator, sciatic and anterior crural nerves, therefore a lesion of the
fourth lumbar would interrupt the passing of these impulses, hence the
malnutrition from the spinal lesion.

The spinal column itself is also affected by this lesion through the.
trophic nerves. The spinal ligaments are relaxed, the spine weakened,
the vertebras abnormally separated on movement of the body. In
chlorosis, the spine is often affected in this way and secondary spinal
lesions are common. The vertebra* also receive trophic impulses from
t he fourth lumbar segment by way of the recurrent nerve. Caries with
psoas abscess, will often follow when the trophic nerve to the vertebra
iti impaired. The ligaments of the sacro-iliac synchondrosis receive
some trophic impulses -from the obturator nerve. A weakness of this
joint will follow a lesion of the fourth lumbar if this particular function
of the nerve is impaired thereby.

There are certain centers located in this portion of the spinal cord.
The center for erection is located in part, in this segment. Landois
says: "The centripetal fibers are the sensory nerves of the penis. The
centrifugal fibers are for the deep artery of the penis, the vaso-dilator
nerves from the first, second and third sacral nerves, (Eckhard's erector
nerves) for the ischiocavernosus and the deep transverse perineal muscle,
the motor fibers from the third and fourth sacral nerves." The lesion
may inhibit this center, thus making erection imperfect or impossible.
This form of impotence is not unusual and is the result usually of two
causes, (1) a lesion which inhibits the activity of the center and (2),

SUP CIRCUMFLEX ILIAC

'sup EPIGASTRIC
^-SUP PUOIC
FEMORAL

^EXT.SUP
FEMORAL

- LONG
'SAPHENOUS

.1NT.SUP.
FEMORAL

^LONG-
SAPHENOUS

Fig. 70. — Showing the superficial veins of the lower extremity. Note the re-
lation to the saphenous opening and that contracture of the tissues would obstruct
the drainage of the limb

APPLIED ANATOMY. 287

abuses of the part. Taylor speaks of the fourth lumbar as the sexual
center. Stimulation at the fourth lumbar or the sensory nerves (pos-
terior division) supplying the buttocks will excite this center. If the
lesion is an irritative one, frequent erection takes place. The probable
explanation is that the lesion produces a congestion of the center. Sleep-
ing on the back with an impacted bowel also produces a congestion of
the spinal cord followed by erection and nocturnal emission.

The center for ejaculation is also located in this segment. Landois
says, "Ejaculation may be induced by mechanical stimulation of the lum-
bar cord in guinea pigs." In man, a lesion of the fourth lumbar artic-
ulation acts as a mechanical stimulation of this center and consequently
emission takes place from any exciting cause. This, like other centers,
may be inhibited or stimulated by a lesion. If inhibited, ejaculation is
impossible or imperfect; if stimulated, it is frequent and takes place
from trivial causes. Congestion of this part of the cord from other
causes is also an important thing to be considered in such cases. Sleep-
ing in the dorsal posture produces hypostatic congestion of this part.

The disorders most commonly caused by a lesion at the fourth
lumbar are flux, diarrhea, constipation; fibroid tumors of uterus, con-
gestion and inflammation of the uterus; sexual disorders, such as im-
potence, nocturnal emissions, satyriasis; disturbances of the lower limbs
and their articulations, such as pain, atrophy, varicose veins, and in-
flammation. The lesion produces disorders by lessening the size of the
intervertebral foramina, thereby producing pressure on (1) nerves that
pass through, and (2) blood-vessels that are in the foramina, thus af-
fecting the drainage and nutrition of the spinal nerve cells.

THE FIFTH LUMBAR.

The fifth lumbar vertebra, in an osteopathic way, is one of the most
important on account of the frequency of its subluxations. This verte-
bra is characterized by a very large body which is thicker in front than
along its posterior border. This produces in part, the anterior curve
of the lumbar spine which is most marked at the fifth. Also the lower
surface of the body seems to be cut away in order to secure better artic-
ulation with the upper part of the sacrum. The transverse processes
are heavier and longer than those of the fourth lumbar, giving better
attachment to the lumbo-sacral ligaments. The superior facets face in-
ward, the inferior forward and outward and are considerably wider apart

288

APPLIED ANATOMY.

ERECTOR SPINft
3.d1a~~ ~ INTERTRANSVERSE

FROM 20. U.

RAL

TOFEMORALART^
'ANTTIBIALN-
MUS.dUTA.TOPERONEI MS. TOKNEEdT'

AOD.BREVIS
ADD. LONGUS
BRA.TOKNEEJT.
GRACILIS M. \~AOD. MAGNUS

CUTA.BRA.

CONNECTS wiTh LOtiiGSAPHENOUS

Fig. 71 — The fourth lumbar segment of the spinal cord, with its nerves and
their distribution.

APPLIED ANATOMY. 289

than the corresponding facets above. The spinous process is usually
smaller and situated more anteriorly than that of the fourth. The in-
tervertebral disc below is quite thick and is the largest of all. The ver-
tebra is located considerably anterior to the other lumbar vertebra,
which fact may account for the frequency of its forward displacement.

The movements of this part of the spine are normally, well marked.
The antero-posterior movements are most marked and possibly on this
account, anterior and posterior displacements are most common. The
articulation between the fifth lumbar and sacrum is a weak point in the
spinal column on account of the fact that a comparatively movable
part articulates with an immovable part, the sacrum. This is also true
of the dorso-lumbar articulation.

The lesions, or subluxations, are similar in character to those of the
lumbar vertebrae above; that is it may be anterior, posterior, or there
may be torsion. The posterior subluxation is caused by extreme flexion
with a strain, as in lifting in the stooping posture. It produces little
trouble in comparison with an anterior deviation of the same degree.
The spinous process is prominent and the distance between it and the
first sacral spine is increased, that is there appears to be a break or sep-
aration at this articulation. The anterior subluxation is more important
than the posterior because it produces a greater effect on the interverte-
bral foramina, that is it lessens their size.

In addition to the usual spinal ligaments there are two special or
accessory ligaments, the ilio-lumbar and the lumbo-sacral, which help
to more securely bind the fifth lumbar to the sacrum. This apparent
precaution against dislocation is taken, on account of the strain to which
this (lumbo-sacral) articulation is subjected.

The lumbo-sacral ligament is very strong and is intimately blended
with the ilio-lumbar ligament. It is triangular below and blends with
the periosteum lining the base of the sacrum and the iliac fossa. The
internal and inferior border or edge, helps to form the foramen between
the fifth lumbar and sacrum, through which the last lumbar nerve passes.
The effect of an injury to this ligament on this nerve can be appreciated
the better on account of this foramen and its relation to the nerves.

The fibers of the ilio-lumbar ligament are about horizontal and
attach the ilium to the transverse process of the fifth lumbar and pedicle
and transverse process of the fourth lumbar vertebra. It is also tri-
angular in shape but with the base attached to the vertebra instead of

290

APPLIED ANATOMY.

ERECTOR SPINS.
4lhL.

"SHT.SAPHENOUS
ITOOUTERSI0EOFF

CUTA.T0 OUTER SIDEOFLE'

TO TOES

ANT.TIBIAL

MUSCULO-
CUTANEOUS™ PERONEI MS.

GRT. SCIATIC
A00. MAGNUS

EXT. POPLITEAL

INT. POPLITEAL
TO POPLITEUSANOPLANTARIS

Fig. 72. — The fifth lumbar segment of the spinal cord, with its nerves and
their distribution.

APPLIED ANATOMY. 291

the innominate. The fourth lumbar foramen is partly formed by it.
This ligament helps to form the posterior boundary of the true pelvis,
reinforces the sacro-iliac ligaments and in part, furnishes origin to the
multifidus spinse and quadratus lumborum muscles. The sacro-lum-
bar and ilio-lumbar ligaments are supplied with blood by the arteries in
relation, the last lumbar, lateral sacral and- ilio-lumbar arteries. Their
nerve supply is from the recurrent meningeal of the fifth lumbar and
twigs from the fourth and fifth lumbar nerves. Many a case of lumbago
results from a sprain of one of these ligaments. The movements of the
joints in relation are impaired, that is there is a stiffening of the joint
or hypermobility and the articulations are weakened. In cases in which
the lumbo-sacral articulation is injured, that is if there is a lesion at this
joint in addition to the injury to the tissues attached, the foramen formed
by the fifth lumbar and sacrum is changed as to size, usually lessened.
If it is increased, the foramen between the fifth and fourth is lessened,
thus a lesion of the fifth lumbar articulation results in a lessening in
size of the foramina. The foramen below the fifth conveys blood- and
lymph-vessels and nerves. The effect on the vessels of a lessening of
the size of the foramen is similar to that described under the various
other vertebra.

The nerves affected, that is those represented by filaments that
pass through the foramen, are the posterior division of the fifth lumbar,
superior gluteal, inferior gluteal, muscular to the quadratus femoris,
obturator internus, erector and multifidus spinse muscles, the great
sciatic and its branches, aortic plexus (perhaps only a few filaments)
hypogastric plexus, recurrent meningeal and twigs to the vertebrae and
ligaments. The malposition of the joint either exerts a stimulating or
inhibitory influence on these nerve strands.

The posterior division of the fifth lumbar nerve sends a filament to
the first sacral nerve and assists in the formation of the middle clunii
nerves. The internal division ends in the multifidus spina? muscle,
while the external becomes cutaneous by piercing the gluteus maximus
muscle. If the lesion causes a stimulation of this nerve, the posterior
division of the fifth lumbar, there would be pain over the lower gluteal
region and contraction of the multifidus spinas muscle. The result of
the contraction is an approximation of the lumbar vertebras or a scolio-
sis toward the affected side, and the movements of the spine wherein
this muscle is used become difficult, the condition being commonly called

292 APPLIED ANATOMY.

lumbago or muscular rheumatism. This nerve is often the seat of pain
referred from pelvic disorders. The anterior division innervates some
of the pelvic viscera and when irritated, the pain is referred to the more
highly sensitive part, the posterior division. The converse is possibly
true; that is, a stimulation of the posterior division will cause a stimu-
lation of the anterior division. If the lesion produces an inhibitory
effect there is numbness or anesthesia in the above named parts with
relaxation of the multifidus spina? muscle.

The superior gluteal nerve is motor to the gluteus medius and min-
imus. The function of these muscles has been given. If the nerve is
stimulated, contraction of these muscles follows, which soon develops
into a contracture. Movements of the lower limbs are difficult and
adduction and abduction of the hip are restricted. If the superior glu-
teal nerve is inhibited by the lesion, relaxation with atrophy of the mus-
cles follows. This nerve is formed from several segments but the lumbo-
sacral cord gives origin to the greater part of the nerve, and the impulses
are carried from center to periphery by nerve filaments that pass through
the fifth lumbar foramen, hence would be subject to injury in subluxa-
tions of the fifth lumbar or sacrum.

The inferior gluteal supplies the gluteus maximus. The function of
this muscle is to produce powerful and forced extension of the hip as in
ascending a stairway, running and jumping. It is an extensor of the
pelvis when the fixed point is below, as in rising from a stooping posture,
and is also called the muscle of copulation by some writers. If the le-
sion interrupts the transmission of the nerve impulses to this muscle,
extension of the hip-joint is weakened in proportion to the degree of
interference, and movements of the body in which this muscle is used,
as pointed out above, become labored or impossible. The opposite
effects occur if the inferior gluteal nerve is stimulated, that is extension
is exaggerated, and flexion both of the hip and pelvis, is opposed by these
glutei muscles, hence is slow and difficult.

The nerve to the quadratus femoris, controls the nutrition and activ-
ity or function of this muscle. This muscle is a powerful external ro-
tator of the femur. In case of inability to externally rotate the femur
or in cases in which external rotation is extreme, this nerve may be at
fault. The same is true of the obturator internus. Supposed rheuma
tism of the hip and limb and stiffness of the hip-joint are due, in many
cases, to contractured conditions of the above named muscles, caused

APPLIED ANATOMY. 293

by a lesion at the fifth lumbar which affects the nerves innervating them.

The great sciatic nerve, the largest nerve in the body, is partly formed
by the fifth lumbar segment and is more or less disturbed as to function
by a lesion of the fifth lumbar vertebra; one of its roots passes through
the fifth lumbar foramen and one through the fourth lumbar foramen,
both of which are in relation with these articulations. These roots are
compressed partly or completely by the malposed vertebra, and, although
the other roots may partly take on the function of those disabled by the
lesion, there will be some effect. These roots, like others, may be stim-
ulated or inhibited by the lesion and since so many nerve filaments com-
pose them, the effect may be localized or quite widely distributed, which
conditions are well illustrated by a condition called Morton's toe, and
general atrophy of one leg. This nerve ''supplies the muscles at the
back of the thigh, and by its branches continued from it, gives nerves to
all the muscles below the knee and to the greater part of the integument
of the leg and foot. The several joints of the lower limb receive fila-
ments from it and its branches." In short, it supplies the above parts
with motor, sensory, secretory, vaso-motor and trophic impulses. As a
result, a lesion of the fifth lumbar may produce motor paralysis or spas-
ticity, anesthesia, or some form of it, or hyperesthesia, lessened or in-
creased secretion, congestion or anemia, hypertrophy or atrophy of the
greater part of the lower limb. This nerve will be discussed more thor-
oughly in connection with the sacro-iliac joint; and suffice it to say in
connection with the fifth lumbar that almost any disorder of the lower
limb may result from a lesion of the fifth lumbar which affects the great
sciatic nerve.

The aortic plexus possibly receives some impulses from the spinal
cord over filaments that pass through the fifth lumbar foramen. This
plexus supplies the blood-vessels in relation and the lower bowel, thus
disorders of the lower bowel may complicate a lesion of the fifth lumbar.
The iliac arteries are supplied by branches extending from the aortic
plexus along these arteries, hence the amount of blood in the lower
limbs is determined to some extent by the size of these arteries, that is,
the condition of the nerves supplying them. From the iliac plexus is
derived the femoral plexus and from this the popliteal; the impulses
originally coming from the lumbar spinal cord.

The hypogastric plexus also receives impulses from the fifth lumbar
segment by way of nerve filaments which pass out through the fifth

294 APPLIED ANATOMY.

lumbar foramen. These filaments are more or less affected by a lesion
of the fifth lumbar, hence the function of this plexus of nerves would
be disturbed. This plexus supplies the internal generative organs and
the lower bowel. From a clinical point of view, the parts most fre-
quently affected are the rectum, vesicle seminales, uterus, prostate,
bladder, ureter and urethra. The diseases associated with a lesion of
the fifth lumbar and resulting from a disturbance of the hypogastric
plexus by the lesion are (1) rectal disorders such as prolapsus, eversion,
ulcers, tenesmus, hemorrhoids, pruritus anior itching piles; (2) disorders
of the vesicle sesminales and its adjacent structures, such as nocturnal
emission, premature emission, imperfect emission, spermatorrhea; (3)
uterine disorders, principally inflammatory conditions and relaxation,
dysmenorrhea and reflex backache; (4) prostatic enlargement and weak-
ness, such as prostatorrhea; (5) disorders of the bladder, such as frequent,
painful and imperfect micturition, and cystitis with tenesmus and calculi;
and (fi) pain in ureter and urethra, or congestion and inflammation with
change in size. Each of the above groups, receives its nerve impulses
almost entirely from the hypogastric via the pelvic plexuses. The le-
sion of the fifth lumbar articulation affects the nerve filaments in rela-
tion which represent some of the nerves forming the above named plex-
uses. Even though these filaments be entirely destroyed, the other
filaments helping to form these plexuses will, in part at least, take on
the function of the disabled nerves but in most cases there is some effect
on the structures supplied by these plexuses. The effects vary since the
degree of disturbance, and the nerve filaments vary in cases in which
the lesions are apparently the same.

The recurrent meningeal nerve and the twigs to the vertebra and
ligaments are affected in a way similar to that from a lesion of the other
vertebral articulations.

The fifth lumbar vertebra is a weak point in the spinal column and
is the seat of reflex pains depending on disorders of the lower bowel and
especially of the generative organs. In many cases the spinal column is
turned or twisted on the pelvis or vice versa. In the first case there is
no change in the relative position of the vertebra while in the second
case, the other pelvic articulations are intact. The lesion is then en-
tirely confined to the lumbo-sacral articulation. To differentiate
between such conditions and a subluxation of the fifth lumbar vertebra,
consider the articulations of the fourth and fifth lumbar vertebra? at

Fig. 73. — Showing effects from a straight lumbar region. The dotted line in-
dicates position of bodies in extension. In such a position, the intervertebral for-
amina are lessened in size.

296 APPLIED ANATOMY.

which joints there will be changes such as irregularity, thickening with
congestion and tenderness if there is a lesion of the fifth.

Tenderness at the spine of the fifth lumbar vertebra, is not diag-
nostic of a lesion of its articulation. In many cases the tenderness is
due to visceral disease that causes a reflex congestion of the posterior
division of the fifth lumbar nerve. It is not a true referred pain but
one due to local changes in the circulation of the blood through the
nerve affected. Pressure increases the amount of pain since it increases
the blood-pressure in the nerve. The fifth lumbar vertebra is especially
affected renexly and on this account, pain on pressure over the spine
of the fifth, is not diagnostic of a lesion of the articulation. Of course
in many cases the pain on pressure is due directly to a lesion of the
vertebral articulations in relation.

The sacEO-iliac articulation is classed by some anatomists, as a prac-
tically immovable joint, that is as belonging to the amphiarthrodial
joints, while it is described by others as having enough movement to be
classed with the diarthrodial joints. This depends on the age of the
patient as well as the condition of patient and joint. In a young person
there is considerable movement at the' articulation, while in the old there
is very little, if any. In the cadaver, the articulation is practically im-
movable on account of the post mortem changes, on which account the
various writers on the subject have determined that the joint is not sub-
ject to dislocation and that there was practically no movement in it.
There is a great deal of difference in the degree of mobility in a cadaver
and a living body, which difference can be demonstrated very readily.
This applies especially to the vertebral and sacro-iliac articulations.

The articular surfaces forming the sacro-iliac articulation are auricu-
lar-shaped, rough, irregular and covered by a thin layer of l^aline articular
cartilage. They are about one and three-quarter inches in length and
about one inch in breadth at the widest or upper part. The articular
surface of the sacrum is concave and faces upward and backward
when the patient is in the erect posture. The writer has found that in
young subjects the surfaces are smooth and glistening, indicating a syno-
vial membrane and sac and mobility. In old subjects the surfaces are
often adhered and as Cunningham states "the joint cavity, which is
little more than a capillary interval, may be crossed by fibrous bands."

The joint is supported and strengthened on all sides by ligaments
which have been arbitrarily divided into the anterior and posterior,

APPLIED ANATOMY.

297

superior and inferior sacro-iliac, and the interosseus. The anterior and
superior are short and comparatively thin; the posterior are larger and
stronger. The fibers are almost transverse and arranged in ridges be-
tween which are foramina, for the transmission of the posterior sacral
nerves. The interosseus is the strongest of all these ligaments. The
fibers are of unequal length and pass in different directions, thus pro-

INTEG-.OVER 6l\UTEAL REGION BACK OF SACRUM
5th.L7

SKIN OFSCROTUM AND
ROOT or PENIS OR
LABIUM MJ.ANO CLITORIS

EXT. SAPHENOUS TO
OUTER SI DEOF FOOT

CUTA'S TO-OU1ER SIDE LEG

TOTOES

ANT. TIBIAL

EXT. POPLITEALOR PERONEAL
INT.POPLITEALTOPOPLITEALANOPLANTARIS

Fig. 74. — The first sacral segment of the spinal cord, with its nerves and their
distribution.

298 APPLIED ANATOMY.

during a crossing or interlacement which strengthens the joint. The
lumbo-sacral and ilio-lumbar, indirectly support and strengthen this
joint since they help to support and steady the sacrum.

The great sacro-sciatic ligament extends from the posterior crest
of the ilium and posterior iliac spines downward and backward to the
sacrum (the lower three segments) and upper part of the coccyx, while
a part of the fibers reach the ischium. The sacrum is, to a great extent,
supported by these ligaments. The sacrum is not the keystone of the
pelvic arch but is shaped in just the opposite way, that is the widest
part is anterior and inferior. The sacro-sciatic ligaments counteract
the downward tendency of the upper part of the sacrum from the super-
imposed weight of the body. They are important in determining the
character of the innominate lesion. A great many of the lower fibers
pass on into the tendon of the biceps muscle "so that traction on this
muscle braces up the whole ligament, and the coccyx is thus made to
move on the sacrum. " (Morris).

The movement at this articulation is slight. In the young it is
quite well marked, also during pregnancy, but in the old, it is slight and
quite commonly, is entirely lost. From clinical indications in cases
treated by the writer, from examination of pregnant cases and from
dissections made there remains no doubt in my mind but that the sacro-
iliac joint is a diarthrodial articulation.

*"The large amount of clinical and anatomical study, which has
been carried on in connection with this subject during the past two
years makes it quite plain that the pelvic articulations, especially the
sacro-iliac synchondroses, are by no means as stable as has been sup-
posed, and that in man and woman under normal conditions, definite
motion exists. It is also shown that the articulations are true joints
having all of the common joint structures, and that this being the case,
they are naturally subject to the same diseases and injuries as the other
joints. When this is once appreciated the character of the articula-
tions is considered, and especially when it is remembered that the ex-
act apposition of these bones is maintained almost entirely by the lig-
aments, the surprising thing is, not that abnormal mobility, and disease
of the joints ever do occur, but that they do not occur more frequently."
Its nerve supply is derived from the sacral plexus, first and second sacral
nerves, posterior divisions, and the superior gluteal nerve.

*Goldthwait, Boston Med. and Surg. Journal, Vol. CLII, No. 21, p. 594.

Al'PLIED ANATOMY.

299

The structures in relation with this articulation and which would
be affected by a subluxation of it are (1) ligaments uniting the two
bones, sacrum and ilium; (2) nerves, the branches going from the sacral
plexus and the anterior sacral nerves; (3) and some blood-vessels, mostly
branches of the ilio-Iumbar vessels. The periosteum will be affected
by a lesion at this joint, also what connective tissue there may be in

EXT.BR/^ INTEG. BACK OF SACRUM
■BRANl |sl?

PLANTAR

CUTA"S TO OUTER SIDE OF FOOT

TO
BICEPS
SHT.HEAD

ADD V MAGNUS

GREAT SCIATIC

INT.AMD EXT POPLITEAL

Fig. 75. — The second sacral segment of the spinal cord, with its nerves and their
distribution.

300

APPLIED ANATOMY.

relation, which binds the roots of the sacral nerves quite firmly to the
articulation and adjacent bones.

MULTIFIOUS SPINS. /INTEG. BACK OF SACRUM

COMM'GBRA. CUTAN.TO
1St.ft2d.T0ES

INT AND EXT. PLANTAR

CUTAN.T0

OUTER 5I0E0F FOOT

TO ADD MAGNUS
GREAT SCIATIC

INT AND EXT POPLITEAL

Fig- 76. — The third sacral segment of the spinal cord, with its nerves and their
distribution.

APPLIED ANATOMY.

301

THE INNOMINATE.

The innominate, the bone which, according to the ancients, bore no
resemblance to any known thing, is irregularly shaped and with its fellow
of the opposite side, forms the lateral walls of the pelvis. In early life,
it is composed of three parts, the ilium, pubis and ischium, which unite
to form one solid bone.

tf^F Jam

■

Wr1-'-

*■(

Fig. 77. — The sacroiliac articulation, with bones in place. (Goldthwait) .

Fig. 78. — Sacro-iliac articulations with the sacrum slightly tilted showing the
separation of the iliac at the pubis as well as at the back. (Goldthwait).

302

APPLIED ANATOMY.

The ilium is the upper part which helps to form the false pelvic
cavity. It flares considerably, the degree of which determines the size
of this cavity. It has anterior and posterior spines, which points are
regarded as landmarks for the location of viscera and for the diagnosis
of changes in the position of the trochanter, sacrum, spinal column and
the relation of one innominate to the other. It has a crest, along which

FORAMEN tor ANT. PRIM.BRA. OF FOURTH LUMBAR

ILIO-LUMBAR LIGAMENT

, FORAMEN FOR LASTLUMBAR N.

SACRO LUMBAR
LIGT.

SUP. SACRO
ILIAC LIGT

jBjjr^ANT. SACRO-
ILIAC LIGT.

GRT. SACR0-
SCIATIC LIGT.

LESSER SACR0-
SCIATIC LIGT.

Fig. 79. — Anterior view of the posterior wall of the pelvis showing the ligaments
connecting the sacrum, innominate and lumbar vertebrse.

pain is often complained of in pelvic disease. The direction of the crest
is changed in subluxations of the bone and it should be examined in all
suspected cases.

APPLIED ANATOMY. 303

The ilium gives attachment to many muscles which, on account
of the peculiar shape and size of the bone, are widely and firmly attached.
In all pelvic examinations, the two ilia should be compared as to height,
direction, degree of flare, spines, tenderness and condition of muscles
attached.

The ischium is of importance in that in subluxations of the innom-
inate its position, is altered and the structures attached to it usually
tightened. Falls on the tuberosities of the ischia often produce a sub-
luxation at the sacro-iliac articulation. The tuberosities are made
the fixed point in the reduction of many subluxations of the in-
nominate, which is accomplished by firmly holding them against an
unyielding surface while the body is bent in various ways. The ischia
often retard the progress of the fetal head in parturition and in elderly
primiparee, labor is often delayed on account of it. The landmarks ol
the ischium are the tuberosity, spine and ramus. The tuberosity is
that part which supports the body while in the sitting posture. It gives
attachment to the hamstring muscles, adductor magnus, gemellus in-
ferior and quadratus femoris. The spine gives origin to the levator
ani, gemellus superior and coccygeus. The pudic vessels and nerve are
in relation with this spine and are often affected by falls or by faulty pos-
in sitting. The ischium helps to form the acetabulum.

The pubes consist of a body and rami. They are of importance in
that they form the anterior boundary of the pelvis, give origin to im-
portant structures, are subject to slight separation during parturition,
and their articulation, the symphysis pubis, is always affected in sub-
luxations of the innominate. In rachitis, the pubic arch is generally
flattened or distinctly angular. The principal landmarks are the rami
and ilio-pectineal eminence.

The innominate articulates with its fellow, the hip and the sacrum,
and in all subluxations of it, all these articulations are more or less affected.

The sacrum is a composite bone formed by the union of the five
sacral vertebrae. It is a large, curved, triangular or wedge-shaped bone
forming the posterior boundary of the true pelvic cavity. When the
patient is in the erect posture, it is at quite an angle, the upper part
receiving the weight of the body which is then passed through the long
axis of the sacrum but at an angle with the body. On this account in
cases of rachitis, the bone is likely to bend under the superimposed weight
of the body and a deformity occurs. In other cases, the bone may turn

304

APPLIED ANATOMY.

instead of bend, and a lesion at the sacro-iliac articulation is the result.
It articulates above with the fifth lumbar, on both sides with the innom-
inata, and below with the coccyx. The superior articular facets are sim-
ilar to those of the lumbar vertebrae except that they are larger, more
concave and considerably wider apart. This articulation has been con-
sidered in the discussion of the fifth lumbar vertebra.

COCCYX

Fig. 80. — Showing the right side of the sacrum. Note the articular surfaces.

The sacro-coccygeal articulation will be treated of under considera-
tion of the coccyx.

The posterior surface of the sacrum is convex, and quite rough on
account of the spines of the coalesced sacral vertebra? and the ridges,
the remains of the laminse. The posterior divisions of the sacral nerves
emerge through foramina on this surface. On this account, these nerves

APPLIED ANATOMY. 305

can be reached quite directly and advantage is taken of this in cases in
which a quick result is wanted; that is, palliative effects can be obtained
by stimulation or inhibition of these nerves. As a rule irritation of the
anterior divisions of these nerves, will produce some effect on the post-
erior divisions, that is metritis is characterized by tenderness over the
posterior surface of the sacrum, especially at the sacral foramina. The
degree of convexity of this surface varies in different subjects. It is
usually lessened in posterior conditions of the lumbar region and in-
creased in anterior conditions. If the fifth lumbar vertebra becomes
anterior it, in the average case, carries with it the upper part of the sacrum.
If the upper part of the sacrum is anterior, a "hump" will be formed
at the sacro-coccygeal articulation; in other words, the angle formed by
the two bones becomes more acute. This surface gives origin to the
multifidus and erector spinae muscles, and the gluteus maximus.

The anterior surface is smooth and markedly concave. It is pierced
by the sacral foramina for the transmission of the anterior sacral nerves
which, after emerging, pass almost directly outward in grooves. There
are indistinct ridges resulting from the union of the bodies of the ver-
tebrae. This surface gives origin to the pyriformis and a part of the
coccygeus muscles. In tumors or other enlargements of the pelvic vis-
cera, these sacral nerves are subject to pressure which, in the average
case, becomes quite painful. The degree of concavity differs in the
male from that in the female and at different ages in the same subject.
In the male, the sacrum is narrow, considerably more curved and not
directed so obliquely backward as in the female.

The lesions of the sacro-iliac articulation will be considered from
two points of view: (1) those resulting from subluxations of the innom-
inate bone; and (2) those from subluxations of the sacrum.

The innominata are subject to partial displacements, in fact an in-
nominate lesion is one of the most common of all bony lesions. The
reason for it is (1), the large size of the bone and the small size of the
articulation, which increase the lever power; (2), the many and power-
ful muscles attached to it, which when brought into use, increase the
lever power mentioned above; (3), the exposed position of the bone, it
bearing the brunt of lifting and other muscular exertions and (4) trans-
mitting at an angle the pressure exerted from below, as in jumping, or
that from above, as in the cariying of a weight.

The bone is most commonly rotated backward and upward on ac-

306

APPLIED ANATOMY.

Sphincter ani

Fig. 81. — A coronal section of the pelvis through the iliac crests,the acetabula,
and the tuberosities of the ischium, showing the posterior part of the pelvis and the
levator ani muscles and rectum in vertical section. (Kelly).

APPLIED ANATOMY. 307

count of the shape of the sacro-iliac articulation and since the force is
directed most frequently and with greatest intensity, from below upward
at a point anterior to the sacro-iliac synchondrosis, i. e., the acetabulum.
The bone may be dislocated directly up, down or any other way; there
may be a separation, but usually there is a combination of two or more,
in the average case; that is, instead of being displaced directly upward
it is at the same time rotated backward, or there is some other combina-
tion. Many subluxations of this bone come from falls, muscular exer-
tion or other conditions that exert a marked strain on the articulation.
Parturition is an important cause. Straining while in a stooping pos-
ture is another important one.
^S^ The diagnosis is based on irregularity at the articulation, tenderness
and disturbance of function of the structures attached to and in rela-
tion with it. For example, if one of the posterior spines is more or less
prominent than its fellow, or if there is a tenderness at the joint often
accompanied by small tumefactions, or if there are pressure symptoms in
some of the nerves in relation, such as the roots of the sciatic nerve, the
chances are that the bone is subluxated. If there is a combination of
two or more of these indications, the diagnosis need not be doubtful.
As to the particular form of subluxation the height of the crest, spines
and other landmarks must be compared with the sound side, as also
must the prominence or other changes be compared. The length of the
limb is indicative but not diagnostic; for example, if the limb is slightly
shorter on the affected than on the sound side, it indicates an upward and
forward displacement but is not diagnostic of it. In making the dif-
ferential diagnosis, rely on palpation and inspection rather than on symp-
toms, noting prominences, depressions, or in short the many slight
•changes in contour.

In order that this be done to the best advantage, the examination
should be made in several different postures, i. e., the erect, sitting and
dorsal and ventral. By so doing it will be easier to differentiate be-
tween the changes produced by a slight shortening of one limb, a slight
lateral curvature, a torsion of the spinal column on the pelvis and sub-
luxations of the innominate. Of all these postures, the ventral is the
best, since in this the relation between the spine and the pelvis can the
better be ascertained.

kThe effects of a lesion of the innominate are many and varied.
■Considerable force is usually exerted in the production of all lesions of

308 APPLIED ANATOMY.

this joint. This is because of the shape, size and character of the artic-
ulation. The joint itself is injured to a greater extent than the joints
in vertebral lesions. The articular cartilage is often torn and sometimes
the synovial sac is broken, or at least impaired, as is indicated by the
swelling and formation of lumps over the articulation. The sacro-iliac
ligaments are stretched, or even partly torn in most instances, the effect
is that of any sprain on the ligaments in relation. They become tender
and thickened and their function is often considerably perverted. In
chronic cases, the ligaments become shortened, and approximation with
lessened mobility, as in the vertebral articulation, is the result.

The "blood-vessels in relation with this articulation are the ilio-
lumbar, lateral sacral and gluteal. The ilio-lumbar is nutrient to the
ilium and furnishes a spinal branch, which passes upward into the spinal
canal carrying nutrition to the lowest part of the spinal cord or cauda
equina. The lateral sacral has to do with supplying the spinal mem-
branes. The gluteal, supplies the muscles in the pelvic cavity also the
pelvic bones, the gluteus maximus, the hip-joint, and the muscles con-
tiguous to the hip-j.oint. These vessels are more or less' affected because
they send branches to the articulation and are, in a part of their course,
in relation with this joint. The effects of a disturbance of them can be
determined by referring to their functions outlined above, the principal
effect being that on the hip-joint and pelvic bones. Malnutrition of
these parts may follow the lesion. This condition leads to hip-joint dis-
ease, dislocation of the hip and imperfect development of parts if the
lesion occurs before the parts are completely developed.

The veins correspond to the arteries and would be affected by the
lesion in a way similar to the arteries. The effects would be manifest
in the muscles around the hip-joint, those inside the pelvis, and the hip-
joint and pelvic bones.

The nerves more or less affected by a lesion of this joint because of
their relation and juxtaposition, are the pudie, small sciatic, muscular,
visceral or nervi erigentes, and the great sciatic. The nerve impulses
passing over the above named nerves come from the spinal cord, sacral
segments, by way of the anterior nerve roots. Each of the above men-
tioned nerves with its branches, is represented in these nerVe roots by
filaments. These nerve roots, especially the lumbo-sacral cord, the
first, second and third sacral, pass across and are quite firmly bound
down to the anterior surface of the sacro-iliac articulation, and thus would

APPLIED ANATOMY.

309

be affected by the slightest deviation of either of the bones forming this
joint. On account of the great number of nerve filaments and the varia-
tions in degree of the lesion, the effects are not the same for lesions that
appear to be identical in different subjects. In one case there may be
pressure on, or irritation of, the filaments which carry impulses to the
uterus, while in another case apparently identical in character, the pres-

PERINEAL BRATO SPHINCTER
AND LEVATOR ANI

COCCYGEUS

TO FOLDOF NATES

To OBT INT

To SCROTUM OR LABIUM MAJUS

INF. HEMORRHOIDAL
TO SPHINCTER EXT.
AND SKIN AROUNDTHE ANUS
COMMUNICATING

DORSAL OF PENIS TO
CONSTRICTOR URETHRAL
CORPUS CAVERNOSUM
SKINOVER G.G.ANO GLANS
COMMU.WITH SYMPATHETIC
(IN FEMALE TO CLITORIS)

Fig. 82. — The fourth sacral segment of the spinal cord, with its nerves and their
distribution.

sure or irritation caused by the subluxation may affect the nerve fila-
ments controlling the second phalanx of the foot.

The thickening of the ligaments in relation with the articulation

310

APPLIED ANATOMY.

in consequence of the arthritis that often follows the injury to the joint,
is responsible for many of the effects on the adjacent structures. Unless
the subluxation is the result of a relaxation, this thickening will be pres-
ent in practically all cases. In the worst cases an osteitis develops and
this like the arthritis, leads to disturbances of the tissues in relation.
Goldthwait points out that in some forms of arthritis the inflammation
may extend to the neighboring parts. "It is in this hypertrophic form
that the joints at times become entirely fused and that the persistent
sciatica or leg pains are so commonly seen. These referred pains are

Fig. S3. — The bon}r pelvis 'with its ligaments attached. Drawn from a dis-
section.

undoubtedly due to the pressure of the hypertrophic tissue upon the
lumbo-sacral cord as it passes over the articulation. "

These nerve roots also carry impulses for the innervation of the
sacro-iliac articulation, thus furnishing an additional reason for the asser-
tion that a lesion of the innominate will affect the sacral plexus.

The pudic nerve is often affected by a lesion of the innominate be-
cause the roots forming it are in relation with this articulation. This
nerve is motor and sensory to the perineum and the external genitalia,
and is the nerve of voluptuous sensation. It divides into the inferior
hemorrhoidal and perineal branches and terminates in the dorsal nerve

APPLIED ANATOMY. 311

of the penis. The inferior hemorrhoidal is motor to the external sphincter
muscle and sensory to the integument around the anus. The sphincter
ani externus, is a voluntary muscle surrounding the anus and attached
to the tendinous center of the perineum and the tip of the coccyx. Its
function is to maintain closure of the anus and to retain the contents
of the lower bowel, especially in muscular efforts in which the intra-
abdominal pressure is markedly increased. In vomiting, coughing and
difficult micturition, or any muscular exertion, the intra-abdominal
and intra-pelvic pressure is increased to a great extent and the tendency
is, to cause expulsion of the contents of the bowel. Exercise is almost
absolutely necessary for the normal activity of the bowels since the
contents are forced lower by it. Lack of exercise is a prolific cause of
constipation. The lesion may stimulate the nerve to the external sphinc-
ter muscle, hence the resistance offered to the expulsion of the feces
would be increased in proportion to the degree of contraction. Con-
stipation from obstruction is the result. In such cases the fecal con-
tents are normal as to shape and consistency, but the stool is small and
is expelled only after great straining. To cure such cases, correct the
lesion, that is, remove the irritation. The muscular condition is the
effect. To relieve, dilate the rectum thus overcoming or removing tem-
porarily, the resistance offered by it. If the lesion inhibits this nerve, the
sphincter muscle relaxes and its function is impaired, it failing to firmly
close the anus. This muscle being voluntary, certain psychic effects
may be obtained by an effort on the part of the patient.

The inferior hemorrhoidal nerve is also sensory to the integument
around the anus. The most common effect of the lesion on this nerve,
is pruritus ani or itching piles. The disturbance is along the nerve trunk,
the effect at the periphery. There may be anesthesia, numbness or dis-
tinct pain in this area; it depending on the condition of the nerve and
the kind of lesion.

The perineal branch of the pudic is sensory to the integument of
the perineum and a part of the external genitalia, and motor to the mus-
cles of the pelvic floor. If the lesion is irritative there will be pain re-
ferred to the perineal body, the integument of the scrotum, or the labium
majus in the female; if paralytic, numbness or complete loss of sensa-
tion in these parts will follow. The perineal branch of the pudic sup-
plies the levator ani muscle. The function of this muscle in conjunc-
tion with its fellow of the opposite side, is to close a greater part of the outlet

312

APPLIED ANATOMY.

I 7

Fig. 84. — Showing the mutual relations of the pelvic viscera as seen upon open-
ing the abdomen through the superior strait. (Kelly).

APPLIED ANATOMY. 313

of the pelvic cavity, support the pelvic contents and, by its contracture,
quite securely close the openings in the pelvic floor. By its contrac-
tion, the perineal body is drawn upward and forward, and in the female,
the posterior vaginal wall is drawn against the anterior, thus lessening
the size of the vaginal canal. Morris says: "It is possible that it ex-
ercises some influence upon the circulation in the prostatic plexus and
in the large pelvic veins which occupy the recess between the muscle
and the viscera, and may also assist in the expulsion of the prostatic
secretion by direct lateral compression of the organ." If the lesion in-
hibits this nerve, the muscle relaxes ; the above .named function would be
partly or completely suspended; the openings in the pelvic floor become
patulous and the floor sinks and remains in a position of descent, every
pelvic structure resting on it sinks to a lower level, hence cystocele, rec-
tocele and prolapsus uteri are the results; the veins dilate, resulting in
malnutrition and varicosities. An innominate lesion produces such
effects by breaking or otherwise interfering with the nerve connection
existing between this muscle and the spinal cord. If the lesion irri-
tates the nerve, the muscle will be in a state of constant contraction, and
constipation and vaginismus are the most common results.

The lesion may inhibit the nerves supplying the other perineal mus-
cles, the compressor urethra and erector penis, causing imperfect erec-
tion. If the lesion is irritative, priapism and satyriasis may develop, but
ordinarily these diseases come from spinal cord affections. The perineal
branch of the pudic also supplies a part of the urethra, the bulbous
portion.

The dorsal nerve of the penis, the terminal branch, supplies the corpus
cavernosum, the skin of the dorsum of the penis, the prepuce and the
glans. The dorsal nerve of the clitoris of the female is distributed in a
similar way. This nerve is principally sensory and perhaps has a pecu-
liar and distinct function. It supplies one muscle, the constrictor urinse.
If the lesion affecting this part of the pudic nerve is paralytic in its ac-
tion, there would follow lack of orgasm, numbness or anesthesia of the
parts innervated and relaxation of the muscle supplied. Lack of orgasm
in both male and female is not an uncommon condition and is due to
disturbance of function, that is suspension of function of this nerve.
Loss of sexual desire is another sequel of such a lesion. Impotency is
also common. If the lesion is irritative, the opposite effects would re-
sult, viz., priapism, premature ejaculation and orgasm, excessive or

314

APPLIED ANATOMY.

unnatural sexual desires, or painful conditions of the glans penis and
prepuce. Other disorders of the glans and prepuce may complicate
the innominate lesion. A case of paraphimosis in a baby was reported
to me as cured by correcting a slight subluxation of one innominate.
The pudic nerve was undoubtedly affected by the lesion with the rather
unusual effect, paraphimosis. The pudic nerve may be affected by other
lesions or disturbed by pressure from faulty posture in sitting, being com-
pressed between the tissues and the spine of the ischium around which
it turns. This nerve has to do mostly with the sexual function but
also supplies the muscles of the pelvic floor. If it is stimulated by a le-

U 03 P<T"">

UDIC
PERFORATINO

Fig. 85. — The fifth sacral segment of the spinal cord, with its nerves and their
distribution.

sion or otherwise, the muscles contract and the activity of the sexual
apparatus is increased. This is well illustrated in cases of masturba-
tion in the early stages. If the nerve is inhibited, whether from a lesion
or by abuse, the muscles of the floor relax and the sexual sense is dulled
or entirely lost. The condition of the pelvic floor is a pretty sure indi-
cation of the condition of the sexual organs. This can be better dem-
onstrated in the female than in the male. A relaxed and patulous
vagina is almost diagnostic of loss, partial or complete, of the sexual
function, that is orgasm is partly or completely gone. The opposite
condition is almost diagnostic of a normal functioning of the part.

The small sciatic nerve is almost if not entirely sensory in function.

APPLIED ANATOMY. 315

It arises from the first, second and third sacral segments, passes out in
relation with the lower border of the pyriformis muscle and descends in
relation with the great sciatic nerve and the gluteus maximus. It
gives rise to three principal branches, the gluteal cutaneous, femoral
cutaneous and the long pudendal. If the lesion affecting the filaments
of the gluteal branch is irritative, there will be superficial pain over the
lower and outer part of the gluteal region; if inhibitive, there will be
numbness or perverted sensation in this area.

The femoral cutaneous filaments supply the integument over the
back and inner side of the thigh. The inferior pudendal is distributed
"to the skin of the upper and inner part of the thigh, and is continued
forward to the outer part of the scrotum (or external labium pudendi),
where its terminal filaments are distributed, after forming communcia-
tions with the external superficial perineal branch of the pudic nerve."
(Quain). An irritative lesion of the innominate will cause pain or per-
verted sensation in the above named parts. Pruritus vulvae is an ex-
ample. Nymphomania and masturbation or excessive venery, often
result from such a lesion on account of the effect on the labia. Lack of
sensation would follow a paralytic lesion.

The small sciatic, extends down the limb and becomes subcutaneous
a little below the knee. It supplies the integument over the calf of the
leg. On account of its origin, the sacral segments, its communications
with the pudic nerve and its branch, the long pudendal, diseases of the
genitalia often produce cramping or pain in the calf of the leg. This
may be due to a disturbance of the great, as well as the small sciatic
nerve. On account of its cutaneous distribution over the gluteal and
femoral regions and its connection with the pudic, and the fact that it
also supplies the pudendum, stimulation of the gluteal region excites the
sexual passion. In sexual perverts, this sort of stimulation is resorted
to in order to arouse the sexual passion. Some writers have pointed
out that the frequent spanking of a child often leads to sexual irritation
or disorder. Perhaps this is true in exceptional cases since it is ana-
tomically possible, on account of the distribution of the small sciatic and
and pudic nerves.

There is a perforating cutaneous nerve, which receives its name
from the fact that it penetrates the great sacro-sciatic ligament, and
becoming cutaneous, supplies a part of the integument over the gluteus
maximus muscle..

Fig. 86. — A sagittal section of the pelvis, showing the rectum drawn away from
the sacrum in order to demonstrate the arteries, veins, and nerves of the sacral and
lateral pelvic regions. (Kelly)-

APPLIED ANATOMY. 317

The nerve to the quadratus femoris muscle, is represented by fila-
ments in the anterior roots of the sacral nerves, and would be more or
less disturbed by a lesion of the innominate. The function of this mus-
cle is to externally rotate the femur. If the nerve were stimulated, the
muscle would contract and external rotation would result so long as
internal rotation of the femur would be difficult.

The nerve to the obturator interims would also be affected by this
lesion, the effect being very similar to that on the quadratus femoris.

The superior and inferior gluteal nerves have been considered. The
effect of an innominate lesion on them would be similar to that of a lesion
of the fifth lumbar.

Cunningham speaks of the visceral branches of the anterior sacral
nerve roots as white rami communicantes. Another writer has spoken of
them as the pelvic splanchnics of Gaskell. At any rate, branches are
given off from the second, third and fourth sacral roots that pass into the
inferior hypogastric or pelvic plexuses and eventually reach the pelvic
organs. The function of these visceral branches is principally motor,
but possibly in addition, vaso-motor, trophic, secretory and sensory im-
pulses are transmitted by them unless they are very different in charac-
ter from the average white rami. Some of these branches, called the
middle hemorrhoidal, supply the rectum. If the lesion stimulates this
nerve, the longitudinal fibers of the rectum contract, the lumen of the
bowel is lessened and constipation from obstruction is the result. Quain,
in speaking of the nerve supply of the rectum, says: "Experiments
upon animals have shown that the longitudinal muscular fibers of the
rectum are supplied with motor fibers from the anterior roots of certain
of the sacral nerves (second, third and in part, the first in the dog) which
nerves also supply inhibitory fibers to the circular coat, whereas the
fibers of the hypogastric plexus which supply the circular muscular tissue
with motor fibers, are derived from white rami communicantes of the
anterior roots of certain of the lumbar nerves, which join the sympathetic
chain and lose their medullary sheath before passing to their distribu-
tion in the muscular coat. " Thus the effects of a lesion disturbing these
nerves can be the better understood when their function is known.

The second, third and fourth send fine medullated branches directly
to the pelvic plexus and indirectly (possibly directly) through the plexus
to the bladder. Quain says that they are the chief motor nerves to the
bladder and are probably distributed to the longitudinal muscle fibers.

318 APPLIED ANATOMY.

An innominate lesion may thus affect the bladder from injury to these
nerves. Any sort of motor disorder of the bladder may be the result.
If the lesion is irritative, there will be frequent micturition and tenesmus;
if the lesion inhibits the passing of the motor impulses designed for the
bladder, there will be difficult and imperfect micturition or motor par-
alysis of the bladder with dribbling of urine.

The nervi erigentes comprise the principal visceral branches of the
sacral nerves. These are named the pelvic nerve by Langley and Ander-
son. The origin of the pelvic nerve varies in different animals but ordi-
narily it is formed by the visceral branches of the second, third and
fourth with the first usually contributing a few fibers. *"Stimulation of
the pelvic nerve causes strong contraction of the bladder, but has no
certain effect on the blood-vessels of the organ; it causes contraction
varying in strength, of both coats of the descending colon and rectum,
the effect being much more constant, and generally greater, in the rabbit
than in the cat and dog; strong contraction of the recto-coccygeal mus-
cle and of the other special muscles of the rectum; dilatation of the
vessels of the mucous membrane of the end of the rectum, and of the
external generative organs; inhibition of the proper unstriated muscle
of the external generative organs, notably the retractor of the penis;
inhibition in the rabbit of the internal anal sphincter, and of some un-
striated muscle in the skin of the ano-genital region."

The distribution and function of this nerve in the human, is proba-
bly very similar to that in the above named animals and consequently,
the effects obtained from stimulation of the one, will in a measure apply
to the other. These nerves that go to form the pelvic nerve, are in rela-
tion with a part of the sacro-iliac synchondrosis and will be more or less
affected by a lesion at this articulation. The lesion will either stimulate
or inhibit the passing of impulses over this nerve as a result of which
there may be two effects from the lesion, that of lessened activity and
that of increased activity. The function of this nerve, its relation to the
synchondrosis and the effect of the lesion on it, explain many of the cases
of disorders in which the bladder, bowel and genitalia are involved.

Some of these visceral branches go across to the vagina, supplying
it with motor impulses. The size of the vagina, unless its muscle fibers
have been torn, is determined by the condition of the nerves supplying
its muscle fibers, hence these branches help to control the lumen of the

*Schsefer's Phys. Vol II, p. 667.

APPLIED ANATOMY. 319

-vagina. An irritative lesion will, if the irritation is marked, produce
vaginismus, a sort of spasmodic contraction of the vaginal walls. Inhi-
bition over the sacrum will often temporarily relieve this condition.
The explanation is that the anterior branches corresponding numerically
to the ones inhibited by the treatment, supply the vaginal walls and
through the effect on the posterior division and effect on the correspond-
ing segment, the irritation is overcome, or the transmission of the motor
impulses is suspended or checked. The better explanation of the effect of
the sacral treatment is that the lesion is corrected and thus is removed
the cause of the irritation to the vaginal nerves. The opposite condition
exists if the lesion inhibits, instead of stimulates these visceral branches.

The motor filaments to the circular muscle fibers of the uterus come
almost entirely from the visceral branches of the sacral nerves. The
function of these circular fibers of the uterus is to oppose the contrac-
tion or rhythm of the longitudinal fibers and to regulate the size of the
outlet or os uteri. In normal cases, the longitudinal and circular fibers
work together; that is, when the longitudinal fibers contract, the circu-
lar fibers relax, as in menstruation and parturition. At other times the
circular resist the action of the longitudinal. The condition of the cir-
cular fibers is governed by the number and character of the motor nerve
impulses reaching them. If they are stimulated, the size of the os is
lessened and vice versa. In innominate lesions, these visceral branches
supplying the uterus are more frequently affected in the female than
any other of the visceral nerves. If the lesion stimulates the nerve,
contraction of the cervix follows, producing dysmenorrhea and dystocia.
If the lesion inhibits the nerves, the cervix and a great part of the body
relax, the os uteri becomes patulous, the blood-vessels are engorged, the
weight of the uterus increases, and its secretions are increased and per-
verted. The size of the uterine blood-vessels is determined to a great
extent by the degree of contraction of the uterine muscle fibers. Menor-
rhagia sometimes results from a subluxated innominate because of ef-
fect on the muscle fibers of the uterus which relax, the blood-vessels
becoming larger, hence congested. Any motor disturbance of the
uterus may follow an innominate lesion on account of its effect on the
uterine muscle fibers. It has not been definitely determined as to
whether or not these visceral uterine branches carry other than motor
impulses, but I surmise that they, like the splanchnic nerves, do.

The various uterine disorders resulting from innominate lesions could

320 APPLIED ANATOMY.

the more easily be explained if this assumption were definitely proven.

Some of these nerve fibers supply the posterior uterine ligaments,
especially the sacro-uterine, the function of which ligament is to sup-
port, to a great extent, the uterus. The attachment of these ligaments
furnishes a pivot around which the uterine movements take place. If
this nerve is stimulated, the uterus will be drawn upward in ascent; if
inhibited, the uterus retroverts and prolapses. In the treatment of
such uterine displacements, the sacro-uterine ligaments must be strength-
ened or a cure is not possible. To do this the lesion, often an innominate
subluxation, must be reduced.

According to Quain, the visceral branches of the anterior sacral
nerves that innervate the prostate gland, are secretory in character.
The gland has a secretion which has to do with thinning the seminal
fluid. Prostatorrhea so often mistaken for spermatorrhea, is a result
of an abnormal activity of this gland. If the lesion is irritative, secre-
tion of the prostate will be increased; if paralytic, it is lessened. The
prostate, in all probability, receives vaso-motor and motor impulses in
part, from the sacral nerves. If this is true, a lesion of the innominate
may produce motor and vascular disturbances of the gland. The ves-
icle seminales and vas deferens also receive some impulses from the
spinal cord by way of the pelvic plexus.

An articular branch from the anterior sacral nerves passes to the
hip-joint. Disturbances of the joint may be the effect of an innominate
lesion on account of disturbance of this nerve filament.

The great sciatic, is the principal nerve coming off from the sacral
plexus, in fact it seems to be a continuation of the plexus. It is com-
posed of two parts, the one portion going to form the external popliteal,
the other, the internal popliteal. The former is derived from the anterior
division of the fourth and fifth lumbar and first and second sacral nerves;
the latter, from the anterior divisions of the fourth and fifth lumbar and
the first, second and third sacral nerves. These parts unite to form a
thick band which passes out of the pelvic cavity through the great sacro-
sciatic foramen in relation with the pyriformis muscle. It then passes
through the buttocks into 'the thigh in the hollow between the great
trochanter and the tuberosity of the ischium. The upper part is covered
by the gluteus maximus and is most superficial while in relation with
the trochanter and tuber ischii. In the thigh, it lies on the adductor mag-
nus muscle, and terminates at or near the popliteal space, where it divides
into two branches, the internal and external popliteal.

APPLTED ANATOMY. 321

The internal popliteal continues as the posterior tibial, which in
turn divides into the internal and external plantar.

The external popliteal divides into the anterior tibial and musculo-
cutaneous. This nerve is chiefly motor and sensory, although it has
vaso-motor, secretory and trophic functions. It supplies motor im-
pulses to some of the muscles on the posterior aspect of the thigh and
practically all those below the knee. It supplies sensation to about the
same areas; also supplies the various articulations of the lower limb.
It is vaso-motor and trophic to the same areas and secretory to the
sweat glands of the lower part of the thigh, leg and foot.

This nerve is affected by an innominate lesion (1), because of the
relation of its roots to the sacro-iliac articulation, and (2), because of
contracture of certain muscles and tissues that are in relation with this
nerve and would be affected by the lesion and (3), because of the vascu-
lar changes in the nerve that are produced by the lesion.

The lesion may stimulate or inhibit the nerve filaments or roots
that go to form this nerve. Only a few of these filaments may be af-
fected, or in marked innominate lesions, many may be disturbed. This
accounts for the variable effects on this nerve and its branches, from a
lesion affecting it. If the lesion is irritative, that is if it produces a
stimulating effect on this nerve, all or only some of its functions will be
disturbed, this depending on the degree and length of the stimulation.

The motor effect varies in different cases, but cramping of the leg
or foot is fairly common. "Morton's toe" is an example. Contracture
of any of the leg muscles may result. If the nerve were inhibited
by the lesion, there would be relaxation of some or all of the muscles sup-
plied by it. Atrophy is present, and if the lesion is extensive, the relax-
ation and weakness are so marked that the function of the limb is almost
completely lost.

The sensory effects of a lesion of the innominate disturbing the great
sciatic nerve, are most common and pronounced. If the lesion is irritative,
sciatica in some form is the usual effect. This disease is characterized
by pain in and along the course of the nerve, which is more or less severe.
Inflammation is usually pi-esent. The disorder follows soon after an
injury to the innominate, sometimes as an ache, sometimes as an acute
pain. Any movement of the hip increases the pain, which is so excru-
ciating in some cases that the patient is scarcely able to endure it. The
patient favors the affected side and in chronic cases, a scoliosis develops,

322 APPLIED ANATOMY.

called sciatic scoliosis, in which the concavity is directed toward the
affected side. The pelvis is usually tilted, but this is the result of the
subluxation as often as the result of posture.

Sciatica is diagnosed by discovering tenderness of the sciatic nerve
at the points at which it is most superficial. These points are (1), a
point about midway between the great trochanter and the tuberosity
of the ischium, and (2), the popliteal space, the first named being the
more important of the two. The innominate lesion produces sciatica
by directly irritating the roots that go to form the sciatic nerve, which
roots cross and are bound down to the sacroiliac joint. In acute cases
in which the pain is intense, the nerve roots are considerably injured.
In the milder and more chronic forms the subluxation is not so marked,
but the long continued irritation produces the chronic sciatica. The
author recognizes other causes of sciatica, but the most common and
important oae is the innominate lesion.

This subluxation may disturb the function of the nerve by causing
contracture of muscles in relation with the nerve, viz., the pyriformis and
the hamstring muscles. Pressure is exerted directly on the nerve by
contracture of these muscles, and if very marked or continued for any
great length of time, the nerve becomes irritated, congested or inflamed
and the condition is called sciatica. In all cases in which the disorder is
well marked there is a perineuritis, while in ordinary simple cases there
is only a congestion of the nerve and the tissues immediately surrounding
it.

Other sensory effects result from an innominate lesion, such as
"neuralgia" of different parts of the leg and foot, cramping of the lower
limb, numbness, itching and burning sensations usually in the bottom
of the foot. This is called erythromelalgia or red neuralgia, of the feet.
As stated in the discussion of the effect on this nerve of a lesion of the
fifth lumbar, any sensory, motor or trophic, or even vasoTmotor dis-
turbance of the lower limb may be the result of an interference with the
functioning of the great sciatic nerve. An innominate lesion is the
most frequent and important of causes that affect this nerve.

*" Referred pains are quite common, and are probably due to the
pressure or pull upon the nerves in the sacral region. The lumbo-
sacral cord passes directly over the upper part of the sacro-iliac articu-
lation, and it is easy to see that a slight displacement or the thickening

*Goldthwait, Loco citra.

APPLIED ANATOMY.

323

Fig. 87. — Showing a twisted pelvis slightly exaggerated. (From photo). The
waist line on the right was almost obliterated while that on the left was deepened.

324 APPLIED ANATOMi".

or nodes resulting from disease might cause pressure upon this nerve
trunk. Undoubtedly the pressure or irritation of the nerve received in
this way causes many of the pains referred to the leg. They may be
referred to any part below the seat of the trouble, to the thigh, the hip,
the calf, or down the back of the le"g following the sciatic distribution.
That the nerves are pressed upon or irritated is not to be wondered at
when the anatomy is considered. In fact, in any displacement that
may occur, or in the hypertrophic arthritic thickening, the edge of the
bone is so exposed that pressure or irritation of the nerve is almost to
be expected. "

Disturbances of the sciatic nerve may cause congestion of the lower
limb, varicose veins, ulceration, caries, or any pathological vascular or
trophic effect, since the function of the nerve is in part vaso-motor and
trophic. Pathological sweating of the feet may also be a result of an
innominate resion producing a disturbance of the great sciatic.

Hilton, in speaking of the sacro-iliac joint, says that affections of it
may be mistaken for hip-joint disease. He says, "it is impossible to look
at the form of the sacrum — its wedge-shape, the broad or massive part of
the wedge being above — or to regard the extent of the articular surfaces
of these bones and the strong ligaments which fix them together, without
percieving that great strength is a part of their natural function. If
any disease should occur at the sacro-iliac joint (and I would add sub-
luxation,) I think it will be apparent what the symptoms may be.
If a patient should have disease there, he could not sit very comfort-
ably even On the sound side, because then the whole weight of the body
would be transferred through the medium of the spine to the sacrum, and
thence produce pressure upon the articular structures of the joint,
which would, if diseased, produce pain. Nor could the patient stand
upright without great pain. " He further mentions the effect on the
obturator, great sciatic and superior gluteal nerves and the psoas magnus
muscle. A great many cases of supposed hip-joint disease are in real-
ity a sacro-iliac subluxation.

The obturator nerve, on account of its relation to the sacro-ihac
joint, is sometimes affected by a lesion of the innominate. Pain in the
hip, but especially on the inner side of the knee on the same side, is the
most common effect.

In innominate subluxations, everything attached to the bone is
more or less affected, because in the production of the lesion the move-

APPLIED ANATOMY.

325

Fig.
photo.)

1. — Lateral curvature of spine. Note effect on contour of hips. (From

326 APPLIED ANATOMY.

merit of the bone was carried beyond the normal range of movement.
The muscles attached to the innominate are noted for their size and
strength, which factor must be considered in the production of innom-
inate lesions. The muscles affected most are in front, the rectus fem-
oris and sartorius; on the side, the glutei and iliacus; and inferiorly, the
hamstring muscles. If the bone is rotated back and up, the most com-
mon form of lesion, the anterior muscles are put on a tension. This
produces a stiffening of the limb followed by impaired movement, and
in many cases, an interference with the return circulation from the lower
limb. Varicose veins sometimes complicate such a displacement. If
the- bone is displaced upward it will affect the iliacus. The muscle
often becomes thickened, and on this account, leads to an error in diag-
nosis in that it is mistaken for some form of tumefaction of the pelvis.
This condition produces a pain or drawing sensation referred to the
iliac fossa. The glutei muscles, when put on a tension, interfere with
the position of the coccyx and the movement of the lower limb. In
lesions in which the ischium is displaced upward or backward, the ham-
string muscles are put on a tension. This produces (1), pressure, directly
or indirectly, on the great sciatic nerve, and (2), interferes with extension
of the leg and flexion of the thigh and both assume a state of partial
flexion. In lesions in which the posterior spines and crest in relation
are displaced backward or downward, the erector and multifidus spina?
muscles are put on a strain which, when continued for a while, produces
an ache in that region. In addition to the muscular effects the various
ligaments are disturbed, not only those of the sacro-iliac joint, but the
uterine ligaments, the broad and ovarian. All these tissues are affected
by the lesion, the result of which is a thickening of the parts and a sense
of pulling or drawing.

The contour of the pelvis and hips is changed by the innominate
lesion, one side or hip becoming larger and higher than the opposite
one. This is more common and noticeable in the female than in the
male. This unsymmetrical condition may in turn affect the spinal
column and often a well defined scoliosis develops.

The length of the lower limb is usually, although not necessarily,
affected. In recent and typical cases, there is a slight shortening of
the limb although the opposite condition may exist.

The mobility of the hip-joint is lessened and the patient complains
of a neuralgia or "rheumatism," as it is most frequently diagnosed by

APPLIED ANATOMY. 327

the layman. The limb may ache or become congested and edematous.

The sensory disturbances come most frequently from the effect on
the sciatic nerve. The congested condition, from obstruction at or
below the saphenous opening; the edematous condition from obstruction
to the lymphatic return. Many a case of pain along the thigh, varicose
veins or congestion of the lower limb, or marked edema of the ankle,
is due to a lesion of the innominate on the affected side.

In all innominate lesions there is some change at the symphysis
pubis. It may not be enough to be palpated but in many cases it is,
and it is a good plan to examine, what Dr. Still has so often called the
" cross bones," for tenderness and irregularity.

In the correction or reduction of innominate lesions, the limb should
be used as a lever and on this account care should be taken not to un-
derestimate the amount of force it is possible to exert when using it as
such.

THE SACRUM.

The sacrum, so-called by the ancients because it was regarded as
the sacred part of an animal and was offered as a sacrifice, is a large
curved triangular bone formed by the union of five separate vertebra?.
It is joined to the innominate by the sacro-iliac articulation, hence dis-
placements of this bone affect the joint and the adjacent structures in a
way similar to that of an innominate lesion. The sacrum has a possible
movement; that is, one of antero-posterior rotation around the sacro-
iliac articulation as a pivot. This takes place to a certain extent during
parturition.

It is subject to displacement downward, forward, backward, or a
combination of two or more of these; that is, rotation and torsion. It
is placed at quite an angle with the spinal column, an angle of about
50 degrees. In subluxations of the sacrum this angle is changed, there
is tenderness at its articulations and possibly irregularity. Forward
rotations of the sacrum are diagnosed by prominence of the lower part
and the angle. If the upper part is rotated forward, the lower part is
brought into prominence and the sacro-coccygeal articulation becomes
more angular. If the upper part is rotated backward the angle is lessened,
the upper part is prominent, the lower part is almost on a line with the
upper part. Descent is diagnosed by height of the innominata as com-
pared with the spines of the lower lumbar vertebrae. In making a diagnosis

32S

APPLIED ANATOMY.

of a lesion of the sacrum consider (1), tenderness at the sacro-lumbar.
sacro-iliac and sacro-coccygeal articulations, and (2), irregularity at
one or all of these joints, height of innominata and angle or position of
the sacrum. In addition to this consider the character of the symptoms,
location of pain and history of injury to part.

The lesions of the sacrum come from causes that ordinarily produce
innominate lesions and in addition, lumbar disturbances such as curva-
ture; falls in the standing posture, the superimposed weight of the body

SPINOUS
PROCESSES

ERECTOR SPIN*
MULTiriOUSSP/N*

Fig. S9. — The posterior aspect of the sacrum,
and the arrangement of the foramina.

SACRAL CANAL

Note the superior articular facets

driving the sacrum downward; and direct injury or certain occupations
that necessitate the patient's sitting bent over a desk or working in a
stooped posture.

The effects on the sacro-iliac joint are the same as those from an
innominate lesion. The effects on the sacro-lumbar articulation are
practically the same as those from a lesion of the fifth lumbar vertebra.

APPLIED ANATOMY.

329

The sacro-coccygeal articulation will be affected and will be considered
in the study of lesions of the coccyx and their effects.
• 0 The structures attached to the sacrum will be more or less affected
by a lesion or partial displacement of it. The glutei and erector spinae
muscles and the great sacro-iliac and sacro-sciatic ligaments are at-
tached. Anteriorly the pyriformis is the principal muscle, and the
sacro-uterine the most important ligament. If the sacrum becomes
more nearly vertical, as is often the case, all these structures will be

1LIACUS

ipBlL '" :i

SACRAL
FORAMINA

BROOVE FOR 5th SACRAL N

Fig. 90. — Anterior view of the sacrum.

changed. If the change of position of the sacrum is gradual, there will
be 'few, if any, indications or disturbances other than a weakening of
this part of the back. The change in the sacro-uterine ligaments usual-
ly affects the uterus. The downward displacement of the sacrum or
a forward rotation of its upper part, lessens the size of the inlet of the
true pelvis, that is the true internal conjugate diameter of the inlet is
lessened so that parturition is difficult on account of delayed engagement

330 APPLIED ANATOMY.

of the fetus. In rachitic subjects, the promontory is bent downward,
often to such an extent that delivery is impossible without resorting to
an operation.

In subluxations of the sacrum, the contour of the spinal column is
changed. The more nearly vertical the sacrum, the more posterior the
lumbar spine and the more nearly straight the entire column. If the
sacro-lumbar angle is lessened, the anterior curve of the lumbar region
is increased. There may be muscular effects. If the lesion is irrita-
tive on only one side, the contracture of muscles on that side will draw
the spinal column to that side.

The condition of the spinal column has a great deal to do with the
position of the sacrum. A posterior lumbar spine will produce a straight
sacrum. The way a great many people sit is responsible for sacral
deviations. They sit on the sacrum instead of the tuber ischii, and the
lumbar spine, is forced into a position of posterior curvature and the
sacro-lumbar angle becomes almost a straight angle. This continued,
will lead to a change in position of the sacrum, which is pathological.

*"The lateral deformities or deviation of the body to one side, due
to the displacement of the bones on one side and not on the other, are
common. The onset may be sudden. The so-called "stitch" in the
back following strain or overwork, is in most instances, due to the slip-
ping of these bones, and in these cases the lesion represents a definite
sprain, the severity of the symptoms depending on the severity of the
injury as with sprains of other joints."

A displacement of the sacrum will affect the sacro-coceygeal artic-
ulation and produce symptoms and signs that are ordinarily attributed
to a subluxated or dislocated coccyx. The sacro-coccygeal articulation
is formed by the articular facets of the last sacral and first coccygeal
vertebrae. The articular surface of the first coccygeal segment is oval
shaped and faces forward and upward. From the upper part two cornua
or projections pass upward and inward and are connected with the
sacral cornua by the sacro-coccygeal ligaments. A foramen is formed
by these through which the fifth sacral nerve passes. This articula-
tion is a hinge joint, its movements being antero-posterior. These
movements are pronounced in parturition and defecation. The con-
traction of the levator and sphincter ani muscles causes it to be
drawn forward; contraction of the gluteus maximus, drawing it back-
ward and to one side.

Goldthwait, Boston Med. and Surg. Journal, 1905.

APPLIED ANATOMY. 331

Lesions at this joint result from displacement of the sacrum or
coccyx. Trauma and strain are responsible for many cases, but muscular
contraction is an important factor in the production of coccygeal sub-
luxations. If the lower part of the sacrum is rotated backward, the sacro-
coccygeal articulation or angle is affected and becomes more acute,
since the tip of the coccyx is not displaced, but held in position by struc-
tures attached to it. If the sacrum is displaced downward the effect
is about the same. Often this sort of sacral lesion is mistaken for an
anterior luxation of the coccyx. In either case the sacro-coccygeal
articulation is affected. In determining which is at fault, the sacrum
or the coccyx, both should be examined for irregularity, tenderness and
disturbances resulting.

In lesions of this joint the ligaments, first of all, would be involved,
that is they are stretched and thickened as in a sprain of any joint. The
muscles attached to the coccyx are affected more than those attached
to the sacrum, since the coccyx is the more movable of the two and is
the one displaced most in ordinary cases.

The muscles attached to the coccyx are the levator ani, coccygeus,
external sphincter ani and gluteus maximus. Their function will be
affected to some extent by the lesion. Contraction is a common sequel
which is followed by rectal tenesmus and constipation, from a lessening
in size of the lumen. Hilton, in speaking of this joint and the glutei
muscles, says: "It must be obvious that if the sacro-coccygeal articu-
lation or the coccyx itself be inflamed, and the gluteus maximus be used
to any extent in the act of elevating the body from the sitting posture
or in sitting down, or in rapid progression, the coccyx or sacro-coccygeal
articulation must be much disturbed. Hence, although the patient
may be able to walk gently, slowly, and carefully, yet on attempting to
stride out he suffers considerable pain from the disturbing influence of
the gluteus maximus During defecation, this muscle (speak-
ing of the external sphincter ani) and the levator ani contracting would
tend to disturb or displace the coccyx and pull it away from the sacrum.
Some of the symptoms of which such patients generally complain are
thus explained. " I would offer in addition to this, cases in which there
is a partial displacement of the coccyx, which is by far more common
than disease of the joint, in which the symptoms would be similar to,
or almost identical with, those outlined above.

The nerves in relation with this joint and which supply the tissues

332 APPLIED ANATOMY.

in relation are (1 ), the pudic, the perineal branches; (2), posterior branches
of the lower sacral nerves; and (3), the sacro-coccygeal. All of these
send sensory filaments to the perineum. The effects of a lesion involv-
ing these nerves would then be sensory in character. Pruritus ani is
the most common sensory effect. Sexual passion is increased, sometimes
to a pathological degree, which is explained by the disturbance of the
pudic nerve or one of its branches. Pain in the perineum is not un-
usual, this resulting from a displacement of the coccyx or abuse of the
function of the pudic nerve.

The coccyx, when displaced, often produces disorders by pressure
or traction on, the tissues attached and the bowel is most affected. If
displaced forward the pressure may obstruct the veins of the rectum,
thus producing hemorrhoids, or it may affect the nerves in relation,
producing effects varying with the degree of pressure and the nerves
involved. This displacement will interfere with defecation and parturi-
tion, and especially if anchylosis of the sacro-coccygeal articulation has
taken place. Falls and blows on the coccyx are most responsible for
its forward displacement. Such injuries dislocate the coccyx and force
it forward into the rectum. The point of the bone mechanically ob-
structs the lumen of the bowel and presses on important structures in
relation, viz., the hemorrhoidal veins, nerves and arteries, thus almost
any disease of the part, such as hemorrhoids, ulceration, constipation,
diarrhea and painful affections, may result. The displacement may be
at the sacro-coccygeal articulation but more commonly at the last
coccygeal joint, and on rectal examination the tip of the coccyx is found
to be directed inward and the angle formed is very acute. The coccygeal
nerves are affected by such a displacement. These nerves are sensory
to the integument in relation and the anterior is motor to the coccygeus.
Coccydynia is a result of this coccygeal lesion.

THE BACK AS A REGION.

The Back as a Region. The surface markings of this region are the
median furrow, the spines of the vertebra, especially the vertebra prom-
inens and first dorsal, the trapezii muscles and the scapulae. The spinal
furrow is formed by two masses of muscles; the erector spinse masses,
which fill in the groove on the sides of the spinous processes, and the
bottom is adhered to and conforms with, the spinous processes. The
spines are most prominent in the upper and lower dorsal areas when

APPLIED ANATOMY. 333

sitting erect, but most prominent in the lumbar region on flexion of the
body. The outline of the trapezii muscles can ordinarily be distinctly
seen. The scapula is quite prominent, its spine and inferior angle being
the parts used as landmarks. The interscapular space varies in differ-
ent individuals, the average distance being about five inches. When
the arms are thrown backward the scapulae touch, when thrown forward
they (the inferior angles) are separated about twelve inches.

According to McClellan, "the most reliable landmarks for clinical
purposes in this region are as follows: The third dorsal spine is about
opposite the bifurcation of the trachea; the fourth dorsal spine indi-
cates the position of the base of the heart, while the eighth dorsal spine
corresponds to the lower borders of the lungs, which, when fully ex-
panded, follow the upper borders of the eleventh ribs. The second
lumbar spine is opposite the termination of the duodenum and also op-
posite the commencement of the cauda equina within the the spinal
canal. The fourth lumbar is opposite the bifurcation of the aorta. "

The integument over the shoulders and upper part of the back is
quite thick and closely adherent to the fascia beneath. On this account
and that of friction from clothing, boils and carbuncles often form in
this area, since the vitality is poor and the circulation not good. The
skin of the lower part of the back is not quite so thick and becomes
thinner from the spine outward. Few sebaceous glands are in the lower
part, while many are located in the upper part, especially over the
scapulae. This leads to the formation of pimples on the upper part of
the back and shoulders. The sensibility of the integument is less along
the spine than at the sides of the thorax. The integument of the back is
innervated by the posterior divisions of the various thoracic nerves, the
internal branches of the upper six and the external branches of the lower
six, supplying it.

The skin may be pigmented from deposits in it from jaundice, or
from friction. If the spinous processes in the lumbar region are yellowish,
it is indicative of a posterior condition with friction from the clothing or
the backs of seats. Leucoderma is present in some cases, being well
marked along the back. In some diseased conditions dermography is
possible. The writer has seen cases resulting from a "going in" of the
rash in measles, in which the least friction would raise a large welt which
at first was white, then becoming congested and red, lasting for several
hours.

334 APPLIED AJVATOMY.

In the examination of the back, it is well to make a test for the
capillary reflex. This is done by pinching up the skin. This, in the
normal patient, immediately produces a red area corresponding in size
to that pinched. If this reflex is slow in responding to the test, or does
not at all respond, it is suggestive of a lack of red blood corpuscles as in
anemia. If the redness remains for quite a length of time, it is sug-
gestive of an impairment of the nervous system and especially of disorder
of the meninges of the cord. The tache meningeale of spinal meningitis
is an example.

To the osteopathic physician, the most important part of the human
body is the spinal column. By its changes in contour and condition the
various visceral diseases can be diagnosed, in most cases. I believe that
every disease is characterized by external changes or signs, and I further
believe that every chronic visceral disorder is manifest by changes in
the spinal column that can be, by the practiced eye and touch, readily in-
terpreted. In short, there are various signs along the spinal column
that point out the weakened or diseased parts of the body. This method
of diagnosing diseases, that is by noting these spinal changes, is dis-
tinctly osteopathic, and I believe the time will come when it will become
such an exact science that the character of the spinal change or lesion
is diagnostic not only of the viscus affected, but the way it is affected.
On account of the importance of the spine in diagnosis, particular study
of it should be made, as to contour and condition, and the various
conditions that change them.

In examining a normal spine note that the spinal furrow is of about
equal width and depth along its entire course, being slightly wider in
the upper thoracic area and slightly deeper in the upper lumbar region
than elsewhere; the spines are regular and in line; that there are four
curves, the anterior cervical, posterior upper dorsal, anterior lumbar
and posterior sacral; that the seventh cervical and first dorsal spines
are large, the spines of the thoracic region small and oblique, while the
lumbar spines are largest. The mobility is good and most marked at the
dorso-lumbar articulation. The normal contour depends on the above
named curves and the development of certain muscles. The spine of a
new-born baby is about straight. When the child begins to sit erect it
forms one continuous posterior curve, and when the child begins to sit,
stand and to walk, the curves begin to form. Eisendrath says: "When
the infant begins to sit up, the weight of the head and shoulders and the

APPLIED ANATOMY.

335

Fig. 91. — Showing the sensor}' innervation of the posterior aspect of the body.
(After Eisendrath).

336 APPLIED ANATOMY.

forward traction on the part of the viscera cause the development of a
backward curve or kyphosis which extends over the whole spine. With
the effort of the child to hold up its head the cervical portion of the
spine gradually bends forward (lordosis). The third curve appears
when the child begins to walk. In order to maintain the upright posi-
tion the child uses its back and gluteal muscles. At the same time the
pelvis is inclined downward, thus throwing the center of gravity of the
body further back. In order to compensate for this the lumbar portion
of the spine is bent forward resulting in the above referred to, lordosis
of that region. These curves are not well marked until the seventh
year, and can be entirely obliterated by traction upon the child's head."*
These curves are maintained in the adult to a great extent by the inter-
vertebral discs which are most developed in the lumbar region where move-
ment is quite free. These discs are very elastic and the elasticity of the
spine is due almost entirely to them. The natural curves of the body
are the anterior and posterior, the least lateral deviation being abnormal.

The muscles that go to make up the normal contour are the erector
spina?, latissimus dorsi, trapezius and rhomboidei; at least these are
the most important. The normal contour varies with the degree of devel-
opment of these muscles and the degree of curvature of the spine.
Certain occupations increase the curves and still the spine is normal.
In occupations in which the patient has to stoop a great deal, the pos-
terior thoracic curve increases and still the contour is, as a rule, normal
for that individual.

The functions of the spinal column are to protect the spinal cord
and its membranes and to permit the spinal nerves to emerge without
injury in all normal movements of the spine, to furnish a fixed point for
action of muscles that move the body, and to support the head and
trunk. If the contour is changed, any or all of these functions may be
impaired, the most common result being the disturbance of the spinal
cord, its membranes, and the nerves branching from the cord. Change
of contour is of great importance to the osteopathic physician, for upon
these changes is the diagnosis best made in many cases and the cause of
disease ascertained. The effects of changes in contour on the spinal
nerves may be overlooked or an error be made in diagnosis unless it be
recalled that the segment that give rise to these nerves, their points of
exit and the level of the corresponding spinous processes vary in differ-
ent regions. The description given by McClellan is as correct as any.
*Clmieal Anatomy, Eisendrath, P. 488.

APPLIED ANATOMY. 337

He says : " There is no means of foretelling the absolute relative positions
of the origins of the individual spinal nerves from the spinal cord but they
may be approximately considered to be as follows: Collectively, the eight
cervical nerves arise between the medulla oblongata and the cord op-
posite the spine of the sixth cervical vertebra. Individually, the first
cervical nerve arises at the interval between the margin of the foramen
magnum and the atlas vertebra, the second and third cervical nerves
arise opposite the axis vertebra, while the fourth, fifth, sixth, seventh
and eighth cervical nerves arise respectively opposite the bodies of the
third, fourth, fifth, sixth and seventh cervical vertebrae. Collectively,
the upper six dorsal nerves arise from the cord between the spines of the
sixth cervical and fourth dorsal vertebrae. Individually, the first, second,
third and fourth dorsal nerves arise respectively, opposite the inter-
vertebral discs below the seventh cervical and the first, second and
third dorsal vertebra?, while the fifth and sixth dorsal nerves arise op-
posite the bodies of the fourth and fifth dorsal vertebrae. Collectively,
the lower six dorsal nerves arise from the cord between the spines of the
fourth and eleventh dorsal vertebrae; individually, they arise opposite
the bodies of the sixth, seventh, eighth, ninth, tenth and eleventh ver-
tebra?. Collectively, the five lumbar nerves arise from the cord between
the eleventh and twelfth dorsal spines. Individually, the first, second
and third lumbar nerves arise opposite the body of the twelfth dorsal
vertebra, and the fourth lumbar nerve arises opposite the intervertebral
disc between the twelfth dorsal and first lumbar vertebra?. The fifth
lumbar nerve, the five sacral nerves, and the coccygeal nerve all arise
from the conus medullaris opposite the body of the first lumbar vertebra,
which corresponds to the spines of the last dorsal and first lumbar ver-
tebra." By referring to the above and recalling the obliquity of the
spines in the various regions, the lesion can be located without much
trouble, in case of injury to the spinal cord or subluxation of a vertebra
that produces pressure on a spinal nerve at its exit.

The tips of the spinous processes are used as landmarks for locating
various structures. Some of these landmarks have been given. Deaver
gives in addition: "The sixth cervical spine corresponds to the highest
level of the apices of the lungs. The third dorsal spine lies opposite the
point where the aorta approaches the spinal column, the highest level of
the lower lobes of the lungs and the bifurcation of the trachea. The
ninth dorsal spine marks the level of the cardiac orifice of the stomach

338 APPLIED ANATOMY.

and the upper limit of the spleen. The tenth dorsal spine locates the
lowest level of the bases of the lungs and the level at which the liver
reaches the abdominal walls posteriorly. The eleventh dorsal spine
locates the lower limit of the spleen, the position of the suprarenal cap-
sule and the upper border of the right kidney. The twelfth dorsal spine
is on a level with the lowest part of the pleura?, the aortic opening of the

Fig. 92. — Model with spine flexed and bent to the left. The boards show the
planes of chest and pelvis. The boards marking the chest, have rotated backward on
the convex side of the curve. (Lovett).

diaphragm, and the pylorus. The spine of the first lumbar vertebra is
situated opposite the renal vessels, the pelvis of ureter, and the pancreas.
The second lumbar spine lies opposite the end of the spinal cord, the
third portion of the duodenum, and the receptaculum chyli. The third
lumbar spine is found just above the level of the umbilicus and below
that of the lower border of the right kidney. The fourth dumbar spine

APPLIED ANATOMY.

339

is located opposite the bifurcation of the aorta and the highest part of
the crests of the ilia. The fifth lumbar spine marks the origin of the
inferior vena cava. The third sacral spine lies opposite the termina-
tion of the sigmoid flexure and the lowest level of the spinal membranes.
The tip of the coccyx marks the junction of the first and second portions
of the rectum."

The movements of the spinal column are of great importance to
the physician in that lesions of the vertebral articulations are indicated
best by disturbances of these movements. A spinal column in which

Fig. 93.-- Experimental double curve (right dorsal, left lumbar) produced in
the model by elevating the right side and having the model twist the upper part to
the left. (Lovett).

340

APPLIED ANATOMY.

the movements are normal, is as a rule a normal one and if there are
visceral disorders they are due to other causes. These movements are
distributed amongst all the vertebral articulations, that is there is move-
ment at every articulation in the normal spine. In the examination of
patients, this point is often overlooked on account of the compensatory
hypermobility of other articulations.

Fig. 94. — Experimental double curve (right dorsal, left lumbar) produced in
the cadaver by elevating the right side of the pelvis and twisting the upper end of
the spine, face to the left. (Lovett).

These movements are produced by muscular contraction and by
gravity. In flexion, the muscles of the front of the column are active,
while in extension the muscles of the back contract. The muscles that

APPLIED ANATOMY.

341

produce extension are stronger than those that produce flexion, hence
in spasms, there is a drawing back of the body as in opisthotonus. Grav-
ity begins to assist just as soon as the body is drawn away from the
perpendicular by the muscular contraction.

The movements are most free in the cervical and lumbar articula-
tions and in these regions, at the atlanto-axoidal and dorso-lumbar
joints. They are considerably less than one would suppose when the
extent of the spinal movements is considered, the explanation being

Fig. 95. — The right side of the pelvis of the cadaver is raised and the upper part
of the spine falls to the left, making a lateral curve convex to the right. (Lovett).

that much of the supposed movement takes place at the hip-joints and
the lumbo-sacral articulation. For example, in flexion the greater part
of the forward movement is in the hip-joints while if you ask the patient
to bend to the side, the pelvis will be tilted to the opposite side, this ex-
aggerating the apparent lateral bending.

There are essentially three movements of the spinal column: flexion
or forward bending, extension, or backward bending, and lateral bend-

342 APPLIED ANATOMY.

ing with rotation. Flexion and extension are most free in the cervical
and lumbar regions while rotation and lateral bending are most
marked in the thoracic, the atlanto-axoidal articulation being excepted.
Flexion in the cervical region is not very marked since much of the
movement is between the occiput and the atlas, and the second cervical

Fig. 96. — The right side of the pelvis of the model is raised and the upper part
of the spine is carried to the right, making a lateral curve convex to the left. (Lovett) .

vertebra or axis. Ordinarily the anterior curve only can be obliterated.
In hyperextension the normal curve can be increased. In side bending,
the movement is fairlv well distributed amongst all the articulations but

APPLIED ANATOMY.

343

the greater part is in the upper part of the neck. There is rotation of
the bodies of the vertebrae to the opposite side, that is, toward the con-
vexity of the curve.

In the thoracic region, there is little flexion or extension, the prin-
cipal movement being that of rotation which seems to be a part of the

Fig. 97. — The right side of the pelvis in the cadaver, is raised and the upper part
of the spine firmly held, making a lateral curve with convexity to the left. (Lovett).

movement in side bending. This movement is practically the same as
that in the neck, the bodies of the vertebras rotating to the convexity,
and the spines toward the concavity of the curve. This should be re-
membered in the treatment of scoliosis since the opposite rotation of the
spines would be expected on first examination. The greater the degree

344 APPLIED ANATOMY.

of flexion of the body at the time of the side-bending, the greater the
degree of rotation, and the higher it occurs in the spine. Side-bending
in the erect posture is accompanied by rotation low in the spine which
is best marked at the dorso-lumbar articulation.

Flexion and extension are the principal lumbar movements, rotation
and side-bending being slight. These movements are not so free as one

Fig. 98. — Model flexed and bent to the left. The card-board indicators have
turned to the left. (Lovett).

would at first think on account of the free movements of the hip-joints
and the lumbo-sacral articulation. *Lovett arrived at the following con-
clusions after careful investigation: " (1) In the lumbar region flexion
♦Boston Med. and Surg. Jour. p. 355, Vol. CLIII.

Fig. 99. — Showing the multifidus spina; muscle. This muscle is involved in
scoliosis. Its contraction produces lateral flexion with rotation to the opposite side.

346

APPLIED ANATOMY.

diminishes mobility in the direction of side-bending and rotation, and
extreme flexion seems to lock the lumbar spine against these move-
ments. (2) In the dorsal region hyperextension diminishes mobility
in the direction of side-bending and rotation. Extreme hyperextension
seems to lock the dorsal spine against these movements. (3) In flexion

Fig. 100. — The trapezii muscles. In colds of the upper respiratory tract, the
parts covered by these muscles are always tender on pressure.

of the whole spine, side-bending is accompanied by rotation of the ver-
tebral bodies to the convexity of the lateral curve, the characteristic
of the dorsal region. (4) In the erect position and in hyperextension
of the whole spine, side-bending is accompanied by rotation of the ver-

APPLIED ANATOMY. 347

tebral bodies to the concavity of the lateral curve, the characteristic of
the lumbar region. (5) The dorsal region rotates more easily than it
bends to the side, whereas the lumbar region bends to the side more
easily than it rotates. (6) Rotation in the dorsal region is accompanied
by a lateral curve, the convexity of which is opposite to the side to which
the bodies of the vertebrae rotate."

Abnormal changes in contour of the back are clue to muscular con-
tractures, curvatures, tumors, enlarged viscera, certain occupations and
some forms of visceral diseases. The muscles most commonly involved
are the erector spina? mass, trapezius, quadratus lumborum, serratus
magnus and the rhomboid muscles. If contracture of any of these mus-
cles takes place, it becomes enlarged and prominent and has a tendency
to draw the spine to that side. Relaxation of any one would make it
appear that the opposite one was contractured or enlarged. Contrac-
ture of the erector spinas mass of muscles produces enlargement on that
side; relaxation or atrophy has the opposite effect. The trapezius when
contractured makes the suprascapular region more prominent. Relax-
ation of the serratus magnus causes the scapula on the same side to be-
come prominent, that is, it becomes winged, thus changing the contour.
If the rhomboids are also relaxed, the interscapular region is widened
and the spine becomes flattened. If there is general spinal atrophy, the
ribs become displaced downward, the normal curves of the spine are
obliterated and the spinous processes become plainly visible.

Curvature of the spine is the most common and important of all the
causes of change in contour of the back. By curvature of the spine is
meant an abnormal bending or swerving of the spinal column, which
is ordinarily accompanied by disturbance of function of that part of the
spine, and of viscera and structures innervated by the nerves that are
in relation with the points of the spine affected. Most curvatures start
from a single lesion, that is, subluxation of a single vertebra or abnormal
movement of one part of the spinal column on another. These lesions
produce curvature either by interfering with the nutrition of that part
of the spinal column, or by causing muscular atrophy or contracture.
Muscular contracture from other causes often leads to curvature. Mus-
cular atrophy produces curvature since the sound side is unaffected and
the muscles unopposed, draw the spine to that side.

The size of the viscera in relation has to do with the contour of the
spinal column, as is evidenced by curvature following a collapse of one
lung. Faulty posture often leads to curvature, and unequal length of

348 APPLIED ANATOMY.

the lower limbs, a tilted pelvis and diseases of the bones,' as in rickets,
are also responsible for many cases.

The forms of curvature vary from a slight flattening of the dorsal
area to a well marked case of scoliosis. Posterior curves are most fre-
quent in the lumbar, and are called kyphoses. An anterior curve is
called a lordosis, and scoliosis is the name given to a lateral curvature.

The kyphosis is possibly the least harmful, compared with the ex-
tent or degree of variation, since the intervertebral foramina are en-
larged rather than lessened by it. This form results most frequently
from occupations involving the stooping posture or faulty methods of
standing and sitting. A general spinal weakness is responsible for most
cases coming under the last named class, and the patient no longer at-
tempts to sit erect but sits with a marked posterior lumbar curve. If
the patient by attempting to sit erect is unable to obliterate the pos-
terior conditio^, it is a pathological kyphosis. Occupational kyphosis
is seldom pathological, neither is the posterior curve is the upper dorsal
region, from old age. Enlargement of the lungs, as in asthma, produces
a kyphosis in the thoracic region. Disease of the body of the vertebra,
as in tuberculosis of the vertebra, will produce an angular curvature
commonly called Pott's disease of the spine.

In order for the spine to be curved abnormally far posteriorly, there
must be a. separation of the spines from thickening of the posterior part
of the disc, partial flexion or compression of the bodies and anterior
portion of the intervertebral disc, or all. In most cases there is simply
a relaxation of the ligaments and muscles along the posterior aspect of
the vertebral column, which weakens the supports and consequently
the spine seeks a position of most ease, that is the patient sits in a semi-
reclining posture. Such conditions are not in reality curvatures, but are
indicative of weakness which will lead to curvature if not soon overcome.
This weakening may be due to a single vertebral lesion or it may be a
part of a general disturbance of nutrition, as in anemia, rickets or any
disease in which the body is poorly nourished. Compression of the discs
may be due to constant pressure on the anterior portion, or it may be
due to disease or loss of elasticity of the disc on account of a vertebral
lesion or injury. The body of the vertebra may be compressed, as in
Pott's disease, thus producing an angular curve. The compression of
of the disc and body of the vertebra is always present in pathological
curves.

A kyphosis produces disease by interfering with the function of

APPLIED ANATOMY.

349

the spine, structures attached, nerves and vessels in relation and viscera
innervated by that area. A pathological posterior curvature weakens
the spinal column, thereby interfering with the support of the head and
body and attachments of muscles. This weakness is directly the result
of mal-alignment of the vertebra;, mal-nutrition and changed relations
of the muscles attached. On account of the change in position, the

_ Ji

Fig. 101. — Lateral view of a boy suffering with Pott's disease of the spine. Note
the angular enlargement. The symptoms in this case were almost completely re-
lieved but the deformity was not materially changed. (From photo).

structures attached will also be changed. This is not an important ef-
fect. The intervertebral foramina depend for their size on the amount
of separation of the vertebra;. In pathological kyphosis the discs are
usually thinned, from the pressure, to such an extent that these foramina

350

APPLIED ANATOMY.

Fig. 102. — Posterior curvature of the lumbar region. (From photo). The pa-
tient had bowel and uterine trouble.

APPLIED ANATOMY. 351

are lessened in size. In order to get this effect, the compression of the
disc must be more marked than in lordosis. In cases in which the fora-
mina are lessened in size, the blood-vessels are compressed and the
passing of nerve impulses over the nerve interfered with. The effects
vary with the degree of compression and the character and function of
the parts innervated by these nerves.

Posterior curvature in the lumbar region is more often pathological
than in other regions. One reasion for this is that it occurs most fre-
quently in this region. The bowel (lower) and pelvic organs, especially
the uterus in the female, are more frequently affected than other viscera.
The impulses supplying these parts are partly or completely cut off and
a form of paralysis of the parts follows. The curvature may be irritative,
but is most commonly inhibitory, therefore there is lessened activity of
the viscera supplied by the nerves affected. Kyphoses produce most of
their effects by lessening the size of the intervertebral foramina, thus in-
terrupting the passing of blood and nerve impulses through them. Pott's
disease comes from an injury to the spine in a child who has a tubercular
taint. The lesion weakens and lowers the vitality of the part to such
a degree that a nidus favorable to the propagation of the tubercle bacilli,
is formed. The body of the vertebra is honey-combed, sometimes
breaks down and in many cases becomes ankylosed. When this takes
place it is called the quiescent stage. If the case is seen soon after the
primary injury, the condition can be cured. A very slight twist of the
spine, a sudden though gentle push in the back, as school children are
wont to do, are usually the initial injuries; in short, a subluxation or
sprain of a vertebral articulation from some cause or other, is the cause.

In the treatment of a posterior curvature ascertain the primary
lesion and correct it if possible. The things to be accomplished in order
to effect a cure in an ordinary case are (1), restoration of elasticity to the
intervertebral discs, this being done by restoring normal nutrition; (2),
the regaining of normal tone to the spinal ligaments, and (3), restoring
the vertebra; to their normal position. The first and second can be
accomplished by repeated attempts at replacement of the displaced ver-
tebrae, and certain exercises that build up the general strength. The
third is usually accomplished gradually by developing ligaments and
muscles, and by repeated attempts at replacement or straightening of
the spine. It is well to ascertain whether or not the curve is pathological,
or whether it is the effect, rather than the cause of the other disorders,

352

APPLIED ANATOMY.

since a great many cases of supposed posterior curvatures are not real,
but assumed, on account of spinal weakness.

Lordosis in a marked form, is most common in the lumbar region
but in mild cases the dorsal region is the usual seat, this being not a
real curvature but a flattening of the normal posterior curve in this
region. Dislocation of the hip, whether congenital or acquired, also

Fig. 103. — Showing contour of spine in a marked case of lordosis in lower thoracic
and upper lumbar regions. These deformities usually start in children, from a le-
sion of a single vertebra. (From photo.)

APPLIED ANATOMY.

353

Fig. 104. — Showing an anterior condition of the upper thoracic region,
photo). Note the compensator}' posterior curve in the lumbar region.

(From

354 APPLIED ANATOMY.

hip-joint disease, are causes of importance. Malnutrition of the lumbar
vertebrae and ligaments, will permit of an exaggeration of the normal
anterior curve in that region. In pregnancy and obesity, the traction
exerted on the lumbar spine pulls it forward and the throwing back of the
shoulders to retain equilibrium, is another important cause. In Pott's
disease of the dorsal vertebrae, a lordosis in the lumbar region forms as a
compensatory curve. Injury to the lumbar articulations, especially the
upper lumbar, by which the vertebrae are forced directly forward, often
leads to a curvature on account of the weakness, change of position and
malnutrition that so often follow such lesions.

In typical cases the discs are compressed, especially the posterior
parts, the articular facets forced tightly together and the interverte-
bral foramina lessened in size. As a result, the functions of the spinal
column, spinal cord, spinal nerves in relation and muscles attached, are
disturbed. In addition to this the function of viscera, innervated from
this part of the spinal cord, is nearly always affected. The greatest ef-
fect results from a lessening in size of the intervertebral foramina. This,
as in kyphosis, interferes with the blood-vessels and nerves in the fora-
mina. Atrophy of the spinal muscles is a fairly common sequel, while
visceral disease is frequent in typical cases. The flattening of the thor-
acic spine, while not a typical lordosis, produces about the same effects.

Scoliosis or lateral curvature of the spinal column is the most com-
mon and important of all the spinal curves. It is defined by Walsham
as a " complicated distortion in which the spine forms two or more lateral
curves with their convexities in opposite directions, whilst the vertebrae
involved in the curves are rotated on their vertical axes so that the
spinous processes are directed toward the concavity of the curves."
According to the same writer, "the immediate cause that underlies the
formation of lateral curvature is the unequal compression of the inter-
vertebral cartilages for long periods." I would add that malnutri-
tion of a part of the disc from a vertebral subluxation or other injury,
is one of the frequent and important of causes.

There are many causes of unequal pressure on the discs. Unequal
length of the lower limbs will produce compensatory lateral curve in the
spine. The unequal length may be real, as in hip-joint disease, disloca-
tion of the hip, and fracture; or apparent, as in a twisted pelvis or in
disease of a leg or foot which causes the patient to favor one side. Col-
larjse of one lung, enlargement of the heart or one lung, or muscular con-

APPLIED ANATOMY.

355

tracture or hypertrophy of muscles on one side, may produce scoliosis.
Muscular contracture is usually secondary to spinal lesions, a tilted pelvis,
or irritative disorders of viscera. Hypertrophy is due to certain occupa-
tions in which one side is used to the exclusion of the other, faulty posture,
as is seen in school children attempting to write on a desk either too high

Fig. 105. — A right lateral scoliosis in a young girl brought on as a result of a le-
sion in the mid-dorsal region and fault}' posture while attending school. (From
photo).

356

APPLIED ANATOMY.

or too low, and the carrying of heavy weights or loads by children.
Muscular atrophy from effects of a vertebral lesion, spinal cord disease,
non-use, or disease of membranes of the cord, permit the unimpaired
muscles to draw the spine to the opposite side. Scoliosis is a common
sequel to cerebro-spinal meningitis and other diseases, such as fevers,

Fig. 106. — Showing a double scoliosis. Note the rotation, flexion line on the
right and atrophy on the concave side. (From photo).

especially typhoid. In children the curvature starts from a wrench or
strain of the spine in which the ligaments and muscles are irritated.

After all the essential cause of scoliosis is faulty posture. If there
is a spinal lesion the patient assumes a position of greate'st ease, that is,

APPLIED ANATOMY.

357

Fig. 107. — Showing the contour of the spine in a case of simple lateral curvature
in a girl seven years of age. Note the scapula;, shoulders, hips and waist line. (From
photo).

tries to protect the weakened or painful part. If from muscular dis-
orders, the posture is the real cause of the unequal pressure on the discs.
If from a diseased lung, the patient assumes an improper posture to pro-
tect the part as well as is possible. In recounting all the causes com-
monly mentioned as responsible for scoliosis, faulty posture is the im-
mediate cause. This may be directly the cause or the faulty posture

358 APPLIED ANATOMY.

may be the result of something else such as a fractured rib, in either
case, the faulty posture is the immediate cause of the curvature.

The effects vary with the degree of curvature, rapidity of develop-
ment, care that the patient takes of the spine, and methods of treatment.
In all cases the spinal column is weakened and the functions disturbed.
The spine is not only bent, but rotation of the vertebra? on a vertical
axis takes place. In ordinary cases the body of the vertebra is rotated
toward the convex side while the spinous processes point toward the
concave side. This is probably due to the fact that the bodies of the
vertebra offer less resistance to the pressure and traction than do the
articular processes, the posterior part of the vertebra being held more
securely than the anterior part by the various spinal ligaments. "The
theory, perhaps, most generally accepted is that of Dr. Judson, who be-
lieves that the rotation is due to the fact that the posterior portion of
the vertebral column, being a part of the dorsal parietes of the chest
and abdomen, is confined by the ligaments and muscles to the median
plane of the trunk; whilst the anterior portion, projecting into the thor-
acic and abdominal cavities, being devoid of lateral attachments, is free
to move either to the right or left of the median plane when the spine is
inclined to either side. "

Another theory offered in the explanation of the torsion or rotation
accompanying scoliosis is that a flexible body bent in two planes at the
same time, is accompanied by rotation. The vertebral column, if normal,
has a series of antero-posterior curves. It is a homogeneous column, con-
sequently side-bending would result in rotation since the flexible spinal
column would be bent in two planes at the same time,viz., antero-
posteriorly and laterally. This is true of all flexible bodies.

In the initial stages only the intervertebral cartilages are affected,
but later on as the curvature progresses and develops, the vertebrae, the
bodies' in particular, become compressed on the concave side after which
it is almost, if not entirely impossible to correct the deformity. The
mobility of the spine is lessened; the muscles on the concave side undergo
atrophy on account of pressure on their trophic nerves and from imper-
fect, or non-use. Those on the convex side increase in size and are made
prominent, partly by increase in size and partly by change in contour of
the thorax.

One of the earliest signs of a scoliosis is a hypertrophy of the muscles

Practical Surgery, Walsham. p, 581.

Al'PLIED ANATOMY.

359

on the convex side of the spinal column, especially the erector spinse mass.
This appears before any palpable deformity of the vertebrae takes place,
or at least before it can be recognized.

The hypertrophy of the muscles on the convex side is the result of
the disturbance of the equilibrium of the body. Immediately after the

Fig. 108. — Showing a simple scoliosis to the right, from atrophy and non-use of
the back muscles. The thoracic muscles were almost entirey paralyzed so that there
was practically no movement of the chest on respiration. (From photo).

360 APPLIED ANATOMY.

body has lost its poise, say for example, it is tilted to the right, the mus-
cles on the left side are brought into activity to prevent gravity from
drawing it further to that side. In the constant effort on the part of the
muscles on the left side to prevent this, they necessarily undergo hyper-
trophy. This muscular enlargement and contracture is the result of the
curve rather than the cause. Some believe that muscular contracture
is an important cause of scoliosis but this is scarcely possible. Muscu-
lar relaxation is by far the more important of the muscular causes.
The character of the rotation which accompanies practically all cases
of scoliosis, contradicts the theory that muscular contracture or con-
traction produces the curve, since it is opposite in direction to that pro-
duced by the action of the muscles.

The foramina on the convex side are increased in size, those on the
concave side lessened. The lessening in size of the foramina produces
more or less pressure on everything that is in them. Pressure on the blood-
vessels interferes with the nutrition of the spinal cord, column and other
structures in relation, such as the spinal membranes and ligaments.
This leads to muscular atrophy and visceral weakness. Pressure on the
nerves results in (1), sensory disturbance, such as pain or weakness in
the spine on movement, a careful gait, stooping posture and lack of inclina-
tion on part of the child to enter into play as do other children; and (2),
motor and trophic disturbances, as are manifest in the atrophied muscles.
Vaso-motor and secretory impulses may be interrupted, leading to se-
cretory and vascular disturbances in areas supplied by these nerves.
The recurrent meningeal nerves are compressed, this leading to vascu-
lar and trophic disturbances of spinal cord and column. These effects
are the same as from lesions of individual vertebra? with the exception
that they are more general.

The scapula on the convex side, if the curve is in the thoracic region
as it is most commonly, is thrown upward and backward, giving it a
winged appearance. The shoulde*- is also higher on that side. This
change in the scapula is one of the very early signs and should be regarded
as an important one. One side of the pelvis soon becomes prominent,
that is the crest on the convex side. The ribs on both sides of the thorax
are changed in position, giving a misshapen appearance to the chest.
Posteriorly, the chest is prominent on the convex side and depressed on
the concave side. Anteriorly, the side of the chest bulges on the side of
the concavity of the curve and the opposite side is depressed. These

APPLIED ANATOMY.

361

changes occur early and -are important signs of a lateral spinal curva-
ture. The deformity of. the thorax is most marked when rotation is
greatest, since the ribs follow the transverse processes of the vertebrae
with which they articulate. In some cases the spinous processes may
remain in the median line until the curvature is well under way, hence

Fig. 109. — Simple lateral curvature of the spine. P. , prominence of the scapula
and ribs. Compare the points marked with an X. There is some rotation as is in-
dicated by the prominence on the right side. (From a photo).

scoliosis should not be diagnosed in every case by position of the spinous
processes.

A scoliosis is primarily caused by an injury to a vertebral articula-
tion Or by any other cause producing fault}" posture, which in turn pro-

362 APPLIED ANATOMY.

duces unequal pressure on the discs. It produces disease by interfering
with the functions of the spinal column, cord, nerves and nerve roots,
muscles, vessels and viscera in relation or connected with the affected
part. Most of these effects result from a lessening in size of the inter-
vertebral foramina. All curvatures are not pathological since compensa-
tion may be complete. In cases in which compensation is not perfect,
the curvature is pathological.

The condition known as a straight spine, is common in certain classes
of people. It is primarily due to weakness of spinal ligaments and
muscles and is found in malnourished, anemic, tubercular patients and
those predisposed to lung diseases, particularly phthisis. It is caused
by relaxation of the ligaments, cartilages and muscles that hold the
spine in its normal position. In most cases a single vertebral lesion is
found, usually at the fourth dorsal articulations, but sometimes slightly
higher or low'er in the spinal column. The effects are explained in the
same way as those in anterior and posterior curvatures, with the ex-
ception that the trophic effects are more marked since the upper and
middle thoracic regions are affected most.

The rigid and hypermobile spines have to do with changing the con-
tour of the back. The rigid spine results from abnormal approximation
of the vertebrse or impairment of the ligaments and muscles which sup-
port and move the spinal column. Old age, standing on the feet a great
deal, inflammatory conditions of the spine, as in meningitis and la grippe,
lesions, thickening of; the spinal ligaments, and rigidity or inflammation
of the spinal muscles all tend to lessen mobility. Fractures, sprains,
subluxations and dislocations of vertebrse are also important causes.
Long continued muscular contracture exerts such a pressure on the
discs that they are abnormally, thinned and flattened. Such a condi-
tion interferes with the function of the spine and lessens the size of the
intervertebral foramina. In constipation and fibroid tumors of the
uterus, a rigid lumbar spine is nearly always found. In the aged, a rigid
spine is not uncommon and is not usually regarded as pathological, yet
in every case in which the intervertebral foramina are lessened in size,
pathological conditions result. In many cases in which the spine is
apparently mobile, there will be found areas of several adjacent vertebrae,
in which motion is decidedly lessened or entirely lost. The movement of
the vertebral articulations should be distributed amongst all of them,
but this is not the case in many spines. At some place, Usually at a

APPLIED ANATOMY.

363

Fig. 110. — Showing a straight spine. (From photo). Note the spinous processes
are visible throughout the entire spine.

364 APPLIED ANATOMY.

break or separation, there is hypermobility, which compensates, so far
as mobility is concerned, for the rigid, immovable area. As mentioned
above, a rigid spine, or even one rigid immovable vertebral articulation,
is abnormal and produces disorders of structures in relation and of viscera
supplied by the nerves passing through the obstructed foramina in rela-
tion.

Hypermobility is the result of relaxation of the supports of the spinal
column, viz., the ligaments and muscles. It occurs most frequently in
improperly nourished young girls. This weakness may be the result of
lesions disturbing the centers for nutrition or it may be the result of
some visceral disturbance especially derangement of the sexual organs.
In all cases of general hypermobility of the spine, the dorsal curve is
lessened, often entirely obliterated, and the lumbar spine is posterior.
The spines of the vertebra? appear to be larger than those of normal
vertebrae; the patient tires easily on the slightest exertion, cannot or
does not sit erect and suffers with various spinal aches which are increased
in intensity with extra Work or strain. This condition produces dis-
orders by interfering with the function of the spinal column, spinal cord,
nerves, muscles and viscera. The spinal column is weak, the spinal
cord poorly nourished, the spinal membranes often congested and in-
flamed, the nerves irritable and the viscera weak, so that almost any
exciting cause will produce marked disorders.

Enlargement of the lungs, liver, distension of the stomach, tumors,
aneurysm and abscesses sometimes change the contour of the back.
Displacement of the ribs, paralysis of the serratus magnus muscle and
contracture of muscles from the various causes, also change the contour
of the back.

Congenital defects, such as spina bifida, produce abnormality in con-
tour of the spine. Spina bifida is a condition in which there is absence
of a portion of the lamina, causing imperfect closure of the spinal canal
at that point. As a result the pressure from within causes a protrusion
of the membranes of the cord, which is characterized by a soft, fluctuating
tumor varying in size with that of the opening. The tumor or sac is
filled with the cerebro-spinal fluid that normally surrounds the spinal
cord. This condition may seriously impair the function of the spinal
cord at and below the seat of the tumor. Paraplegia is a common sequel.

In some cases there is an abnormal development of a spinous process
which is mistaken for a lesion. There are other causes and forms of

APPLIED ANATOMY. 365

irregularities, such as large, uneven spines and breaks or separations that
are often due to changes confined to the spinous processes; that is, it is
an apparent, not a real, lesion since the articular processes are not in-
volved. In chronic cases of diabetes mellitus the spinous processes of
the lower dorsal and upper lumbar vertebra? are enlarged and prominent.
Often there will be found lateral deviations that are simply irregular-
ities due to a bending of the spinous process. Changes in contour of
the upper dorsal spine, indicate weakness of lungs; middle dorsal, weak-
ness of stomach and liver; lower dorsal, weakness of kidneys; lumbar
region, weakness or disease of the lower intestinal tract and pelvic organs.
These changes of contour, if pathological, are accompanied by either
tenderness, muscular relaxation or by weakness of viscera innervated by
that part of the spinal cord in relation.

Tenderness and aching of the spine are very common symptoms.
When in the upper thoracic region, they are suggestive of colds, la grippe
and lesions of the vertebrae or ribs. In the interscapular region, they are
suggestive of lung and heart disease, occupation neuroses and pelvic and
mammary disorders ; in the middle and lower portions of the thoracic spine,
they are indicative of stomach and liver disorders ; lower dorsal and upper
lumbar, disorders of kidneys, spleen and small intestines; in the lumbar
region, they are almost diagnostic of disorders of the bowel and pelvic
generative organs. In all of these areas the tenderness or ache may be
due to a subluxation of a vertebra or rib, in fact tenderness of a verte-
bral spine is one of the most certain indications of a lesion of that ver-
tebral articulation. Tenderness of the spine may be due to reflex irrita-
tion of the sensory nerves supplying the spinal column; that is, if there
is an irritative disease of a viscus the segment of the spinal cord that
supplies the viscus, will be affected, which in turn causes the pain to be
referred to the spine. Similarly, the muscles supplied by the affected
segment undergo contracture, hence contracture of spinal muscles is
indicative of an irritative disorder of viscera in relation.

If there is excessive tenderness along the spine, it is suggestive of
spinal irritation or neurasthenia. In many cases there is ovarian irri-
tation. In all cases there is a congested condition of the nerves of the
back and disturbances of the spinal cord and its membranes. In other
cases, the toxemia is the cause of the irritation of the sensory nerves of
the back, this giving rise to the extreme tenderness on account of the
malnutrition. An error in diet will produce both tenderness at or near

w'ja

'Hi:,!!*'}'

JjKHt"

&*m

Fig. 111. — Lateral view of the spinal column. Note the relation of spinous pro-
cesses, foramina, bodies and nerves

APPLIED ANATOMY. 367

the fifth dorsal spine, and contracture of muscles in this region. In
railway spine, in which there is concussion of the spinal cord, the effects
vary with the degree of disturbance of the cord. In some cases there is
a dislocation, in others a subluxation, or a fracture or crushing of the
vertebra;. In the so-called railway spine, I believe the trouble in the
average case, is due to a vertebral subluxation which produces the pain
or anesthesia or the paralysis. The symptoms in railway spine are often
anomalous from the usual viewpoint, but from the standpoint of sub-
luxations of the vertebra?, most of the symptoms are explainable.

Fracture of the spine is rare and is the result of severe trauma. If
it occurs above the fourth cervical vertebra, death is the result, but if
at points below, paraplegia is the sequel. Death may result from frac-
tures at these points on account of hypostatic congestion of the lungs
or other viscera, interference with nutrition and elimination or, from
exhaustion. The effects are determined by the location and degree of
the fracture. It is hard in many cases to differentiate between fracture
and dislocation or subluxation. Careful palpation, by which crepitus
can be discovered if it is a case of fracture; the severity of the paralysis
or effects on the spinal cord, they usually being very marked in cases of
fracture; and the use of the X-ray, especially if the lumbar region is the
seat of the injury, will reveal the nature of the injury.

THE SPINAL CORD.

The vertebral column is tunneled by a foramen in which the spinal
cord is located. The cord is much shorter than the spinal canal, reach-
ing only to the upper border of the second lumbar vertebra in the adult
and in an infant, to the third lumbar vertebra. It is about eighteen
inches long and varies in its diameter, being smallest at points of greatest
mobility. It is surrounded and protected by the meninges and the
cerebro-spinal fluid. The cord is well protected, a thing that is essentially
necessary on account of its delicacy and function. Deaver says in re-
gard to its protection: "The free mobility of the spinal column as a
whole; the slight amount of movement between any two vertebra?; the
elastic intervertebral discs which break up force and shock applied to
the spinal column; the comparatively large size of the spinal canal in
the cervical and lumbar regions where the mobility is most marked; the
curves of the spinal column which lessen shock and force; suspension of
the cord in the spinal canal by the ligamenta denticulata; the spinal dura

368

APPLIED ANATOMY.

> Mr

Fig. 112. — Lateral view of the spinal cord.

APPLIED ANATOMY. 369

mater which is so tough that the cord may be ruptured without lacera-
tion of the dura; and the cerebro-spinal fluid." Although the cord is
surrounded by these safeguards, it is often affected in many ways, as
stated below.

The cord is composed of white and grey matter. The white matter
contains the nerve fibers cemented together by the neuroglia. These
nerve filaments are divided, on account of function and relation, into
columns, the anterior and lateral being motor, the posterior, sensory.
Dana says, "On physiological and embryological grounds the columns are
further subdivided as follows: The anterior columns are divided into
direct pyramidal tract and anterior fundamental column. The lateral
columns are divided into lateral fundamental columns, lateral limiting
layers, crossed pyramidal tracts, direct cerebellar tracts and antero-
lateral ascending and descending tracts, or Gower's column. The pos-
terior columns are divided into the posterior internal column or column
of Goll, postero-external columns, or column of Burdach, the ventral
zone, the comma, the oval zone, the triangular column and rim zone or
column of Lissauer. "

The grey matter occupies the center of the cord and its parts are
arranged like the letter H. It is composed principally of nerve cells
with some nerve fibers and neuroglia. Each lateral half presents two
horns, the anterior and posterior, the two halves being connected by a
commissure. The nerve cells are arranged in groups. Dana says:
"The cells are surrounded by a rich plexus and end brushes, as well as
by the supporting neuroglia matrix, a little connective tissue and many
small blood-vessels. The cell groups are named in accordance with
their position, internal, antero-lateral, median, posterior or sensory cells,
cells of Clark's column. " The blood supply of the cord, and especially
of the grey matter, is of great importance since many diseases of the
cord are the direct result of conditions that affect it. It is supplied
with blood from the vertebral, ascending cervical, superior intercostal,
dorsal intercostal, lumbar and sacral arteries. The vertebral artery
gives off the anterior, posterior and lateral spinal. The anterior,
according to Church "gives off about three hundred branches called the
anterior median arteries which penetrate the anterior fissure at a right
angle to the parent stem. At the commissure they enter the cord and,
without dividing, turn toward the right or left anterior horn." The
white matter in the anterior portion of the cord is also supplied by

Fig. 113. — The spinal and gangliated cords.

APPLIED ANATOMY. 371

branches from this artery. This artery is reinforced by the lateral
spinal branches. The posterior spinal arteries enter into an anastomosis
with the lateral spinal, thus forming a plexus extending along the entire
cord. Twigs are given off which supply in particular the posterior
horns' of the grey matter. They are regarded by most observers as "of
the terminal variety and therefore do not anastomose." According
to Church there are three arterial districts: (1), "That only supplied by
the anterior system; (2), that supplied only by the posterior system; and
(3) that irrigated by both systems. It will be apparent from these facts
that arterial disease may induce lesions mi the posterior half of the cord,
or in the anterior half. Further, the infection or obliteration of a single
anterior median artery will practically destroy the corresponding horn. "
The lateral spinal branches pass through the corresponding foramina
with the nerves and in its sheaths of dura mater, and supply in particular
the corresponding segment of the spinal cord. The lateral spinal, for
the upper part of the spinal cord, come from the subclavian, while the
lower part is supplied with blood by the thoracic and abdominal aorta.
Dana says: "It is an interesting fact that at or a little below' the point
where the blood supply changes from the subclavian above the heart to
the aorta, below, pathological disturbances frequently occur (transverse
myelitis). " On account of the length of the anterior and posterior spinal
arteries they are not subject, according to Church, to the direct impact
of the cardiac impulses. "Arterial pressure is also slight, and the venous
outlet into the plexuses about the dura mater is not an advantageous
one in the erect position." The lateral spinal branches come from the
dorsal branches in the different regions. This artery sends a branch
into the cord, the lateral spinal, and continues as the muscular artery
to the muscles of the back. In contractured conditions of muscles as we
ordinarily find them, the muscles are congested. In such cases, the
circulation through the muscular branch is practically obstructed, the
blood backs up into the lateral spinal branch and the spinal cord becomes
congested. The conclusion from this is that contractured muscles of
the back produce congestion of the spinal cord, and that any treatment
which lessens the contracture of these muscles, will better the circulation
through the spinal cord.

The veins correspond in their distribution to the arteries. The
blood from the cord substance is gathered into the anterior and posterior
system of veins, which empty into the lateral spinal except at the ex-

372 APPLIED ANATOMY.

treme upper part of the cord, at which place some of the blood passes
into the sinuses of the brain. Most of the venous blood is gathered by
the venae azygi. These veins are subject to pressure, on account of their
position, from enlargement or congestion of viscera in relation or from
long continued pressure, as in a lingering illness in which the patient
assumes the dorsal posture without much change. Contractured mus-

. cles have an effect on the veins similar to that on the arteries, that is the
spinal cord becomes congested in such cases.

The spinal cord has the following functions: (1) conductivity,
conveying motor impulses from, sensory impulses to the brain; (2)
centers that control the activities of viscera and the size of the blood-
vessels; (3) centers for reflex action; and (4) control of nutrition of parts
to which its nerves extend. In short, its functions may be classified as

■ (1) a conductor of impulses, and (2) a series of nerve centers. These
functions of' the spinal cord may be disturbed by many things.

Lessened mobility of the spine weakens nature's protection of the
spinal cord against injuries. The various shocks are less completely
broken, the discs are less elastic, the ligaments are more tightly drawn,
and the spinal column usually impacted, thus lessening the size of the
intervertebral foramina. Lessened mobility of the spine produces a
vascular change in the cord, since the contractions of the spinal muscles
are of great value in the circulation of the blood through the spinal cord,
and these contractions have almost, if not completely, disappeared in
stiff spines. This is explained by the relation of the muscular, to the
spinal branch of the artery that supplies both. Instead of the normal
contractions, are found muscular contractures which interfere with the
circulation to the cord. If the lessening of mobility is localized in one
or two intervertebral joints, the effects are not so marked but the func-
tion of that part of the spine is suspended. Lessened mobility of the
spine then affects the spinal cord principally through the effects on its
circulation, this coming about through a lessening of the size of the in-
tervertebral foramina, lack of normal contractions of the spinal muscles
in relation, and the presence of muscular contractures in these same
muscles. This condition also lessens the elasticity of the spine, hence
the spinal cord is not so well protected against jars of the body or in-
juries. A stiff spine is more easily injured than one in which the motion
is good, other things being equal, and when fracture, dislocation or
subluxation of a vertebra occurs, the spinal cord is always affected.

Fig. 114. — Showing changes in contour of the spine. B., normal spine; A., Flat-
tening of the thoracic region; C, posterior in lower thoracic and upper lumbar re-
gions. Note the effects on the size of the intervertebral foramina. Compare posi-
tion of the coccyx, angle of sacrum and line of gravity.

374 APPLIED ANATOMY.

The intervertebral discs assist in the protection of the spinal cord
in that they lessen the jar on the cord from running, etc., and permit of
free movement of the spinal column. If their elasticity is lessened,
if they are thinned, or if one side is malnourished, they the less securely
protect the spinal cord since the spinal cord is more easily disturbed,
as in concussion; the foramina are lessened, hence impairment of nutri-
tion from which spinal curvature develops.

A change in the normal curves of the spinal column, as in straight
spine or any curvature, will more or less affect the spinal cord, depend-
ing on the character, rapidity, and degree of the change. The normal
curve lessens,to the greatest extent,the effects of shock and force. A change
in the curve of the spine thus makes the cord more susceptible to shock
and concussion. In addition, the circulation and nutrition are affected
on account of the change in size of the intervertebral foramina; thus
producing pressure on blood-vessels and nerves. The functions of the
cord are impaired then, from the interference with the passing of nerve
impulses and of blood, to and from the cord.

The cerebro-spinal fluid commutes the force of a shock and thus
prevents injury to the cord. This fluid may be pathologically lessened
or increased in amount, which conditions predispose to injury of the cord.

Lesions of the articulations of the vertebra? and ribs are responsible
for most disturbances of function of the spinal cord. As in some of the
conditions described above, I believe most of these effects come from a
partial or complete closure of the intervertebral foramina. If a vertebra
be subluxated in any way, either the foramen above or below it, is lessened
in size, the amount of change depending on the degree or extent of the
lesion. The artery supplying the cord with nutrition is thus partly or
completely ligated. The same is true of the veins and lymphatic vessels.
Circulatory disturbances of any character may then follow the lesion.
Congestion, especially venous, is the most common since the vein is af-
fected more in proportion than is the artery. Contracture of muscles of
the back will have a similar effect. The nerves passing through the
foramen, the recurrent meningeal and the common trunk of the spinal
nerve, are also compressed. The recurrent, carries trophic and vaso-
motor impulses to the cord and its membranes. The effect is that of
congestion or anemia with its consequent disturbance of function. The
common trunk carries afferent impulses to and efferent impulses from
the spinal cord. The cord may suffer especially from the effects on the

APPLIED ANATOMY. 375

afferent roots. This disturbance of the afferent roots often comes from a
spinal lesion, that is from subluxation of a vertebra. The pressure on the
efferent nerve fibers produces muscular and visceral disorders, which in
turn, disturb the circulation of the spinal cord, affecting its functions. If
the lesion be irritative, it will produce a thickening and increased vas-
cularity of the ligaments, a stimulation of the nerves, contracture of
muscles and disturbance of the meninges, this being in the form of a
congestion or inflammation. Hyperesthesia of the spine is a sequel to
the last named condition.

The functions of the spinal cord may be affected by pressure, as
in complete dislocation or fracture of a vertebra, and in tumors, whether
vascular or otherwise. The effects vary with the degree of pressure,
jDaraplegia, however, being the most common effect. The pressure_ is
not only on the blood-vessels and nerve roots, but is directly on the cord
itself and results in interference with both conductivity and the gen-
erating of nerve impulses. Transverse myelitis occurs in cases of frac-
ture and complete dislocation.

The condition of the spinal column is a good index to the condition
of the spinal cord, or conversely, disturbance of function of the spinal
cord is manifest by changes in the spinal column. A rigid spine, in which
the rigidity is due to muscular contracture, is suggestive of disease of
the anterior or lateral columns, as in spastic paraplegia. General re-
laxation or paralysis of the spinal muscles indicates a chronic transverse
myelitis. A tender spine is suggestive of a congested cord or inflamed
or congested spinal membranes. Atrophy of a localized portion of the
erector spina? mass of muscles, in indicative of inactivity of the trophic
and motor cells in the corresponding segments.

Abuse of function of certain viscera, especially the gastro-intes-
tinal and genital tracts, will affect the functions of the spinal cord. It
is a general law that activity produces congestion or hyperemia. If the
fingers are vigorously opened and closed, hyperemia follows. If the
brain is used, a greater amount of blood flows to it. If the stomach is
stimulated from the ingestion of food, it becomes congested and in addi-
tion the nerve centers in the spinal cord become congested. If sexual
intercourse is indulged in, not only the parts directly concerned become
hyperemic, but the spinal cord — that part giving rise to the nerves that
take part in the process — also becomes hyperemic. In abuse of function
of the viscera the congestion in the spinal cord becomes pathological.

'376 APPLIED ANATOMY.

Paraplegia from hemorrhage in the cord has resulted from vigorous
coitus. Contracture of the spinal muscles follows a short while after
the ingestion of something indigestible. Overactivity leads to path-
ological congestion. In cases of insanity due to worry, I believe that a
localized part of the brain is overworked, is constantly used to the ex-
clusion of other parts, consequently, after a while the congestion becomes
a pathological one. The treatment is rest, diversion of the mind, or
anything to equalize the cerebral circulation. Thus it is with the spinal
cord, sexual abuses repeatedly produce congestion of the genital cen-
ters until finally they become pathologically congested and thus the
cord is affected as to function.

The functions of the cord are often disturbed by a toxemia. This
may come from tetanus, syphilis, or in fact from any form of toxic ma-
terial that may be in the blood. This toxemia produces at first a con-
gestion, but later on in chronic cases, an inflammation. The disturb-
ance of function varies with the kind and intensity of the poisonous ma-
terial, opisthotonous occurring in acute cases, sclerosis in chronic cases.

The effects of disturbance of function of the spinal cord, vary with
the part affected and the way it is affected. If the white matter is dis-
turbed, conductivity is impaired. The motor columns may alone be-
come diseased as in spastic paraplegia, or the sensory columns may be
affected as in tabes dorsalis. If the motor columns are affected by the
lesion, the brain can no longer exert an inhibitory influence on the various
muscles and nerve centers, and the reflexes are exaggerated. The
various centers often act independently of the higher centers as is dem-
onstrated by the involuntary evacuation of urine and feces. If the part
of the cord below these centers is involved, there will be retention or
dribbling of urine. In other cases of transverse myelitis, motion and
sensation are lost in parts below the lesion, since motor impulses arise
in the brain and the sensorium is the .receiver of all sensory impulses.
If conductivity is only disabled or partly lost, there will be a partial
connection between the brain and parts below the lesion. Painful im-
pressions are supposed to be carried by the grey matter; sensations of
touch by the lateral columns and the grey matter. Both of these col-
umns are in the side of the cord opposite to that of the stimulus; that
is, if the left side of t-he cord were affected, the effects would be on the
right side of the body.

The vaso-motor centers in the cord are usually affected by lesions

APPLIED ANATOMY. 377

of the vertebral articulations and by disease of the cord. Gowers says : "The
sympathetic nerves to the vessels are influenced from the spinal cord.
It is probable that the path is by the fine fibers of the anterior roots and
that most of the constrictor fibers leave the cord between the third dor-
sal and second lumbar, while the dilator fibers are more widely scattered,
many arising in the upper dorsal region, while others leave the cord in
its lumbar and sacral portions (pelvic outflow). Some facts of disease
suggest that the subsidiary vaso-motor centers are situated in the inter-
mediate grey matter; and this conclusion is supported by the important
researches of Gaskell, which refer the function to the small cells of the
intermedio-lateral tract which he traces upward to the vaso-motor
center in the medulla. " The effect on the cord of a lesion or other dis-
turbance may be that of stimulation or inhibition. If the former, con-
traction at least for a while, of the blood-vessels governed by that part
will take place, while if the vaso-motor centers are inhibited, dilatation
of the vessels will result. Thus congestion or anemia may result from
these vaso-motor disturbances. The head and face have their vaso-
motor centers in the lower cervical and upper dorsal portions of the spinal
cord. If the lesion inhibits these centers, congestion of the above
parts takes place; if the lesion is irritative, anemia is the result. Con-
gestive headaches, congestion of the eyes or any part of the head and
face, can often be cured by correcting a lesion of an upper dorsal vertebra.
I believe that every muscle fiber of every artery and vein in the body is
represented in the spinal cord by a cell which nourishes it and controls
its action. These cells are grouped and constitute the vaso-motor cen-
ters. The cell must be properly nourished and the line of communica-
tion between it and its muscle fiber must be clear, if it is to act normally.
If the impulses are interrupted or if the cell is inactive, the muscle fiber
is not properly nourished and becomes relaxed. If the cell or its nerve
filament is stimulated, contraction of the muscle fiber results.

The sensory effects are manifest on the opposite side of the body;
that is, a lesion of the left side of the cord would be manifest by sensory
disturbances on the right side of the body. Girdle pains, as in locomo-
tor ataxia; numbness or anesthesia, as in atonic paraplegia from trans-
verse myelitis; perverted sensation, as in syringomyelia; and disturb-
ances of tactile sensations and of heat and cold are the principal sensory
effects of lesions or diseases that disturb the sensory columns of the
spinal cord.

378 APLLIED ANATOMY.

The motor effects of disturbance of the functions of the spinal cord-
are paralysis, with atrophy or with spasticity, which are represented by
simple paraplegia and spastic paraplegia. The motor impulses may be
entirely cut off, partly inhibited or stimulated by the disturbance in the
spinal cord. The muscular fibers in the various viscera are more or
less under the control of the spinal cord. Gowers says: "Although
the viscera are under the immediate control of the sympathetic system
of nerves, they are related to centers in the spinal cord, and it is from
these centers that the controlling influence is really derived, probably
by means of the finer fibers of the anterior roots. The relation is the
most direct and important so far as concerns the disease of the spinal
cord, in the case of the organs over which the will has an influence, the
rectum and the bladder. " The visceral effects of a disturbance of the
spinal cord would therefore, be increased or lessened peristalsis, that is
increased or 'decreased activity above or below the normal. Diarrhea
is an example of the former, constipation of the latter. In chronic spinal
cord diseases, the sympathetic gangliated cord attempts to take on the
function of the spinal cord, sometimes successfully, as is illustrated in
cases of transverse myelitis in which the sympathetic cord controls-
nutrition, circulation and, to a certain extent, the various reflex pro-
cesses.

The sexual function is always disturbed in spinal cord disease.
This disturbance ranges from complete impotence to priapism. This
applies especially to diseases that involve the lumbar enlargement of the
cord.

The trophic effects of spinal cord disease are sometimes wonder-
fully rapid and extensive. The trophic cells are in the anterior horns of
the grey matter of the spinal cord. Every part of the body receiving
impulses from the spinal cord would be affected by any disease of the
cord involving these centers. This trophic influence is exerted prin-
cipally through the motor nerves. It involves muscles, ligaments, bones,
skin and viscera. The tone of muscles depends on activity of the center.
The effects of impairment of this function of the spinal cord would be
malnutrition, relaxation, caries and the formation of bed sores or necrosed
areas, if the disturbance is acute or destructive, as in some cases of mye-
litis.

The spinal cord is a very important part of the cerebro-spinal axis.
It not only transmits impulses to and from the brain, but originates

APPLIED ANATOMY. 379

many •impulses. Its activity or function depends on the condition
and amount of blood circulating through it. Lesions of the vertebrae
affect both and give rise to disturbance of function. Many of the re-
sults obtained by osteopathic treatment come from restoring normal
circulation to and from the spinal cord. To do this, correct all anatomical
derangements, such as subluxated vertebra? and contractured muscles,
that lessen the size of the intervertebral foramina or produce in any
way, congestion of the muscles or cord.

THE RIBS.

The ribs, together with the sternum, form the thorax on the sides
and front, the bodies of the thoracic vertebra? forming the posterior
wall. They are flattened, twisted, hoop-like bones which articulate
with the bodies and transverse processes of the thoracic vertebra? and
are so arranged that their length and obliquity increase from above
downward, the former to the false ribs, the latter to the tenth. This
obliquity is so great that the sternal end of the rib is several vertebra?
lower than the vertebral end of the same rib. They are divided into
true, false and floating, which number seven, three and two, respec-
tively.

A typical rib consists of a head, neck, tubercle, angle and shaft.
The head is divided into two parts by a ridge which gives attachment to
a ligament, the inter-articular. The facets are slightly concave, the
lower usually being slightly the larger and articulates with the upper
part of the body of the vertebra in numerical correspondence. The upper
articulates with a facet on the lower part of the vertebra above. The
movement at these facets is slight, being a sort of rotation. The neck
is the constricted portion between the head and tubercle. It is smooth
anteriorly but its posterior surface is rough for attachment of ligaments
and muscles. The tubercle consists of an enlargement which has two
parts, an articular and a non-articular. The articular part is slightly
convex, of oval shape, faces downward, backward and slightly inward
and articulates with the facet on the transverse process of the corres-
ponding vertebra. The movement at this articulation is a slight up and
down one with some rotation. The non-articular part gives attachment
to the costo-transverse ligament. The angle of the rib corresponds to
the point of greatest curve, there being a rough ridge which runs ob-
liquely across the shaft. It is the part that can be best palpated in up-

380

APPLIED ANATOMY.

NECK

ANGLE

FOR COSTAL
CARTILAGE

Fig. 115. — A typical rib.

APPLIED ANATOMY. 381

ward subluxations of the rib, in which case the angle appears at a prom-
inence which is usually quite tender. The prominence is due partly
to thickening of the tissues and partly to the displacement upward.
Beyond the tuberosity, each rib is prolonged as a twisted, flattened, thin
hoop, which part is called the shaft. It presents an upper border which
is rounded and smooth and considerably thicker than the lower border.
This gives attachment to the internal intercostal muscles and a few
fibers of the external intercostals. In upward subluxations of the rib,
this border can be quite clearly outlined.

In enlarged chests, as in asthmatic patients, the ribs are drawn up-
ward and forward, thus bringing into prominence the upper border of the
rib. The lower border or edge is quite thin. It is grooved for the
passage of the intercostal nerve and vessels, the outer edge of the groove
being quite sharp. It gives attachment to the external muscle, while
the inner edge gives attachment to the internal intercostal muscle.
Near the anterior end of the rib, the groove disappears and its lips or sides
unite to form a rounded edge. The openings in the rib for the passing
of blood-vessels are in the floor of the groove. They are called nutri-
ent foramina. This border of the rib can with difficulty be palpated in
a full chested subject, but in patients suffering with pulmonary tuber-
culosis, or from emaciation from any cause, it can be readily outlined.
In such cases the ribs are in a position of descent, and the lower the
sternal end, the shorter the antero-posterior diameter and the more
prominent the lower edge. In downward displacement of the anterior
end of the rib, the lower edge can.be plainly outlined. This furnishes
a reliable sign in the diagnosis of a rib lesion. In collapse of the lungs
the lower edges almost, if not actually, overlap, as does the weather-
boarding of a house.

The external surface is smooth and convex, thus conforming to the
general curve of the thoracic wall; that is, the first rib faces upward;
the upper ribs, .upward and outward; the middle, outward; and the
lower ribs outward and slightly downward. Some muscles are attached
to this surface, such as the pectoralis major and serrati muscles. The
inner surfaces face opposite to the external and give attachment to the
parietal layer of the pleura. As each rib approaches the sternal end it
becomes twisted on its axis in addition to the curve. This gives it a
spiral shape which can best be appreciated by placing the rib on a plane
surface, it being found that the two ends can not be kept down at the

382 APPLIED ANATOMY.

same time. The curve and twist are most pronounced at the angle of
the rib. Many a person owes his life to the obliquity and curvature of
the rib, since they the better deflect the course of a pistol ball, which
follows the rib instead of directly entering the thoracic cavity. The
anterior end of the rib is larger, more porous and has a cup shaped de-
pression for articulation with the costal cartilage.

A typical rib has three articulations, two with the vertebra and one
with the costal cartilage. The articulation of the head of the rib with
the bodies of the vertebras is a diarthrodial one and is classed as a hinge-
or ginglymoid joint on account of the character of its movement. The
head has two facets, the upper one articulating with the vertebra above,
the lower one with the vertebra below and the center of the head articu-
lates with, or rather is attached to, the intervertebral discs by means
of the interarticular cartilage. On account of this arrangement, sub-
luxation of a .vertebra will quite readily affect the head of the rib.

The ligaments of the costo-vertebral articulations are the capsular,
stellate or costo-vertebral, and the inter-articular. There are also two
membranes corresponding to the two articular facets of the head and
separated by the interarticular cartilage. Perhaps they have something
to do with the "popping" sound which is often heard on movement of
the head of the rib. The capsular ligament entirely encloses the articu-
lation and is attached to the contiguous vertebrae, intervertebral disc and
rib a little beyond the articular margins. The stellate seems to be a
thickened portion of the anterior part of the capsular and consists of
three glistening bands which pass upward, forward and downward from
the head of the rib to be attached to, or inserted in the bodies and disc
of the adjacent vertebras, the upper fasciculus going to the lower part
of the vertebra above, the middle to the disc and the lower to the upper
border of the vertebra in numerical correspondence. These fasciculi
are in relation with, and to a certain extent reinforced by, the anterior
common ligament of the vertebral column.

The interarticular, attaches the ridge on the head of the rib to the
intervertebral disc in relation, thus dividing the joint into two separate
compartments. It does not hold the head of the rib tightly against the
vertebra, but permits of a moderate amount of motion, as in rotation of
the rib in respiration. In subluxations of the rib, this ligament is in-
jured which often results in a deposit, this thickening it and interfer-
ing with the movement of the head of the rib. These costo-vertebral

APPLIED ANATOMY.

383

articulations are innervated by filaments from the anterior divisions
of the thoracic nerves in relation.

Each typical rib articulates with the tip of the transverse process
of its corresponding vertebra. This articular facet, in the case of the
upper five thoracic vertebra, faces forward and slightly upward, thus
giving support to the parts above, while the facets on the transverse

SUP PROG.

TRANSVERSE PROC

POST. COSTO
TRANSVERSE

Fig. 116. — Costo-vertebral articulations viewed from the right tide.

processes of the remaining thoracic, face forward and slightly downward.
There are two ligaments uniting the tubercle of the rib to the transverse
process, the capsular and costo-trans verse, the latter being subdivided

384 APPLIED ANATOMY.

into the anterior or superior, posterior and middle costo-transverse.

The capsular is a loose, thin envelope that surrounds the articula-
tion, enclosing a synovial membrane. The superior or anterior costo-
transverse ligament, consists of fairly strong bands which pass upward
from the upper border or crest of the neck to be attached to the trans-
verse process of the vertebra immediately above. The inner border helps
to form the foramen through which pass the posterior branches of the
intercostal nerves and vessels. In cases of subluxations of the rib in
which this ligament is injured or impaired in any way, the size of this
foramen would be lessened, hence there would be pressure on the nerves
and vessels passing through. This applies especially to the veins and
nerves. Pain or tenderness at the tuberosity of the rib or congestion of
the integument, in relation often results from pressure on the sensory
nerves and veins. The posterior costo-transverse ligament runs trans-
versely and attaches the non-articular part of the tuberosity of the rib
to the top of the transverse process. The middle costo-transverse, con-
sists of short fibers that connect the posterior aspect of the rib with the
front of the transverse process. It is always affected in an ordinary
lesion or subluxation of the rib. The innervation is the same as that of
the costo-vertebral articulations, viz., filaments from the intercostals
in relation.

The movement of a typical rib is essentially one of rotation upward
and outward on its axis which is directed obliquely forward and inward,
passing through the costo-transverse and costo-vertebral articulations.
In inspiration, the rib rotates upward on its articulations, thus drawing
the anterior end upward and forward as it tends to assume the horizontal
position. Perhaps, in addition to the rotary movement at the costo-
transverse articulation, there is also a gliding one, the rib moving di-
rectly upward, especially in case of the lower ribs.

THE FIRST RIB.

The first rib is distinctly peculiar on account of its size, form, it
being almost flat, and its degree of curvature. The head is small and
has only one facet for articulation with the side of the body of the first
thoracic vertebra. The neck is slender, longer and more nearly round
than that of other ribs. It is slightly flattened from above downward,
is smooth anteriorly and rough posteriorly for attachment of ligaments.
The angle is exaggerated by the tubercle which is quite .large. The

APPLIED ANATOMY.

385

facet on the tubercle is small and articulates with a corresponding one
on the transverse process of the first dorsal vertebra. This facet on the
transverse process of the vertebra, is concave and faces slightly upward.
On this account the weight from above is the better supported and in
displacements of the first rib, it determines to a great extent the direc-
tion of the deviation, that is, it is most easily displaced upward. The shaft
lies practically in one plane,so that if the rib is placed on a plane surface,
it lies almost flat. Its superior surface looks forward and upward and
has a tubercle for the attachment of the scalenus anticus muscle, and a
groove immediately behind the tubercle for the artery, also a groove in

COSTO-CENTRAL
SYNOVIAL SAC

ANT. COSTO- CENTRAL
OR STELLATE LI GMT.

MID. COSTO- A0^& 11%

TRANSVERSE LIGT. / gfM ''/$*&$.

POSTERIOR COSTOTRANSVERSE LIG MT W$$ COSTOTRANSVERSE SYNOVIAL SAC

Fig. 117. — The costo-vertebral articulations viewed from above.

front for the subclavion vein, thus the muscle separates the artery
and vein. To this surface are attached from before backward, the follow-
ing muscles: subclavius, scalenus anticus, serratus magnus, scalenus
medius, levator costse and accessorius. These muscles on contracting,
either fix or draw upward the rib. If they are in a state of contracture,
they displace the rib upward. On account of attachment of most of the
muscles posterior to the middle of the rib, the posterior end of the
rib would be moved most on contracture of the muscles attached to the
upper surface. The lower surface, smooth and flat, acts as a subcostal

386 APPLIED ANATOMY.

groove and gives attachment to the external intercostal muscle; the
inner edge thin, sharp and markedly concave, gives attachment to fascia.

The movements of this rib are slight, consisting of a slight up and
down or gliding movement with some rotation. As in any rib, if it were
not curved, the movement at the transverse process would be greater than
at the head, but the twist in the rib permits of elevation of the anterior
end with rotation at the costo-transverse articulation. This will apply-
better to the ribs that have a marked twist than to the first rib.

The landmarks used for locating this rib are for the sternal end, the
sterno-clavicular articulation; the rib being immediately below and
back of it; for the vertebral end, the vertebra prominens and transverse
process of the seventh cervical, the angle of the rib being at the point
of intersection of a horizontal line passing through the spine of, and a
vertical line passed through the tip of the transverse process of, the
seventh cervical. The angle and posterior part of the shaft can be
palpated at the anterior border of the trapezius.

The vessels in relation are the subclavian artery and vein, which
■cross its upper surface, and the superior intercostal artery and vein,
which cross the head of the first rib. The superior intercostal artery
supplies the muscles, in relation, the rib and a part of the spinal column
and cord, the spinal branch entering through the intervertebral foramen
with the eighth cervical nerve. The corresponding veins drain the muscles
and spinal cord in relation. The subclavian vessels at this point carry
the blood to and from the arm. Some lymphatic vessels are in relation,
principally those draining the mammary gland, axilla and arm.

The nerves in relation with the first rib are the first intercostal,
nearly all the nerves going to make up the brachial plexus, the recurrent
meningeal and the stellate ganglion with its branches and communica-
tions. In addition to the above, the inferior cervical ganglion would be
affected since it is in relation with the head of the first rib. As a result
of a lesion affecting the nerves in relation, many organs and structures
some distance from the seat of the disturbance would be affected.

The lesions or subluxations of the first rib in nearly every case, con-
sist of an upward and backward displacement of the vertebral end.
This increases the obliquity of the rib and the fullness or prominence of
the muscles and tissues in relation with the vertebral end. The upward
subluxation results most frequently from muscular contracture or spas-
modic contraction. The most important muscle is the scalenus medius.

APPLIED ANATOMY.

387

In spasms of the neck and shoulders the rib may be forcibly drawn or
forced out of place. The deviation is indicated by the tense condition
of the scaleni muscles and the prominence of the rib particularly at the
vertebral end. If both upper ribs are involved, the sternum is drawn
inward and the clavicles down, so that the space between the clavicle

SERRATUS
MAGNUS

Fig. 118. — Showing the first and second ribs.

and first rib is lessened in size. There is tenderness at the costo-trans-
verse articulation and, in some cases, along the upper surface of the rib.
There is disturbance of function of tissues in relation and structures in-
nervated by nerves that are commonly affected by a lesion of the first

388 APPLIED ANATOMY.

rib, viz., the stellate and inferior cervical ganglia and the first thoracic
nerve.

The effects vary considerably in the different cases. The muscles
attached to the rib are usually contractured but this is often a cause of
the displacement as well as an effect. The tissues attached to the rib
are disturbed, such as the fascia and pleura. Sometimes these effects
are manifest only or principally by soreness on deep inspiration. The
blood-vessels in relation are disturbed either by direct pressure or con-
traction of tissues with which they are in relation. Congestion of the
spinal muscles, the spinal cord and possibly the upper limb is a common
sequel. The muscles undergo contracture and the centers located in
the eighth cervical and first dorsal segments of the spinal cord, are dis-
turbed as to function. Pain in the arm and along the first intercostal
space is a sequel. Heart disturbances, principally functional in char-
acter, are riot unusual. This comes from effect on the stellate ganglion
which is in relation with the head of the rib. Lung and bronchial dis-
orders are more common than heart affections, as a result of this lesion.
This is because of the filaments from the spinal and gangliated cords that
pass to the lungs and bronchi are impinged by the subluxated rib.

The circulation to the head and face may be disturbed on account
of the rib lesion interfering with the passing of the vaso-motor impulses
to the head and face, they going over the gangliated cord and ganglia.
The throat is often affected by this lesion, through the effect on the in-
ferior cervical ganglion and its connection with the laryngeal nerves.
A hacking cough is very often caused by such a lesion. In the various
disorders of the throat characterized by congestion or inflammation, it
is advisable to examine the first rib for the suspected cause. It may be
that the subluxation is producing the effect by direct pressure on blood-
vessels, but I believe these effects result from disturbance of the vaso-
motor supply to these parts, which conies to a great extent from the in-
ferior cervical ganglion and spinal cord, the upper thoracic portion.

The thyroid gland is in many cases, affected by a subluxation of the
first rib. The effect is one of congestion and hypertrophy. The best
explanation is that the subluxated rib, by disturbing in some way the
inferior cervical and stellate ganglia, interferes with the vaso-motor
supply to it, which seems to be principally along the inferior thyi-oid
arteries. The inferior cervical ganglion gives off a branch to this artery
and vein which controls, to a large extent, the amount of blood in the

RECTUS
CAPITIS ANT MINOB

RECTUS CAP. ANT. MAJOR

RECTUS
CAPITIS LATERALIS

INTERTRAMSVERSALIS

LONGUS- COLLI

SCALENUS ANTiaJS
SCALENUS MEOIUS
SCALENUS POST,

BRACHIAL
PLEXUS

AXILLARY
ART.

£-***,

LYMPHATICS

Fig. 119. — Front view of the neck showing the relation of the scalene muscles to
the ribs. Note that their contraction will lessen the space between the first rib and
the clavicle and thus compress the structures in this area.

390 APPLIED ANATOMY.

gland. The vertebral end of the rib is usually displaced upward and
backward, thus forcing the head of the bone against the gangliated cord
or directly against the ganglion. This is not the only bony lesion found
in diseases of the thyroid gland, but forms the most common and im-
portant.

The character and causes of subluxation of the first rib are not
rightly understood in_many cases, since the contracture of the muscles
attached to it is of prime importance, while the usual treatment to
"lower" the rib is ordinarily useless in such cases. In other cases,
the rib may be displaced from trauma as in a fall, in which the neck is
jerked violently to one side or the shoulders thrown upward as in falls
on the arms and hands. By the powerful and sudden contraction of the
scalene muscles, the rib in such cases, is drawn upward at the vertebral
end. In all such lesions, a lowering of the rib is indicated since it is not
held out of place by contracture of the muscles yet in some cases, the
muscles become contractured on account of the injury to them. Pos-
terior luxations of the first thoracic vertebra are responsible for many
of the displacements of the first rib. In the carrying of weights on the
shoulders it is possible, in fact common for some change in contour to
take place in the upper thoracic vertebrae. As is the case with most
rib lesions, the corresponding vertebrae are usually subluxated, which is
the cause of the rib lesion.

Lesions along the middle and lower parts of the neck are primarily
responsible for the rib disturbance, on account of effect on muscles.
On the other hand, many disorders attributed to a displacement of the
clavicle are due to upward subluxation of the first rib, as in some affections
of the arm.

THE SECOND RIB.

The second rib is somewhat larger than the first, but like it, is con-
siderably curved and little twisted. The head has two facets which
articulate with the first and second dorsal vertebra?. An angle is pre-
sent which is external to the tubercle. The shaft presents two surfaces
which are almost plane. The upper faces upward and outward. Near
the middle of the shaft is a roughened eminence for attachment of the
digitations of the serratus magnus. Between this roughened eminence
and the tubercle there are attached five muscles: the scalenus posticus,
serratus posticus superior, musculus accessorius, the cervicalis ascendens
and the levator costaa.

APPLIED ANATOMY. 391

The principal landmark of the second rib is its articulation with the
sternum, it forming a transverse ridge across the sternum which cor-
responds to the junction of the first and second parts of the sternum.
Posteriorly, it can be indistinctly outlined by pressure at the transverse
process of the second dorsal vertebra on a level with the spine of the first
dorsal. If the muscles are contractured or if there is much adipose tissue,
it is very hard to accurately outline it. The pleura is attached to the
inner surface of the rib, while to the outer surface are attached the lig-
aments and muscles which are, in addition to those named above, the
intercostals. The intercostal vessels are in relation with this rib and
are, in all likelihood, always more or less affected by a subluxation of it,
either directly or indirectly, through traction on adjacent tissues.

The nerves in relation with the second rib are the second thoracic
nerve, with its anterior or intercostal branch, and its posterior division;
the sympathetic gangiiated cord; the second thoracic sympathetic gang-
lion and its branches, the pulmonary, cardiac, aortic; and branches that
go to the vertebra, ligaments, spinal cord and meninges.

The movements of this rib are like those of a typical rib except that
they are less marked. Like the first rib, it is fixed by muscular con-
traction during deep inspiration.

The most common lesion or subluxation, on account of the attach-
ments of muscles, is an upward and backward deviation of the verte-
bral end. The scalenus posticus and levator costa? muscles are attached
near the tubercle and by their contracture, the vertebral end will be
drawn upward and backward and held in that position. This can be
diagnosed by the condition of the muscles, they being contractured; prom-
inence of vertebral end; retraction of sternal end; and by the fact that
usually the sternum is also less prominent; tenderness at the costo-
transverse and chondro-costal articulations and disturbance of function of
structures attached, or viscera innervated by nerves in relation with the rib.

The effects of a lesion of this rib are most pronounced in the lungs,
pleura, bronchi and second intercostal nerve.

Broncho-pneumonia is dependent, to a certain extent, upon a sub-
luxation of this rib. The lesion may be secondary to repeated colds in
which the upper thoracic muscles are always contractured or it may
be the result of trauma or sprain. These conditions result in displace-
ment of the ribs, which is usually very slight. The subluxation affects
the passing of vaso-motor and other impulses from the spinal and gang-

392 APPLIED ANATOMY.

Hated cords to the lungs and bronchi, by producing pressure on the
gangliated cord, second thoracic sympathetic ganglion or the pulmonary
branches. These impulses arise in the spinal cord, upper thoracic seg-
ments, pass out over the anterior nerve roots, common nerve trunk,
white ramus, second thoracic ganglion and efferent branches which go to
form the posterior pulmonary, plexus. On account of the relation of the
second rib to these nerves, the connection between the spinal cord and
lungs is impaired or entirely broken, hence vaso-motor, secretory and
trophic disorders follow.

In tuberculosis of the lungs, these rib lesions are present in nearly
all cases. They are causative in some cases, while in others they are
resultant. Repeated colds produce repeated contractures of the spinal
muscles. These contractures interfere with the circulation of blood to
the spinal cord and the position of the vertebrae and ribs. The ribs are
drawn up at.the vertebral end and depressed at the sternal end. The
nerves that innervate the muscles of respiration are inhibited, respira-
tion is shallow and the chest movements are lessened; trophic and vaso-
motor nerve impulses are to a great extent cut off, and venous conges-
tion of the bronchial circulation with degeneration of the living tissue
takes place. The tubercle bacillus, which is ever ready, finds in this
devitalized area a nidus favorable for its propagation, hence the disease
known as tuberculosis of the lungs.

The explanation of a subluxation of the second rib producing tuber-
culosis of the lungs is, that the subluxation of the rib interrupts the tro-
phic and vaso-motor lines of communication between the spinal cord and
the lungs or else it produces direct pressure on the lung substance.

Pleurisy may be a complication of lung disorders or pleuritis, but in
many, is also an effect of a lesion of the second rib. The explanation is
(l),that the displaced rib presses directly on the intercostal nerve, thus
producing pain in the parietal layer of the pleura to which it is distri-
buted, and (2), since the pleura is directly attached to the rib a sublux-
ation of the rib, however slight, would produce traction on, or injury in
some way to, the pleura. Bronchitis is often the result of lesions of the
upper ribs. Chronic bronchitis with cough is in most cases the result
of a subluxation of the second or third rib. The reason for it is the fact
that these rib lesions disturb the innervation of the bronchial tubes which
are almost entirely innervated by way of the pulmonary plexus. Chronic
cough of a bronchial nature,is the result of irritation of the sensory nerves

APPLIED ANATOMY. 393

lining the tubes, the irritating factors being congestion and hypersecre-
tion of the bronchial mucous membrane. It may be due to irritation
of the pleura or lungs, the cough being an attempt on the part of the
body to eject or otherwise rid itself of the irritating factors. The motor
nerves supplying the bronchioles may be affected by this rib lesion and the
size of the lumen changed. If the nerves are stimulated the bronchioles
contract and the condition is called asthma on account of its effects on
respiration. The coughing is due to irritation of the bronchial mucous
membrane and that lining the larynx as well. The different parts of
the respiratory tract are correlated so that a disturbance of one part will
usually manifest itself in another part of the same tract. It is a well
known clinic fact, that chronic cough, bronchial or laryngeal, in most
cases, comes from a subluxation of the second rib, but may be a reflex
effect of many visceral disorders and irritation applied to distant parts.

Many impulses arising in the upper part of the thoracic spinal cord
pass out over the white rami into the gangliated cord, thence upward to
the head and face. These have been described before. (See second
thoracic segment). These impulses supply blood-vessels, glands, mucous
membranes and muscles with vaso-motor, secretory, motor, and trophic im-
pulses and possibly control sensation. In this connection should especially
be mentioned the circulation of the brain, the pupil of the eye and the
salivary glands, the submaxillary in particular.

Congestive headaches often follow subluxation of the second rib
especially on the left side. The explanation is, (l),that the vaso-motor
impulses to the various cerebral vessels are inhibited by pressure of the
head of the rib on the nerve trunk conveying these impulses, hence
dilatation of the blood-vessels of the head, and (2), this lesion in addi-
tion, may excite the cardiac accelerators, which condition results in the
forcing of more blood into these already dilated vessels of the brain.

Displacement of the second rib is associated in some cases with
mammary disturbances. Extirpation of one breast causes a weakness
of the eye on the same side. The connection is through the upper spinal
segments. A subluxation of the second rib will interrupt this connec-
tion, or perhaps in some cases, irritate the nervous mechanism, since the
nerves tracts or trunks are in relation with the rib and are subject to
pressure when the rib is out of its normal position. The mammary gland
may be affected in different ways by this rib lesion. Imperfect or non-
development, mastitis and disturbances of secretion and nutrition can

394

APPLIED ANATOMY.

be rightfully attributed to disorders of the upper ribs. The explana-
tion is that the rib lesion disturbs the innervation of the gland, which
comes by way of the intercostal nerves.

The arm on the same side is often affected by a lesion of the second
rib. Most of the trophic and vaso-motor impulses to the upper extrem-
ity come from the upper thoracic spinal cord. These impulses pass out

611..CERVICAL VERTEBRA

SYMPATHETIC GANGLIA

Fig. 120. — Showing the relation of the structures in the intervertebral
foramina to each other and to the ribs and vertebra?.

APPLIED ANATOMY. 395

from the spinal cord over the anterior nerve roots, through the inter-
vertebral foramen over the common nerve trunk and reach the arm by
passing into and up the sympathetic gangliated cord and over the
brachial nerves. This cord with its second thoracic sympathetic gang-
lion, is in relation with the head of the second rib. In all subluxations
of the rib, the head of the rib is changed as to position and often presses,
directly or indirectly, on the gangliated cord, thus interfering with the
line of communication connecting the upper thoracic segments of the
spinal cord and the arm.

The muscles attached to the rib and those innervated by the nerves
in relation with the second rib are affected by this lesion. If contrac-
tured, which they will be if the lesion is irritative, their function is dis-
turbed, circulation through them altered and a sense of ache usually
accompanies the condition. In acute cases there may be a distinct
pain which will ascend to the back of the neck and head. In occupation
neuroses, an ache is very commonly found between the shoulders or on
the affected side. Relaxation with atrophy and weakness may follow
instead of contracture, but irritation seems to be the usual primary effect
of a typical subluxation of any bone.

In recent cases of a subluxated second rib, pain or ache along the
course and distribution of the second intercostal nerve, combined with
a dry, irritative cough often leads to the diagnosis of tuberculosis of the
lungs. Deep inspiration is painful, the patient is drawn forward to
better shield the affected side, circulation through the lungs is lessened
in amount and rapidity, and the patient has the general appearance of a
consumptive. In some cases tuberculosis develops but can be pre-
vented by the proper treatment, which consists of correction of the rib
lesion. Tenderness on pressure along the course of the second rib is
present in practically all lung affections. The intercostal nerve and its
branches are congested in such cases as well as the tissues in relation.
Tenderness here may be the result of over use of the intercostal and
serrati muscles.

THE THIRD RIB.

The third rib is classed with the typical ribs, hence needs little, if
any, separate mention. It is longer, more twisted and curved than the
second, but not so much so as the fourth rib. Its external surface faces
more nearly directly outward than that of the second rib. The sternal

396 APPLIED ANATOMY.

end can be readily located by refering to the sternal end of the second
rib which forms a ridge on the sternum at the junction. of the first and
second portions. The third intercostal space is the largest, and unless
this is remembered when making a physical examination of the chest,
it might be regarded as an abnormality. The second intercostal space
is next in size.

This rib gives attachment to the pleura and the various chest mus-
cles. Among the most important are the levator costae, serratus magnus
and intercostals. The third intercostal artery and vein are in relation
with the shaft and head. The third thoracic nerve with its anterior and
posterior divisions, the sympathetic gangliated cord, and the third sym-
pathetic ganglion with its branches, are also in relation. The viscera
in relation are the heart on the left side, and the lungs.

The movements of this rib are not so marked as those of ribs lower.
They consist, of a rolling and gliding movements at the costo-trans-
verse articulation. There is some rotation at the head but the move-
ment here is less than at the costo-transverse articulation. The rib is
thus everted and elevated at the sternal end and with this, all the diameters
of the chest are increased.

The third rib is a typical one and on this account, its lesions are
typical and the kinds of lesions and their description that apply to this
rib, will apply to all of the true ribs. The subluxations of this rib vary
but the most common is the one in which the rib is drawn up at the ver-
tebral end and inward and downward at the sternal end. This sort of
displacement is characterized by increased obliquity of the rib; depression
at the sternal end, it being displaced slightly inward and downward; un-
due prominence of the tubercle which is due to the displacement upward
at this point so that it is the more easily palpated, and to a great extent
this prominence is due to the ligamentous thickening at the costo-trans-
verse articulation; increased prominence of the lower edge; a lessening
in size of the interspace below at the sternal end and increase in size of
the corresponding space at the vertebral end; tenderness at both ends
and often along the lower edge of the rib ; and disturbance of function of
the rib so that its movements are impaired and painful. The function
of the costal joints, like that of any joint is movement and in diagnosing
any osseous subluxation, a test of the mobility should be made. This is
done in the case of the costal articulations by causing the patient to fill
the lungs to their utmost capacity. In practically all rib subluxations

APPLIED ANATOMY. 397

that are really causing trouble, unless it is a very chronic case, there
will be some sort of pain or discomfort on deep respiration since the move-
ment of the rib is greatest in deep inspiration. In chronic cases, the
movement may only be restricted and not necessarily painful.

The rib may be displaced upward at both ends. This is diagnosed
by the change in the intercostal spaces, the one above being lessened and
the one below increased, throughout their entire course.

A twisting of the rib is indicated by prominence of one of the edges
it depending on the character of the twist as to the edge involved. The
most common type is an upward twisting in which the lower edge is
thrown outward. Such subluxations are diagnosed by the prominence
of an edge.

It is possible for the vertebral end to become displaced downward
from trauma or severe sprain of the body, this displacement could
scarcely result from muscular contracture on account of the direction
of the muscle fibers attached to the rib.

In all rib lesions, it is well to remember that both ends of the rib
are affected but the degree of movement is greatest at the sternal end.
Inflammatory material collects around the vertebral end in traumatic
cases and is responsible for many of the effects. There is an enlargement
at the articulation which can be palpated in the case of the costo-
transverse joint.

The effects of a lesion of the third rib vary with the degree of the
subluxation, length of standing, cause of the lesion and condition of the
body. It directly affects the pleura, lungs and possibly the pericardium
and heart by pressure. Through disturbance of nerves, it will affect
the head and face, arm, lungs, bronchi, heart, mammae, spinal cord and
muscles of the back in relation. Pleurisy is an effect because of direct
irritation of the pleura. Pneumonia and pulmonary tuberculosis re-
sult because of the effect on the nerve supply to the lungs, the sympa-
thetic cord being affected by the subluxation partly from pressure of the
rib and partly from the inflammatory material.

Angina pectoris and the various functional disorders of the heart,
result because the displaced rib produces pressure on the third sympa-
thetic ganglion, thus interfering with the connection between the cardiac
centers in the spinal cord and the heart. The head and face receive im-
pulses from the spinal cord as low as the third dorsal.

398 APPLIED ANATOMY.

A lesion of the third rib interferes with the nervous connections as
well as the activity of the spinal cord centers by pressure on the gang-
liated cord. The centers for the arm are as low in the spinal cord as the
fifth dorsal and the lesion of the third rib will break the line of communi-
cation between these centers and the arm.

The mammary gland is affected from disturbance of the intercostal
nerves and blood-vessels. The muscles in relation are contractured or
relaxed by a lesion of this rib on account of effect on the third pair of
thoracic nerves. The spinal cord is disturbed by the lesion through its
effect on the blood-vessels that supply it, particularly the veins. The
veins draining the cord are in relation with the ribs, and any deviation
will more or less affect the drainage.

THE FOURTH RIB.

The fourth rib is slightly longer, more twisted and more curved
than the third. It is of greatest importance on account of the fre-
quency of its lesions, in relation to heart and pleural affections. The
sternal end is most easily located by noting the position of the nipple,
it being on the rib, or by counting down from the second rib which can
always be found on account of the ridge across the sternum.

The movements are a little more marked than those of the third
and it is oftener subluxated than the ribs above. It has in relation with
its principal articulations the costo-vertebral and costo-transverse, the
fourth sympathetic ganglion with its branches, and the fourth pair of
thoracic nerves and their anterior and posterior divisions, the recurrent
meningeal nerve, the rami communicantes and the various arteries and
veins going to and from the spinal cord and thoracic structures.

Perhaps the structures most easily and most frequently affected of
those named above, is the vein which drains the spinal cord and muscles.
Any or all of them are more or less affected in a typical case.

The lesions or subluxations of the fourth rib are like those of a
typical rib, the most common form consisting of an upward movement of
the vertebral end, while the sternal end is drawn downward and inward,
and with this there is rotation so that the lower edge is brought into
prominence and the intercostal space above is enlarged at the sternal
end. There is tenderness at all its articulations and usually a thicken-
ing of the ligaments, which is most marked at the costo-transverse joint.

Affections of the heart are the most common effects of a subluxa-

APPLIED ANATOMY.

399

tion of the left fourth rib, while lung, pleural and bronchial disorders
often result from a lesion of the fourth rib on the right side. Angina
pectoris, especially the false type is in almost, if not all cases, due to a
lesion of this rib. The reason for it is that the innervation of the heart
is .by way of the sympathetic ganglion and its efferent branches, all of

INT. bra. (cutaneous)

POST PRIM. DIVISION.

EXT bra/muscular)

RECURREMT BRA."

ANT CUTANEOUS"

Fig. 121. — Showing origin, course, relations and distribution of a typical thoracic
nerve.

which are in relation with the head of the fourth rib. The efferent im-
pulses come primarily from the spinal cord (the fourth segment in par-
ticular). The fourth intercostal nerve is also derived from the fourth
segment of the spinal cord. An irritation applied to the sympathetic
ganglion or cord will cause the pain to be referred to the cerebro-spinal

400 APPLIED ANATOMY.

nerves in close relation, which, in this case, is the fourth thoracic and
its branches. The pain in angina pectoris seems to be mostly in the
intercostal nerves while some of it is in the posterior division, in the ulnar
and possibly the pneumogastric and cardiac plexuses. In some cases,
the rib undoubtedly presses directly on the heart, thus interfering with
its contractions. In true angina, there seems to be a disturbance of nutri-
tion of the heart, which is due, partly at least, to a lesion of the fourth
rib. The entire left side of the chest becomes tender and remains so
nearly all the time. This signifies that the intercostal nerves are con-
gested or slightly inflamed. This is the result of some vaso-motor dis-
turbance, principally at the vertebral end, or the drainage is interrupted,
thus leaving the nerve engorged with blood or otherwise stimulated
Nearly all pain is due to pressure on a nerve, the most frequent form of
pressure being congestion of blood in and around the nerve. This con-
gestion is, in -many instances, I believe, the result of muscular con-
tractures. Again, angina pectoris may be the result of some disturbance
of the accelerator cardiac nerves which causes painful contraction of the
heart, as in the case of the stomach, uterus or small intestine. We do
know that in nine-tenths of all cases of angina pectoris there is a lesion
of the fourth or fifth rib on the left side and that the correction of the
lesion brings relief. We also know that in such a lesion, the cardiac
accelerators, the sensory cardiac, also the trophic and vaso-motor nerves
to the heart are in relation with the rib and would be disturbed by a
lesion of the rib. We also know that these nerves connect with the
fourth intercostal. Our premises being true, since they have been proven
by clinical experience, the conclusion is that the rib lesion produces
angina pectoris by (1) producing pressure on the nerves connecting the
spinal cord and heart, thus interfering with the motor, sensory, trophic
and vaso-motor impulses; (2) by producing pressure on or irritation of
the fourth or fifth intercostal; (3) or by producing pressure directly on
the heart, thus lessening the space in which it has to beat.

Conditions usually described by the layman as "smothering spells."
are also due to lesions of the fourth or fifth rib on the left side. They
produce effects in two ways: (1), by pressure on the heart, and (2), by
disturbing the motor impulses so that the heart has great difficulty in
beating, which condition is always accompanied by dyspnea or a choking
sensation.

Palpitation is another form of heart disorder that 'follows a

APPLIED ANATOMY.

401

lesion of the fourth rib on the left side. The subluxated rib in some
way interrupts or otherwise impairs the motor supply of the heart so
that the amount of nerve force varies instead of being regular. The
rapidity of contraction of the heart is determined by the number and
intensity of the motor impulses sent to it; in other words, the contrac-

SYMPATHETIC CORD
FOURTH DORSAL VERT
INTERVERTEBRAL OR SPINAL GANGLI/
RAMI COMMUNICANTESx

Fig. 122. — Showing the relation of the gangliated cord and its branches, to the
heads of the ribs. A portion of the bodies of the vertebra? has been removed thus
exposing the spinal cord and its nerves. Rib lesions affect these nerves.

402 APPLIED ANATOMY.

tion in an effect. The rib lesion, by stimulating the cardiac nerves, in-
creases these impulses, hence an effect in proportion to the degree of
stimulation. The nerves become more irritable, responding to any stim-
ulation, as from exertion, fright, etc. In short, the displaced rib affects
the motor supply of the heart by pressure on the gangliated cord, the
rami communicantes, nervi efferents, or it affects the cardiac centers in
the spinal cord by interfering with the circulation of blood through
them.

Arrhythmia is explained in a similar way. The nerve feed to
the heart is not regular, hence the contractions of the heart are not reg-
ular. The interruption of the nerve impulses is caused partly by the
rib pressing on the nerve over which the impulses pass, viz., the white
rami, sympathetic gangliated cord or the nervi efferentes. What is
known as an irritable heart is the result of a similar condition. The
nerve supply, is unstable, irregular and subject to increase from almost
any exciting cause. The rib lesion is the cause, as it interferes with
the passing of various impulses to the heart.

In some dissections made by the author it was found that some of
the efferent branches of the upper thoracic ganglia passed forward di-
rectly into the pneumogastric nerve. These fibers were traced down the
sheath'of the nerve and finally appeared to form a component part of
the tenth. This condition very materially helps the explanation of why
upper thoracic and rib lesions affect the heart, producing palpitation,
arrhythmia and other disorders. In all cardiac affections the fourth
and fifth ribs on the left side should be carefully examined, since clin-
ically, lesions of these have been found in nearly all cases. Even in organic
heart disease these ribs are found to be in an abnormal condition.

Mammary disorders, such as non-development, tenderness, mastitis,
ulceration, abscess, tumors and disturbances of milk secretion, often
result from a lesion of the fourth rib on the same side. The explana-
tion lies in the fact that the innervation, blood supply, drainage and
lymphatic vessels are in relation with the fourth rib, as well as the gland
itself. A displacement of the rib, however slight, will in some way af-
fect the gland directly or indirectly through the effects on the blood sup-
ply and innervation. Many cases of ulceration that had been diag-
nosed as cancer, have been cured by adjusting a rib that intercepted the
venous drainage of the breast, thus causing the blood to stagnate and
undergo decomposition.

APPLIED ANATOMY. 403

Disorders of the lungs and pleura arise from a subluxation of the
fourth rib. They are similar to those arising from a lesion of the third
rib, hence do not merit a separate description here. Pain or ache be-
tween the scapula? is most often the result of a rib lesion, the fourth
being most frequently out of place, in such cases. The explanation is
that the deviated rib produces an impingement on the posterior division
of the fourth thoracic nerve. This division passes through a ligamentous
foramen formed by the costo-transverse ligaments and this foramen is
usually lessened in size by the rib lesion. As a result either the sensory
filaments are directly affected or else muscular contractures arise from
irritation of the motor filaments. A lesion of the fourth rib may also
produce an inflammation of the intercostal nerve or what is commonly
called "shingles." This, however, may follow lesion of any rib.

THE FIFTH RIB.

The fifth rib is a typical one and differs in appearance and shape in
no particular from that of the fourth. It is slightly longer, a little more
curved and quite commonly dislocated and fractured. It furnishes a
landmark for the heart (apex beat) and its subluxation is the cause of
many sensory disturbances usually referred to the lungs and heart. It
has in relation with it the usual intercostal vessels and nerves, all of
which are more or less involved by a subluxation of the rib. The most
important muscles attached to it are the levator costse and serratus
magnus. A lesion of this rib especially affects its movements, thus
hampering respiration, making it painful and shallow.

The pleura is attached to this rib and is the seat of much of the pain
which comes from the rib lesion. In lobar pneumonia this is particu-
larly marked. The viscera in relation which would be affected by the
lesion are the lungs, heart and sometimes the stomach. The right
fifth rib may by its displacement affect the liver. The lungs and heart
are affected in a way similar to that in lesions of the fourth rib. Also the
mammary gland is affected (see fourth rib). The special points to be
remembered in connection with a lesion of the fifth rib are (1), pleurisy, or
what is commonly called a catch in the side; (2) functional disorders of
the heart when the left fifth rib is involved; (3) affections of the lobes of
the lung, and (4), disturbances of that part of the chest wall, as in lobar
pneumonia.' The fifth rib is more often fractured than any other on
.account of its position, it being most exposed of all the true ribs.

Fig. 123. — Showing the course, relation to ribs, and distribution of the inter-
costal nerves.

APPLIED ANATOMY. 405

In experiments performed on dogs, *McConnell states: "Under
anesthesia the dog's middle and lower dorsal region was sprung forward
with fairly moderate force.

Six weeks later dissection revealed an anterior "break" between
the tenth and eleventh dorsal vertebrae. Also, the fourth and fifth ribs
on the right side were sprung upward at the vertebral ends. Muscles
and ligaments over and between the injured vertebras and ribs, very tense
and rigid.

Macroscopic hemorrhagic spots from the size of a pin-point to head
of a pin were found in the sympathetica opposite the "break" and in the
corresponding rami on both sides. Congestion of spinal nerves between
the tenth and eleventh ribs.

Stricture in the lower third of the jejunum.

The microscope revealed pathological congestion of the above af-
fected nerves, that is, intracellular congestion."

THE SIXTH RIB.

The sixth rib is slightly more obliquely located than those above,
its costal cartilage is longer and forms a more acute angle with the ster-
nal end of the shaft. The interspaces are not so wide, decreasing in size
from the third down. The sixth intercostal vessels are in relation with
this rib, a groove being formed for them on the under surface of the
rib. The vein is most easily affected. The sixth intercostal nerve, the
gangliated cord, sixth thoracic ganglion, great splanchnic nerve and the
rami are also in relation. The pleura, liver and stomach are in rela-
tion ar"i are affected by direct pressure in inward subluxations, or what
is usually called, a depressed condition of the rib. This rib is subject to
the usual rib subluxations and the diagnosis is based, as in other ribs,
on effects; position and comparsion, with other ribs.

The sensory effects are characterized by disturbances of sensation in
region supplied by the sixth intercostal and its branches and in the
region supplied by the posterior division of the sixth thoracic
nerve. The lesion is most commonly an irritative one, therefore pain
is the most common of the sensory effects. The pain is felt at the sternal
end of rib, along the lateral cutaneous branch and at the vertebral end.
The integument is tender to the touch and respiration is "catchy."
There may be numbness or complete anesthesia in the same areas. The

♦Journal of A. O. A., Vol. V, p. 16.

406 APPLIED ANATOMY.

explanation of these sensory effects lies in the fact that when the rib is
displaced it presses on or otherwise irritates or affects the sixth thoracic
pair of nerves. In some instances the pain or ache is undoubtedly due
to the congestion of the nerve which results from the subluxated rib.

There will be some thermic effects along the sixth intercostal space
in a lesion of the sixth rib. The surface temperature is most commonly
lowered. Some disturbance of the sensibility of the liver and stomach
result from this lesion, since the afferent impulses from these viscera
pass through the sixth ganglion which is in relation with the head of the
rib .and would be disturbed by a lesion of the rib. If the impulses are
increased, there will be pain either in the viscus or in the cerebro-spinal
nerve — the sixth intercostal. This nerve is the seat of pain in a great
many visceral disturbances, especially of the stomach and liver, the pain
being a referred one and is explained by Head's law. The muscles of
the back and chest supplied by the sixth thoracic segment, become tender
as a result of the contracture and irritation of the muscular sensory nerves.

The motor effects of a lesion of the sixth rib are muscular contrac-
tures and perverted peristalsis of the liver and stomach. The muscles
in relation with the rib and those supplied by the sixth thoracic segment,
become contractured in cases of lesion of the sixth rib. This is the re-
sult of irritation (fatigue or over-stimulation) of the motor nerves or
the result of traction on the muscle. The motor Impulses that pass to
the liver and stomach, in part pass through the sixth thoracic sympathetic
ganglion. A lesion of the sixth rib will interrupt or in some way disturb
the function of the ganglion, hence some motor effect in the above named
viscera. If the lesion irritates the ganglion, splanchnic nerve or ramus,
there is usually excessive peristalsis in the viscus supplied. This lasts
as long as does the stimulation, after which the opposite effect sets in.
If the lesion is paralytic, the opposite result will occur. Experimentally,
it seems that stimulation of the splanchnic nerves causes a lessening of
peristalsis in the viscera, while inhibition produces the opposite effect.
Clinically, it is proven that inhibition applied to the spine will tend to
lessen peristalsis if the parts are not in a normal condition. The more
nearly normal the parts the less the effect of either stimulation or inhi-
bition. After all it is a question of adjustment. If the rib lesion is
causing an irritation and the disturbance is overcome, whether by stim- .
ulation, inhibition or some other means, the effect must be the same,
that is inhibitory. If the rib lesion is producing an inhibitory effect,

APPLIED ANATOMY. 407

correction of the lesion will necessarily produce a stimulation, regard-
less of the way in which it is corrected.

A lesion of the sixth rib will cause a lessened or increased secretion
in the liver, stomach and sweat glands, it depending on the character
of the lesion, that is whether it is irritative or paralytic. In the case of
the viscera, secretory impulses pass from the spinal cord by way of the
sixth thoracic sympathetic ganglion, thence over the great splanchnic.
A displacement of the sixth rib will intercept or stimulate these impulses.
If they are intercepted, secretion is lessened although it does not depend
entirely on the secretory nerves, but in part upon the quantity and
quality of the blood. If they are stimulated, secretion is increased.
This is true experimentally in cases in which the parts are in a
healthy condition. Clinically, it seems that the opposite is true. This
is best demonstrated in catarrh of the stomach. There is a sort of par-
alytic condition of the spinal muscles, stomach, and in fact all the tissues
in relation. The accumulation of mucus in the stomach may be due to
weakness of the muscles of the stomach wall, the peristalsis not being
strong enough to expel it, but I am of the opinion that there is a hyper-
secretion of mucus, and that the lesion produces inhibition rather than
stimulation.

Excessive secretion of sweat along the sixth interspace is explained
by the rib lesion disturbing the function of the sixth intercostal nerve,
one of its functions being that of carrying secretory impulses from the
sixth ganglion to the sweat glands in the integument over the sixth in-
terspace.

Vaso-motor impulses to the intercostal arteries, spinal branch, mus-
cular branches to the spinal muscles, and the various abdominal arteries
supplied by the great splanchnic nerve, pass through the sixth thoracic
sympathetic ganglion and white rami and would be involved in a typical
lesion of the rib. Congestion of the parts supplied by the arteries named
above will result if the lesion inhibits the passing of the vaso-motor im-
pulses, while anemia will result if the lesion is irritative. The veins are
similarly supplied with vaso-motor impulses and will be affected by this
lesion. The venae azygi are also affected by this lesion, through disturb-
ance of their innervation, and since these veins drain the spinal column,
cord, thoracic wall and muscles of the back, disturbances of these parts
are common.

The trophic effects of a rib lesion are noted in muscles, bones and

408 APPLIED ANATOMY.

other tissues supplied by the sixth intercostal, the recurrent meningeal,
and the sixth thoracic sympathetic ganglion. All nerves are more or
less trophic to the parts supplied, hence any disturbance of the above
named nerves will produce some trophic effect. The muscles suffer
most and soon the median furrow becomes widened, the ribs begin to
prolapse, the antero-posterior diameter of the chest decreases and res-
piration becomes shallow. Necrosis of the rib is sometimes a sequel to
the lesion. Weakness of the walls of the stomach is also a trophic effect
of the lesion.

*McConnell states in experiments on dogs: "Two weeks after
operation dissection showed the fourth, fifth and sixth ribs on the right
side dislocated upward at the vertebral ends.

The usual muscular tension and rigidity of the spinal ligaments in
the area affected.

Marked inflammation and hemorrhage of the sympathetic chain,
the rami, posterior spinal nerves, the intercostal, the posterior and an-
terior nerve roots, the meninges of the cord for a diameter of a quarter
of an inch surrounding the exit of the fifth spinal nerve on the right side, '
and along the anterior commissure. The pathological condition here was
exceptionally marked. The dog was sick and inactive for a week fol-
lowing the first forty-eight hours after the operation.

Enlargement of spleen to over twice the normal size. "

THE SEVENTH RIB.

The seventh rib is the lowest of the true ribs. Its costal cartilage
is longer than that of the ribs above. Its relations, lesions and effects
of lesions, are similar to those of the sixth rib. When subluxated, the
muscles attached to it are either relaxed or contractured. Those affected
are the levator costse, serratus magnus, intercostals, the abdominal mus-
cles and the diaphragm. All of these muscles have to do with respira-
tion, therefore in a lesion of the seventh rib, respiration is disturbed.

In relaxation of these muscles, prolapsus of the ribs results. In
contractures of the muscles, normal movements of the ribs are impaired,
while in some cases the rib is drawn out of place. A lesion of the seventh
rib will, in some cases, produce relaxation of these muscles; in others,
contracture, on account of (1) attachment of these muscles to the rib,
and (2) through disturbance of the seventh pair of thoracic nerves.

♦Journal A. O. A., Vol. V, p. 16.

APPLIED ANATOMY. 409

The blood-vessels affected by this lesion are the intercostal vessels
with their spinal and muscular branches, the gastric and hepatic vessels.
Clinically, it seems that the veins are affected more often and more
readily than the arteries. As a result there may be anemia or conges-
tion of the muscles of the back, seventh intercostal space, pleura, spinal
cord, stomach and liver. The explanation is that the lesion exerts
pressure on some of these vessels, while others are affected through their
innervation which is hv way of the seventh thoracic ganglion and great
splanchnic.

The nerves affected by a lesion of the seventh rib are the seventh
thoracic spinal nerve with its posterior and anterior, or intercostal
branches, the recurrent meningeal nerve, the gangliated cord and the
seventh thoracic sympathetic ganglion with its branches, viz., the great
splanchnic, aortic, and filaments to the vertebra and ligaments. The
lesion may stimulate or inhibit the passing of impulses over these nerves.
There may be relaxation of contracture of the muscles supplied by the
seventh dorsal segment or sensory disturbances in the integument of the
back and the seventh interspace. The pleura is usually involved, partly
through its nerve supply and partly on account of its attachment to the
rib. The passing of impulses over the great splanchnic is disturbed,
hence vaso-motor, secretory, motor, sensory and trophic disturbances,
most commonly found in the stomach and liver. All of these nerves
are in relation with the seventh rib, or the impulses passing over them
pass over nerves that are in direct relation; that is, the impulses passing
over the great splanchnic, also pass over the rami, gangliated cord, and
common nerve trunk of the seventh thoracic pair of nerves and are in
relation with the head of the seventh rib.

The viscera affected by a lesion of the seventh rib are the stomach
and liver, the seventh rib on the left affecting the stomach, while a le-
sion of the corresponding rib affects the liver. This may be explained in
two ways: (1), relation of the rib to the viscera, and (2), relation of rib
to the nerve supply to them. These effects vary in that the lesion in one
case is irritative, while in another it is inhibitive. Thus it may produce
excessive peristalsis, activity and pain; or lessened peristalsis, lessened
activity and a general paralytic condition of the viscera.

The spina] cord, spinal column, ligaments and muscles are also af-
fected by the lesion. Indigestion, biliousness, pleurisy with respiratory
disorders complicate acute cases. The diaphragm is also disturbed in

410 APPLIED ANATOMi'.

that its position is changed, its openings altered in size and its contrac-
tions hampered. The author has had some experience with cases of
hiccough in which the trouble was caused by a lesion of the lower ribs,
the seventh being at fault. The lesion seemed to irritate the diaphragm,
and as a result the attack came near terminating fatally. By lifting
the rib, that is by correcting the rib lesion, the irritation was relieved and
the hiccough ceased immediately. The importance of this sort of lesion
in the persistent types of hiccough is underestimated, since in many of
them the ribs that give attachment to the diaphragm are often found to
be in a state of descent, or more commonly a single rib is twisted in such
a way that it has an irritative effect. The explanation is based (l),on
attachment of the muscle (diaphragm) to the rib, and (2), irritation of
the intercostal nerves which help to innervate the diaphragm. Thermic
changes, the interspace becoming cold, and localized perspiration are
often associated with the lesion of the corresponding rib. I' have often
found a lowering of the surface temperature along the seventh and eighth
interspaces on the left side in chronic catarrh of the stomach.

The sternal end of the rib is subject to irregularities in that the
cartilage is often forced upward or outward. In rickets and adenoids of
the throat, there is often found a depression or shallow, wide groove cor-
responding to the upper attachments of the diaphragm to the chest wall.

THE EIGHTH RIB.

The eighth rib belongs to the false ribs, so-called because it does not
articulate directly with the sternum, but with the cartilage of the seventh
rib. The false ribs have a greater range of mobility and are more elas-
tic than are the true ribs. The obliquity is greater and this is often de-
cidedly increased in cases of general weakness and from tight or im-
properly worn clothing.

The movements of this rib are upward and outward in inspiration
and downward and inward in expiration. In all lesions of this rib these
are impaired, in acute cases made painful, while in the chronic they are
lessened, this resulting in descent or prolapsus. The lesions of this rib
are similar in character to those above, torsion and depression of the
sternal with elevation of the vertebral end, being the most common.
In this sort of displacement the lower edge is turned outward to such an
extent that it can be readily palpated. The interspace below at the
sternal end is decreased in size, while that above is increased.

APPLIED ANATOMY.

411

CERVICAL

Fig. 124. — Drawn from a dissection at the A. S. 0. to show the thickness of the
skin of the back and points of emergence of the cutaneous nerves. Note the arrange-
ment of the muscle fibers.

41'2 APPLIED ANATOMY.

The effects of a lesion of this rib, vary with the degree and length of
standing of it. The sensory effects are most common and important
from a clinic point of view and will be considered first. The sensory
nerves involved directly are the eighth thoracic with their branches, the
anterior and posterior divisions. The gangliated cord in relation con-
tains some afferent fibers that convey impulses from the abdominal
viscera to the spinal cord, thence by it on to the sensorium. This af-
ferent tract is impaired by a lesion of this rib and on this account, the sen-
sibility of the viscera is increased or decreased by it. Pain from vis-
ceral irritation is often referred to the cerebro-spinal nerves branching
from the segment that supplies the viscus, as in hepatic colic. The con-
verse is also true that is, pain in the viscus is produced by the irritation
caused by the subluxated rib.

Painful affections of the liver, are caused in some cases by this lesion.
Pain in the pleura, in the eighth interspace and in the intercostal mus-
cles in relation, is the result of this lesion irritating the eighth inter-
costal nerve, since it supplies these structures. These sensory disturb-
ances cause respiration to be imperfect, jerky and shallow. There may
be a perversion of function of these sensory nerves, this producing ting-
ling sensations or, what is technically called, formication. There may be
numbness of the parts or other sensory disturbances that commonly
result from inhibition of a sensory nerve. All these sensory effects are
explained by the relation of the sympathetic cord, eighth thoracic nerve
and their branches, to the eighth rib.

The motor effects of this lesion are characterized by contracture or
relaxation of the muscles supplied by the nerves in relation, and by lessen-
ed or increased peristalsis of the viscera supplied by the part of the great
splanchnic nerve which is in relation with this rib, viz., the liver, bile
ducts, stomach, and small intestine, upper part. The diaphragm is
affected, this interfering with respiration and the return of the blood from
parts below the muscle.

The vaso-motor effects are manifest by dilatation or constriction of
the vessels of the muscles of the back, the thoracic wall, pleura, cord,
stomach, liver, pancreas, and duodenum. The vaso-motor impiilses
to these parts pass over the splanchnic, recurrent meningeal, and eighth
thoracic nerves and they are in relation with the eighth rib.

The secretory effects are localized sweating along the eighth inter-
space and altered secretion in the viscera supplied with secretory im-

APPLIED ANATOMY. 413

pulses by the great splanchnic nerve, viz., the liver, pancreas and stomach.
The principal effects of a subluxation of this rib are, pain along the
course of the rib, pleurisy, shallow and painful respiration, and liver dis-
turbances such as biliary colic.

*McConnell states in experiments on dogs in which the ribs were
displaced: "Three weeks after the production of the lesions, dissection
showed the eighth rib on the right side and the seventh rib on the left
displaced upward as the vertebral ends.

The muscles, superficial and deep, contiguous to the lesions, were
rigid.

There was marked inflammation of the corresponding sympathetics
and rami (macroscopic ally and microscopically).

Enlargement of the spleen to twice normal size."

THE NINTH RIB.

The ninth rib furnishes a landmark for the location of the gall-bladder
and the spleen. The upper edge of the spleen is in relation with the
left ninth rib, while the costal cartilage of the right ninth rib is in rela-
tion with the gall-bladder. The costal cartilage of the rib is often in-
jured by falls on the side, and sometimes by injudicious treatment. Its
lesions are similar in character to lesions of the ribs above and the effects
are about the same as those of the eighth rib. A lesion of this rib will
affect the innervation of the small intestine, liver, spleen, pleura, gall-
bladder, a portion of the peritoneum and the muscles in relation, espec-
ially the diaphragm. These effects occur because of the relation of the
rib to the nerves mentioned, on account of which the displaced rib exerts
pressure directly on one or more of them.

The disorders associated with this lesion are biliary colic, congestion
of the liver, affections of the small intestines, intercostal neuralgia,
girdle pain, herpes zoster, pleurisy and other respiratory disorders caused
by effects on the diaphragm.

This rib is subject to downward displacements on account of the at-
tachment of muscles, such as the serratus posticus inferior and dia-
phragm, and on account of the obliquity of the rib and the shape of the
articular facets. The facets on the transverse processes of the lower
thoracic vertebra? face slightly downward, while those of the vertebra?
above face slightly upward. This is, in the case of the upper ribs, for
*Journal A. O. A., Vol. V, p. 14.

414 APPLIED ANATOMY.

the better support of the chest as in the carrying of weights, while in the
case of the lower ribs, it gives greater freedom to the movements of the
diaphragm. Perhaps this accounts for the frequency of prolapsus or
downward displacement of the lower ribs.

It is claimed that pressure applied to the vertebral end of the right
ninth rib will relieve hepatic colic. This is explained by the fact that the
afferent impulses from the gall-bladder and bile ducts pass over that
portion of the great splanchnic and gangliated cord, that are in relation
with the head of the right ninth rib and most if not all, the impulses to
and from the liver and gall-bladder pass over the right side. Perhaps a
better explanation is that the inhibition lessens the number and inten-
sity of the motor impulses hence dilatation of the duct follows.

THE TENTH BIB.

The tenth rib is classed with the peculiar ribs because it has a single
facet for articulation with the body of the tenth thoracic vertebra. It
is long, curved and has the usual groove, tuberosity, and angle. The
distance between the angle and the tuberosity is greater than in the ribs
above, also the obliquity is greater.

The mobility is greater than that of the ribs above, and it is more
subject to displacement from contraction of the muscles attached to it.

It is in relation with the spleen, liver, and suprarenal capsule; the
pleura and diaphragm; and the lesser splanchnic and tenth thoracic
nerves and their branches and connections.

The lesions of this rib cause disturbances of function in a way sim-
ilar to those of other ribs, that is, by direct pressure on structures or
indirectly, through effects on nerves and the spinal cord. The costal
cartilage of this rib is often broken off but causes little trouble, other than
a local weakening of the part.

Pain in the abdominal wall near the umbilicus is one of the most
common of effects of a lesion of this rib. It is explained by the fact that
the tenth intercostal nerve is in relation with the rib and is impinged on
by the subluxated rib. The pain is usually referred to the periphery
of the nerve, hence the pain is felt at the umbilicus. This pain may be
one referred from disease of the small intestine as in intestinal indiges-
tion, or from kidney disorders as in acute inflammation.

A relaxed abdominal wall is due, in many cases, to a dropping of the
lower ribs, and the tenth, takes part is the general descent: In some

APPLIED ANATOMY. 415

cases the lesions of the ninth and tenth ribs seem to be the primary
causes. In anemia, this rib is usually displaced downward but it may
be an effect instead of a cause. In irritative lesions of this rib, the ab-
dominal wall is tender and contractured. This is explained by the stim-
ulation of the tenth .intercostal nerve. The abdominal muscles in re-
lation with this rib, connect with their spinal center, by way of the
tenth intercostal nerve. If this connection is broken, relaxation of the
muscles takes place, but if the nerve or its communicating branches are
stimulated, contraction or contracture of the abdominal muscles is the
result. The nerve connections existing between the spinal cord and
small intestine are often interfered with by this lesion, and some dis-
order of these parts is the result. This is also true of the kidney, and
ovary and consequently any disease of these parts may be the result of a
lesion of this rib. Respiration is affected through the disturbance of
the diaphragm, this muscle being attached to the rib.

The principal diseases caused or predisposed to, by this lesion are
Bright 's disease, intestinal indigestion, ovarian colic and in fact any dis-
order of the ovary. The most common effect in recent cases is pain in
the abdomen at or near the umbilicus, which is often mistaken for peri-
tonitis, appendicitis, ovaritis or some disease of the intestines.

THE ELEVENTH RIB,

The eleventh rib is peculiar in several respects. It has a single facet
for articulation with the body of the eleventh thoracic vertebra, a poorly
developed angle, no tubercle and no neck. It does not articulate with
the transverse process of the vertebra, is short, twisted but little, and the
anterior end is pointed. The subcostal groove is shallow and the end of
the rib is tipped with cartilage which is pointed and occasionally broken
off by trauma or by injudicious treatment as in the ninth and tenth ribs.

On account of- the marked mobility of this rib, it is called a floating
rib. This free mobility is due to the fact that the sternal end is free,
while the vertebral end has only a single articulation. The position of
this rib is then controlled to a great extent, by the condition of the mus-
cles and other tissues attached to it. This ought to be taken into consid-
eration when we attempt to reduce a dislocation of it since it will do little
if any good to correct the subluxation unless the muscles attached to it
are restored to a normal condition.

This rib acts as a stay or support for the muscles attached to it as

416 APPLIED ANATOMY.

do the ribs of an umbrella. It is fixed by the muscles attached below
and thus furnishes a fulcrum for the action of the respiratory mus'cles
and especially the diaphragm. These muscles are the external oblique,
transversalis, serratus posticus inferior, accessorius, ilio-costalis, levator
cos'tae, and the intercostals. The pleura, parietal layer, lines the inner
aspect of the rib. The left one is in relation with the spleen while on the
right side the liver is in relation. The upper part of the kidney is some-
times in relation with the rib.

The lesions of this rib are usually of two kinds, the one in which the
anterior end is turned downward, thereby increasing the eleventh inter-
costal space, the other in which the rib is rotated forward and upward and
the point carried up under the tenth rib. In this case the rib seems to
be forced directly inward as well as rotated. The first is diagnosed by
finding the lower edge of the rib prominent, the point turned downward
and outward^ the intercostal space widened at the anterior end and lessen-
ed at the vertebral end and by finding tenderness along the vertebral end
of the rib. The position as it is determined by palpation, is typical in
the second case. The point of the rib is felt with difficulty if 'at all.

The effects of a lesion of this rib vary with the degree, the way in
which it occurred, the length of standing and the condition of the tissues
attached to it. The pleura and muscles are affected since they are at-
tached to the rib. The spleen and liver are affected because they are
in close relation. If the rib is dislocated inward as is often the case from
improperly worn clothes, it presses directly on these viscera. I
have made dissections in which I found grooves in the liver caused by
tight lacing, by which the ribs were forced into the substance of the
liver.

The intercostal vessels in relation, will in some way be affected by
the lesion, and as a result, the circulation of that part of the spinal cord
will be disturbed. These blood-vessels are in relation with the head of
the rib and when a subluxation occurs, pressure is exerted directly on
the vessels.

The nerves in relation that would in ordinary cases be affected by
a displacement of the rib, are the eleventh thoracic with its anterior and
posterior divisions, the sympathetic cord and the eleventh ganglion and
its branches which connect it with the cerebro-spinal nerves in relation,
and the nervi efferentes of this ganglion.

Pseudo-appendicitis is one of the most common of results of a lesion

APPLIED ANATOMY. 417

of this rib. The patient describes a pain that is in the right iliac fossa,
which is similar to if not identical with that of true appendicitis, of the
chronic form. There is tenderness on pressure, on extension of the body,
and usually some indications of bowel disorder. These symptoms re-
sult from the lesion irritating or otherwise affecting the eleventh inter-
costal nerve, which is distributed to the iliac fossa. The point of greatest
pain is at McBurney's point, that is midway between the umbilicus and
the anterior superior spine of the ilium. In true appendicitis, the pain
is referred over this same nerve hence the error in diagnosis. The nerve
also supplies the muscles of the abdominal wall in relation, hence when
it is irritated as it is in most cases of subluxation, the muscles contract,
become tender and the patient with difficulty can extend the limbs or
bend the body backward.

In many cases of supposed ovarian disease, the eleventh rib is sub-
luxated and presses on the eleventh intercostal nerve, which produces
pain in the same area as is found in organic disease of the ovary. In
true ovarian disease, the pain is referred to the areas innervated by the
eleventh intercostal, since this segment of the spinal cord supplies the
ovary. Head's law very nicely explains these referred pains and espec-
ially those from ovarian and bowel disorders. A "stitch" in the side
is so often caused by a lesion of this rib. On account of its free mobil-
ity, extreme lateral flexion of the body or sudden twists will often cause
the rib to be pulled from its normal position by muscular action. This
produces an irritation of the nerve so that any movement of the part
produces a pain of such a character that it is familiarly called a "catch."

Kidney, ovarian and bowel disorders often result from a lesion of
the eleventh rib since the connection existing between the spinal cord and
these organs is interfered with by the lesion. The explanation is that
this connection is by way of the lesser splanchnic nerves, the white rami
and the gangliated cord. These nerves are in relation with the head of
the eleventh rib and will beyond doubt, be impinged on by a subluxation
of the rib; or the blood-vessels going to and from the spinal cord
through the eleventh intervertebral foramen will be pressed on and thus
the nutrition of the cells located in this segment which give rise to
the impulses passing out over the above named nerves will be in-
terfereed with. Clinically, it is a demonstrated fact that a lesion of
this rib will produce disease of the kidney, ovary and bowel.

The condition of the abdominal muscles is, to a certain extent, con-

418 APPLIED ANATOMY.

trolled by the condition of this rib. The explanation is that the motor
and trophic impulses to these muscles pass out over the eleventh inter-
costal nerve and it is in relation with this riband would be affected by a
lesion of it. The lesion may be an irritative one and contracture would
be the result or it may be a paralytic one, in which case relaxation would
be the sequel. In other cases, the effects are the result of traction or
pressure on these muscles since most of them are attached to this rib.
I will mention the diaphragm as a special example. Its position and
function are always more or less disturbed by a lesion of the eleventh rib.
As a result, the openings in it are lessened in size this in turn causing
congestion of parts below and a greater strain is thrown on the heart.
Dr. Still has often mentioned this fact in connection with heart disturb-
ances such as palpitation, arrhythmia and even regurgitation and hyper-
trophy.

Hiccough is the best example of disturbance of function of the dia-
phragm as a result of a rib lesion. The traction on or irritation of, this
muscle, causes it to contract spasmodically ,which condition is called
hiccough. This is especially true of the worst types of this disease
which ofttimes proves fatal.

THE TWELFTH RIB.

The twelfth rib has a single facet for articulation with the pedicle
of the twefth thoracic vertebra. The rib is but little twisted, short,
pointed at the anterior extremity, and the shaft is narrow, rounded and
smooth above, and rough and sharp on its inferior aspect. It has no
angle, neck, tubercle, nor subcostal groove. It has a greater range
of movement than any of the ribs and is in reality, a floating rib. Like
the eleventh rib, its position is determined by the condition of the tissues
attached to it. It acts as a stay and support of the sides of the abdominal
parietes. As in the case of the eleventh rib, it, when fixed by contrac-
tion of the muscles below, acts as a fulcrum for the respiratory muscles.
It is fixed from below by the quadratus lumborum muscle, some of the
abdominal muscles and the ligamentum arcuatum externum.

This rib is in relation with the kidney and usually the large bowel.
The attachment of muscles is the same as for the eleventh rib except that
the quadratus lumborum is only attached to the twelfth. In addition,
it gives attachment to some of the ligaments of the diaphragm.

The rib is subject to displacements similar in character to those of

APPLIED ANATOMY. 419

the eleventh, that is the anterior end may be forced downward, or up
under the eleventh rib. The normal obliquity is less than that of the
rib above, yet it is often found in such a state of descent, that it almost
or actually touches the crest of the ilium. This is the result of a general
weakening of the abdominal walls. The rib may be pulled down by the
contraction of the quadratus lumborum muscle which is attached to the
lower border of the rib.

On account of its position, it is subject to displacement from the
wearing of improperly fitted clothing and especially from the wearing
of belts or tight bands. Other lesions result from muscular contraction,
and forced lateral flexion or extension of the body. These lesions produce
disease by pressure on adjacent tissues, traction on muscles and liga-
ments attached, pressure on viscera in relation and by pressure on the
nerves and blood-vessels in the twelfth thoracic intervertebral foramen.

The motor effects are characterized by contracture or relaxation of
the abdominal muscles, and by increased or decreased activity of the
ureters, tubes and intestines. The muscular effects are explained by
the fact that the nerve supply of the abdominal wall comes in part from
the twelfth thoracic, and this nerve is either stimulated or inhibited by a
lesion of this rib, because it is in relation. If stimulated, there will be
contracture of the lower abdominal muscles but if the subluxation in-
hibits the passing of motor impulses along the nerve, there will be a
relaxation of these muscles. In many cases, the contractured or relaxed
condition of these muscles is due to other causes and the rib lesion is sec-
ondary. The principal sensory effect is pain in the iliac fossa. Pain or
some sensory disturbance is referred to the back, crest of the ilium, and over
the hip as low as the great trochanter, that is, in the areas supplied by the
twelfth intercostal nerve. Visceral pain and sensory disturbances of
the peritoneum sometimes result from this lesion on account of the re-
lation of the rami communicantes to the head of the rib. Usually the
pain is referred to the cerebro-spinal nerves in relation, instead of the
sympathetic. On this account, irritation of visceral nerves having their
course in the twelfth thoracic segment, either peripherally or along their
course as at the head of the rib, will result in the pain being referred to the
cerebro-spinal nerves in relation, that is the twelfth thoracic. This ex-
plains the fact that in most cases of ovarian, kidney and intestinal dis-
orders, the pain or ache is felt in the back or along the course and distri-
bution of the twelfth thoracic. The secretory and vaso-motor disorders

420 APPLIED ANATOMY.

resulting from this lesion, are explained through the above mentioned
nerves, that is the rami, lesser and least splanchnics and the sympathetic
ganglia, since these nerves carry vaso-motor and secretory impulses to the
above mentioned organs. Disorders of the integument of the lower
part of the back are sometimes the result of a lesion of this rib, since
the nerves carrying trophic, vaso-motor, sensory and secretory impulses,
are in relation with the rib and are involved in many cases. A localized
eruption as in herpes zoster and excessive secretion of sweat in this region,
are the most common of these disturbances.

THE THORAX.

The thorax is formed by the ribs, the sternum and costal cartilages
in front, the shafts of the ribs on the side, the bodies of the thoracic or
dorsal vertebras and their discs behind. In shape it resembles a trun-
cated cone, -flattened antero-posteriorly, and rounded laterally. These
structures are so arranged that they form a movable frame work to which
are attached the muscles of respiration and which protects the heart and
lungs.

The sternum, which is composed, in the adult, of three flat spongy
bones, is of interest to us in that the lower end, the ziphoid appendix, is
often depressed as in certain occupations in which the patient assumes a
stooping posture, or in certain diseased conditions of the bones, as rickets.
The costal cartilages connect the sternum with the true ribs. They
vary in length and obliquity. The upper cartilages are short, the lower
large and oblique. The right side of the chest is usually larger than the
left, possibly on account of the fact that most people are right handed.
According to Holden, the diameters of the chest at different levels in the
average male skeleton are as follows: "The antero-posterior diameter, at
the inlet, is two and one-fourth inches; at the junction of the manubrium
and gladiolus, four and one-half inches; and at the outlet, five and three-
eighths inches. The transverse diameter at the inlet measures four and
three-eighths inches, between the second ribs, seven inches; between the
third ribs, eight and one-eighth inches; gradually increasing between the
succeeding ribs, it attains its maximum between the ninth ribs, where it
measures ten and five-eighths inches; and gradually diminishes below that
level." The vertical diameter in increased in inspiration.

The female thorax differs from the male in that its capacity is smaller,
the sternum shorter, and the lower opening smaller in proportion than

APPLIED ANATOMY.

421

is that in the male. The mobility of the upper part is greater. This is
possibly due to the compression, of the lower ribs from the wearing of
certain kinds of clothing. The ribs are smaller and more oblique. The
free mobility of the upper ribs permits of greater enlargement of the
thoracic cavity in adaptation to the requirements of pregnancy. If this

Fig. 125. — Showing a subluxation of the eighth rib on the left side. IT. upward
displacement at the vertebral end; A. widening of the interspace below; D. down-
ward displacement at anterior end; B. widening of the ninth interspace in the mid-
axillary line. Compare the interspaces on the two sides. (From photo of dissec-
tion made at the A. S. O.).

422 APPLIED ANATOMY.

were not true, pregnancy would interfere to a considerable extent, with
respiration on account of the pressure on the diaphragm.

In most cases it: is easy to locate or count the ribs, but in obese people,
the landmarks are obliterated and on this account we quote Holden's
rule for counting the ribs:*

"(a) The finger passed clown from the top of the sternum soon comes
to a transverse projection, slight, but always to be felt, at the junction of
the first with the second bone of the sternum. This corresponds with
the middle of the cartilage of the second rib.

(b) The nipple of the male is placed, in a great majority of cases,
between the fourth and fifth ribs, about three quarters of an inch ex-
ternal to their cartilages.

(d) A line drawn horizontally from the nipple round the chest cuts
the sixth intercostal space mid-way between the sternum and the spine.
This is a useful rule in tapping the chest.

(e) When the arm is raised, the highest visible digitation of the
serratus magnus corresponds with the sixth rib. The digitations below
this correspond respectively with the seventh and eighth ribs.

(f) The scapula lies on the ribs from the second to the seventh, in-
clusive.

(g) The eleventh and twelfth ribs can be felt even in corpulent per-
sons, outside the erector spinas, sloping downward.

(h) One should remember the fact that the sternal end of each rib
lies on a lower level than its corresponding vertebra. For instance, a
line drawn horizontally backward from the middle of the third costal
cartilage at its junction with the sternum, to the spine, would touch the
body, not of the third dorsal vertebra, but of the sixth. Again, the end
of the sternum would be about the level of the tenth dorsal vertebra.
Much latitude must be allowed here for a variation in the length of the
sternum, especially in women."

Movements of the Kibs.

In inspiration, all the diameters of the chest are increased, which is
accomplished by the action of certain muscles which draw the anterior
ends of the ribs up, and on account of the shape of the ribs, this increases

♦Landmarks Med. and Surg. Holden, p. 22.

APPLIED ANATOMY.

423

Fig. 126. — The right side of the thorax. The lines denote the position of the right
lung.

424 APPLIED ANATOMY.

both the anteroposterior and lateral diameters of the chest. The lower
ribs are drawn downward and the upper ones are fixed by the scaleni
muscles, therefore the vertical diameter is possibly increased. The
' uscles of inspiration are the diaphragm, by the contraction of which,
the vertical diameter is increased, the scaleni, levatofes costarum, serratus
posticus superior and the external intercostals. The movements. of the
chest are hampered by abnormal conditions of these muscles or dis-
placements of the ribs. The movements should be symmetrical, quite
free and without pain. In cases of lung disease, the movement is found
unilateral, decidedly lessened and painful, particularly in cases of pleu-
risy and adhesions.

The surface markings of the chest are of importance to the practi-
tioner, since there are so many changes of contour from diseases of the
lungs or heart or the great blood-vessels, which can be diagnosed by
noting their relation to certain of the landmarks of the thorax.

The heart is placed obliquely in the chest cavity, with its base at the
junction of the second costal cartilage with the sternum and its apex at
the junction of the fifth rib with its costal cartilage. To locate its base,
draw a transverse line across the sternum a little above the level of the
third costal cartilage. The base extends to about one-half inch to the
right of the sternum and one inch to the left. The apex is, in the normal
heart, located at a point about two inches below the left nipple and one
inch toward the medium line. This corresponds to the fifth interspace.
Holden says a neeedle introduced in the third, fourth or fifth right inter-
costal space close to the sternum, would penetrate the lung and the right
auricle. A needle passed through the second intercostal space close to
the right side of the sternum would, after passing through the lung, enter
the pericardium and the most prominent part of the bulge of the aorta.
To locate the pericardial region in which there is cardiac dullness, accord-
ing to Latham, make a circle of two inches in diameter around a point
mid-way between the nipple and the end of the sternum. This region
will indicate sufficiently for all practical purposes, that part of the heart
which lies immediately behind the wall of the chest and is not covered
by lung nor pleura. The aortic valves are behind the third intercostal
space on the left side. The pulmonary valves are behind the junction of
the third costal cartilage and the sternum on the left side. The tri-
cuspid valves are right behind the sternum at about the level of the fourth
costal cartilage. The mitral valves are behind the third ' intercostal

APPLIED ANATOMY. 425

space just to the left of the sternum. Therefore, in organic heart dis-
ease, the murmur is heard over these spaces, the location depending on
the valve affected.

The upper border of the pericardium corresponds to the junction of
the first and second portions of the sternum, that is, the sternal end of
the second rib. It is somewhat elliptical in shape and extends to the
right as far as the para-sternal line, to the left, to the mid-clavicular line
and downward to the diaphragm, with which it is united. It is attached
to the sternum in front and the fifth costal cartilage on the left side. In
effusions the operation called paracentesis is performed through the
fifth or sixth interspace of the left side, this depending upon the degree
of distension.

The pleura extends upward to a line drawn from each sterno-clav-
icular joint to the prominence at the junction of the first and second
parts of the sternum. Eisendrath says: "The two pleurae run parallel
to each other, the right passing a little beyond the median line. The
space between them corresponds to the location of the anterior mediasti-
num. At the fourth rib, the left pleura leaves the sternum and passes
outward in an oblique manner, following the left border of the sternum
to the sixth cartilage. The space thus left between it and the sternum,
corresponds to that portion of the pericardium which is in contact with
the chest wall. On the right side the pleura continues almost to the
ensiform process, and then passes gradually outward, crossing the lower
border of the seventh rib in the mammary line, the ninth rib in the axillary
line, and the eleventh near the spine. "

The highest point of the pleura is about one and one-half inches
above the clavicle, which corresponds to the apex of the lung. The
lowest point is the twelfth rib. It extends almost to the tip of this rib.

The surface markings of the lungs are almost identical with those of
the pleurae except that they do not extend so low. The only difference
is that the lower portions of both lungs are at the sixth rib in the mam-
mary line, the eighth rib in the axillary and the tenth rib behind. Dur-
ing inspiration the lower border of the lung moves downward through
the space of one rib. The position of the lungs as well as their condi-
tion is determined by percussion, which is best done with the patient in
the sitting or erect posture.

The arch of the aorta corresponds to a line drawn from the junction
of the costal cartilage of the left side and the sternum, to the upper border
of the second rib on the right side.

426 APPLIED ANATOMY.

The trachea and bronchi are in the median line and correspond to a.
line drawn from the upper margin of the sternum to the level of the sec-
ond rib. Bifurcation takes place at the second rib.

The surface markings of the attachments of the diaphragm corres-
pond to a line drawn around the body passing through the ensiform
cartilage and bony ends of the sixth ribs to the body of the first lumbar
vertebra. During the contraction of the diaphragm, the position of the
ribs is changed. In cases in which the ribs are softened, the diaphragm,
by its contraction, often produces a groove, called Harrison's groove.
This is the result of rickets or attacks of asthma or other obstructive
respiratory disorders.

The spleen corresponds to the ninth, tenth and eleventh ribs and is
slightly anterior to the axillary line. In enlargements of this organ it is
displaced forward and downward and produces a marked change in
contour of the left side.

The kidneys are in relation with the twelfth rib,hence have little
to do with the contour of the chest, although in enlargements
of the organ, a fullness at the vertebral end under the twelfth rib, is found.

The stomach lies almost entirely on the left side under the true
ribs, but is often prolapsed on account of relaxation or distension. In
distension, it is displaced downward and to the right. It extends slightly
across the median line of the body.

The nerves of the chest wall are the intercostal, which are in rela-
tion with the under surface of the ribs. At the points at which the per-
forating branches emerge, that is, at the angle of the rib and the axillary
and parasternal lines, there is marked tenderness in cases of displace-
ments of the ribs, pleurisy and intercostal neuralgia.

The arteries are the intercostal, which are derived from the thoracic
aorta. The veins of the chest wall correspond to the arteries and most
of them empty into the azygi. The lymphatics of the upper part empty
into the axillary glands. The deep lymphatic vessels of the chest wall
are the intercostal and diaphragmatic, which eventually empty into the
internal mammary lymphatic glands. The superficial, as stated above,
empty into the axillary glands, therefore diseases of the breasts will
produce enlargements of the axillary glands, as in cancer. The super-
ficial glands of the chest wall are the pectoral and the epigastric. The
pectoral drain some of the lymphatic vessels of the mammary gland.
The deep lymphatic glands of the chest wall are the intercostal (exter-

l2TJi RIB

Fig. 127. — Posterior view of the thorax. (After Cunningham). Note the re-
lation of the kidneys to the twelfth rib and the pleura.

428 APPLIED ANATOMY.

nal, anterior and posterior) and internal mammary. The posterior
intercostal glands are of interest to us in that they lie opposite the heads
of the ribs and therefore would be affected by rib lesions. They drain
a part of the intercostal spaces, the spinal canal, the muscles of the back
and the diaphragm.

The contour of the chest is determined more by the size and condi-
tion of the viscera, that is, the heart and lungs, than by any other thing.
It is conical in form, the broader part of the cone being the upper part.
The walls are convex but this varies considerably in different patients
on account of the difference in muscular development, the amount of fat
deposited and the condition of the bony parts. Change of contour re-
sults from change in size of the viscera, from certain occupations, dis-
eases of the air passages, abnormalities or diseases of the spinal column,
and the general condition of the patient.

In spinal -diseases, the contour of the chest is usually changed. In
diseases in which the mineral matter of the bone is decreased, as in rick-
ets, the contour of the chest is also altered. These changes of contour
are of vast importance to the physician, because they are indicative, if
not diagnostic of the condition of the vital organs and particularly the
heart and lungs. If the chest is flat, that is if the antero-posterior dia-
meter is lessened and the lateral diameter apparently increased, the ribs
more oblique, the sternum depressed, we call it a tubercular chest. These
seem to be hereditary cases, especially those predisposed to pulmonary
tuberculosis, although it does not necessarily follow that tuberculosis
is present in a person who has a flat chest. In such cases the ribs are
very flexible, expansion is lessened and the pectoral and other muscles
are not well developed. This can be remedied partly by deep breathing
exercises on the part of the patient to develop the lungs, and partly by
the correction of lesions which interfere with the innervation of the mus-
cles which hold the ribs in normal position. This muscular atrophy or
non-development, may be partly the result of non-use of the muscles, or
the result of rib or thoracic lesions which interfere with the trophic
nerves to them. By advising the patient to take exercise, these muscles
will be developed because of the increased rate of inspiration. The res-
piratory muscles lift and thereby produce a pressure vacuum in the
thoracic cavity and the air rushes in to fill this. Therefore, if the pa-
tient does not exercise, these muscles are not used and do not develop,
and even atrophy, if they have once been developed.

APPLIED ANATOMY.

429

The barrel-shaped chest is short and round, that is, its anteropos-
terior diameter is nearly as long as its transverse and is indicative of
emphysema. In such cases the ribs are almost horizontal and the inter-
spaces increased, and respiration is carried on almost entirely by the

Fig. 128. — Showing the deltoid and pectoralis major muscles. The movements of
the arm are dependent to a great extent on the normal activity of these muscles

430 APPLIED ANATOMY.

diaphragm. The chest wall moves but little during respiration and the
ribs seem to have become fixed in this abnormal position.

The chest is found to be deformed in rickets, there being a beady
condition along the junction of the ribs with their costal cartilages and
immediately below this there is a groove, called Harrison's groove. If
asthma occurs in such a case, the deformity called "Pigeon" or "funnel
breast, " may result. In Pigeon breast, the sternum and costal cartilages
project beyond the ends of the ribs. The transverse diameter is shortened
while the antero-posterior diameter is lengthened. The beaded condition
to which has been applied the term "rachitic rosary, " is due to the thick-
ening of tissues at the junction of the ribs with their cartilages. Deaver
quotes Treves saying, that the explanation of this deformity is:
"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
equalized. If in inspiration there is an impairment to the entrance of
air, the atmospheric pressure upon the external wall of the chest must
produce some effect, being unbalanced by a light pressure upon the inner
chest wall. In children, and especially in rickety children, the thorax
is very pliable and elastic, and if a constant impediment exists to -the
entrance of air, as afforded, for example, by greatly enlarged tonsils, the
thoracic walls may yield in time to the unbalanced pressure brought to
bear upon them at each inspiration. The weakest part of the thorax
is along the.costo-chondral line on either side, and it is here that the pari-
eties yield most conspicuously in such cases, and by this yielding the de-
formity is produced."

The funnel breast is characterized by a deep depression at the lower
part of the sternum. It is believed to be the result of obstructed breath-
ing as in hypertrophied tonsils, and adenoid growths in the throat.
These obstructions interfere with respiration so that during inspiration
the lower part of the sternum is forcibly retracted. The patient often
assumes a bent posture, the ribs are soft and the development of the
lungs seems to be interfered with. Sometimes it attacks only one side
and in some of the author's cases a depression was found as wide and
deep as the hand, which corresponded with the sixth and seventh ribs.

Scoliosis produces a unilateral enlargement of the chest. This is
the result of rotation of the vertebrae which invariably complicates a
case of lateral curvature. The ribs are carried with the transverse pro-

APPLIED ANATOMY.

431

cesses so that in a right lateral curvature the left side of the chest would
be prominent and the left side would be depressed. The contour of the
chest will be changed in kyphosis, it becoming more nearly round, that
is, barrel-shaped. In lordosis the antero-posterior diameter of the chest
is lessened and this is one of the most common of conditions in which

Fig. 129. — Showing an extreme case of progressive muscular atrophy, resulting
from injury by fall from bicycle. The lesions were at the second and third thoracic
articulations. Death resulted from pneumonia. There was little thoracic respira-
tion. (From photo).

the chest and spine are affected. It seems to be a general rule that in
posterior deviations, the antero-posterior diameter of the thorax is in-
creased and the obliquity of the ribs lessened, while in anterior condi-
tions the opposite effects occur.

4H2 APPLIED ANATOMY.

Unilateral enlargement is due to cardiac hypertrophy. This can be
determined by locating the heart by percussion and noting the location
of the enlargement. A shrinking of one lung has the effect of making
the opposite side appear to be enlarged. In old pleural adhesions, the
chest is flattened and movements are lessened in the affected area. On
account of this, the opposite side is developed to such an extent that
there is really enlargement. In collapse of one lung due to destruction of
tissue as in tuberculosis, the chest wall becomes depressed over that area
and the opposite side becomes enlarged. Unilateral enlargements may
also be due to hypertrophy of the spleen, or if on the lower right ride,
to hypertrophy of the liver. The usual cause of slight unilateral en-
largement is scoliosis. A displacement of two or more ribs may also
cause a slight change in contour on the affected side.

It is important to be able to ascertain the cause of a change of con-
tour as well as the degree of enlargement. To do this accurately, in-
spection as well as palpation should be made. In some cases there is
bi-lateral shrinking of the chest due to diseases of the lungs, principally
old adhesions. By causing the patient to take a deep inspiration, the
degree of movement can be ascertained and by this to a certain extent
•the extent of the adhesion.

In certain occupations the contour of the chest may be changed as
in miners, shoe-makers or those whose occupation requires a stooping
or bent posture. This is accompanied by a posterior condition of the
thoracic spine and is usually not pathological.

In the weak and anemic, the ribs often get down, sometimes as the
cause of the condition, but more commonly as the result. The ribs are
held in normal position by the tonicity and contraction of the thoracic mus-
cles and if these muscles are not well nourished and if there are lesions
which interfere with their innervation or nutrition, relaxation results and
the ribs become more oblique and closer together. In such cases the
lower edges of the rib evert, so that in extreme cases they even overlap.
This obliquity may be due to tight lacing. All the diameters of the
lower part of the chest are decreased and the ribs are often forced as
low as the crest of the ilium and the ilio-costal space is almost obliter-
ated, the great muscles of the back are atrophied and the movements
of the body impaired. The viscera in relation are compressed and the
writer has seen cadavers in which the liver was furrowed by the ribs in
relation having been forced into it.

APPLIED ANATOMY.

433

The muscles which have to do with the contour of the thorax are the
pectoral, intercostal, serratus magnus and the muscles of the back. The
muscles on the front and side of the thorax all stand out prominently
in the normal case, but in so many diseases they are atrophied. Deep
breathing is to be advocated, partly on account of the development of
the lung which follows, and partly on account of the development of the

Fig. 130. — Showing the change in contour of the chest in a marked case of angu-
lar curvature (Pott's disease).

434 APPLIED ANATOMY.

muscles of the thorax. The contour of the thorax is partly governed
by these muscles, therefore in cases in which they are atrophied, the
contour is abnormal.

The contour of the chest may be changed by pleural or pericardial
effusions. Ordinarily, the interspaces are only enlarged and appear
puffed, but in some, there is marked swelling of the wall. The charac-
ter and location of the swelling with the presence of disease of the heart
or lung, and the tenderness elicted on pressure over the area, make the
diagnosis of the cause of the change of contour fairly easy.

The general contour differs very materially in different people. In
some the character of the clothing, Occupation and the degree of muscu-
lar development so change the contour that there is a wide deviation
from the normal. The effects are measured by the amount of pressure
exerted on the viscera and the changes in the individual ribs which
affect the gangliated cord and other important structures in relation
with the head of the rib. If the changes come on very slowly, the vis-
cera may become adapted to their changed relations as rapidly as the
changes occur, while in most cases of deformity of the thorax, it is the
result not the cause of the visceral disease.

Tenderness of the chest is suggestive of a diseased condition of the
lung, heart or pleura or of a subluxated rib. In pneumonia, the tissues
over the diseased area, become thickened and tender. In chronic dis-
ease of the lung there is tenderness on pressure over the interspaces.
Such tenderness is, in all probability, due either directly to the rib lesions
that are the primary cause of the disorder, or to the changes in the spinal
cord which are the result of the disease; these affecting the intercostal
nerves that supply the chest wall. Pleurisy and pericarditis are accom-
panied by tenderness in the chest wall in relation with the diseased area.

A localized lowering of the surface temperature, is suggestive of a
lesion of the rib in relation or of disease of the viscus innervated by the
segment that supplies the affected part. This is true of chronic dis-
eases and especially of chronic gastritis. Localized sweating has a sim-
ilar significance. The anatomical explanation lies in the fact that the
vitality of the affected part is lowered either by the rib lesion directly or
else by the effects of the disease on the spinal cord or the blood-vessels
supplying the nerve tissues.

APPLIED ANATOMY. 435

THE ABDOMEN.

The condition of the abdominal wall is of great importance because it
is a fairly reliable sign of the condition of the viscera of the pelvic, as well
as of the abdominal cavity. The various abdominal diseases as well as
pelvic disturbances are depicted in the abdominal wall. It may be an
enlargement or simply a tenderness. The abdominal wall extends from
the costal arches to the crests of the ilia. It is elastic, changes its form
readily and adapts itself to changes without injury to itself. A blow,
such as a kick or a fall upon some sharp object will often cause no injtiry
to the wall, but will produce a serious laceration of the abdominal con-
tents. It is composed of integument, fascia, fat, muscles, peritoneum and
fibrous tissue.

The contour of the abdomen, that is, its prominences and depressions,
is governed by the size of the viscera, the amount of fat, or the presence
of tumors or visceral enlargements in the abdominal cavity. The ac-
cumulation of fat in this place is very marked and McClellan cites a case
in which it was four and one-half inches thick.

The enlargements of the abdomen are due to many things. Ascites
produces a symmetrical enlargement, which is diagnosed by a change of
contour with change of position, coupled with this, is usually a history of
liver disorder. On percussion or palpation, it is usually easy to determine
that the enlargement is due to the presence of fluid. Pregnancy pro-
duces a change in the contour of the abdomen after the third month.
This is determined by the signs and symptoms of pregnancy. The en-
largement is at first symmetrical and later on becomes somewhat un-
ilateral. Pelvic tumors, if large enough to be forced out of the pelvic
cavity, produce a change of contour of the abdomen. The enlargement
is not symmetrical, but usually there are irregularities which can be clearly
palpated. In enlargement of the spleen, the contour of the abdomen is
changed. Sometimes the tumor extends past the median line in which
case, the abdomen is quite large.

In congestion and hypertrophy of the liver, there is a unilateral en-
largement of the abdomen. The diagnosis as to the cause of the enlarge-
ment, is based on the palpation and percussion of the liver, and the loca-
tion of the enlargement. Peritonitis will produce a symmetrical enlarge-
ment. The accumulation of gas in the bowels will produce some change
in the contour, which is most pronounced in the retention of menses.

Fig. 131. — Anterior view of the areas of distribution of the sensory nerves of the
skin (shown on the left side of the body), and distribution of sensation according to
segments of the spinal cord (shown on the right side of the body). (After Eisendrath).

APPLIED ANATOMY. 437

The accumulation of fat in the abdominal wall produces a prominence
which is often mistaken for tumors. Occasionally a unilateral ventral
hernia is found, in which case the contour of the abdomen is changed in
proportion to the degree of protrusion. Enteroptosis, gastroptosis, ab-
dominal tumors and distension of the urinary bladder from retention
of urine are other causes of enlargement of the abdomen.

Retraction of the abdomen is most frequently due to emaciation, or
due to constitutional disease, as cancer or "to any other disease in which
the nutrition of the body is affected. In chronic intestinal indigestion
the abdominal wall is shrunken and the patient assumes a stooping pos-
ture. In such cases the abdominal wall is contracted and the patient
assumes this position on this account, it being the position in which
there is the greatest rest to these muscles. In injury of the knee or elbow
we have an analogous condition, in which there is a partial flexion of the
joint.

There are certain lines which are fairly constant. In the female
the lineae striae are present as the result of stretching of the abdominal
wall from pregnancy. These lines are also found in cases where the
walls have been stretched from any other cause, such as ascites or other
enlargement. The recti muscles can be seen and the slight transverse
depressions between the different parts of these muscles can usually be
outlined. These are called the lineae transversa?. In some cases the
recti muscles become separated and a vertical groove results which cor-
responds to the point of separation. The umbilicus is a landmark which
is used for certain measurements and for locating some of the abdominal
viscera. It is on a level with the disc between the third and fourth lum-
bar vertebra, or in some cases, of the body of the fourth. It is a de-
pressed cicatrix, which varies in depth in different individuals. In the
young, it is often everted and in the aged, it is retracted. In pregnane y,
accumulation of gas or other enlargements, it is usually everted. In
chronic intestinal diseases it is found retracted. Its depth is probably
due to the degree of shortening of the urachus, which is attached to the
scar. In some cases the scar fails to close properly and an umbilical
fistula is formed through which urine passes.

The anterior superior spines of the ilia are,in an average sized person,
prominent and are used as landmarks for the location of other parts and
measurements of the lower limbs. The substernal angle furnishes the
landmark for the location of the pyloric end of the stomach, which is a

438

APPLIED ANATOMY.

Fig. 132. — Surface markings (on the left side) of the thoracic and abdominal
viscera. (After Eisendrath). C. C, costoclavicular line; U. L., upper lobe of lung;
L. L., lower lobe of lung; C. A., costal arch; S., spleen; 1, transverse colon; 2, descend-
ing colon; 3, sigmoid.; A., anterior superior spine of the ilium; T., trochanter.

APPLIED ANATOMY. 439

few inches directly below. This angle or interchondral space, is formed
by the divergence of the cartilages of the false ribs. The depth and width
of this angle varies with the shape of the thorax. It is narrow in women
who wear tight clothing and in cases of the dropping of the lower ribs or
a lessening of the antero-posterior diameter of the thorax from any cause.

The abdomen is arbitrarily divided into regions by the passing of
vertical lines from the cartilage of the tenth rib and superior spines of
the ilia, and transverse lines through the cartilage of the eighth rib and
the spines of the pubes. These regions thus formed are called the right
hypochondriac, epigastric, left hypochondriac* right lumbar, umbili-
cal, left lumbar, right inguinal, hypogastric and the left inguinal. It
is thus divided for the purpose of describing the position of the viscera
and that of the better describing the location of abdominal enlargements
or disease of the abdominal viscera.

The abdominal aorta corresponds to a line drawn from a point
slightly to the left of the ensiform cartilage to another point on a level
with and immediately to the left of the umbilicus. In all organic dis-
eases of the stomach and intestines such as gastritis and enteritis, the
pulsation of the aorta is markedly increased, sometimes to such an ex-
tent that they can be seen. In thin people the artery can be palpated
quite distinctly and in the above mentioned diseases, its walls seem to be
thickened. The celiac axis is given off about five inches above the um-
bilicus, the renal artery is about four inches above. The iliac arteries
radiate from the umbilicus downward and outward to a point which is
about mid-way between the anterior superior spine of the ilium and the
symphysis of the pubis. The internal iliac, is given off at a point about
two inches below the umbilicus.

The liver lies in the hypochondriac and epigastric regions and some-
times extends across to the left hypochondriac region. Its anterior
margin extends about an inch below the costal cartilages and can be pal-
pated in the average case, during respiration. In congestion or hyper-
trophy of the liver, this margin can be readily palpated. It is tender to
the touch and often feels hardened. The upper border of the liver reaches
as high as the dome of the diaphragm, the right fourth interspace in the
mammary line, the eighth rib in the mid-axillary line and the tenth rib
in the scapular line. Posteriorly, it extends to the tenth and eleventh
thoracic spine and the bodies of the vertebras. It extends across the
median line about one and one-half inches, and in unusual cases, it reaches

440

APPLIED ANATOMY.

Fig. 133. — The regions of the abdomen.

APPLIED ANATOMY. 441

the left mammary line. Deaver says: "The liver reaches as high
as the transverse line drawn through the lower end of the meso-sternum;
in the mammary line this transverse line passes over the fifth intercostal
space or lower border of the fifth rib. The upper surface of the left lobe
of the liver is opposite a transverse line drawn through the lower end of
the meso-sternum. The upper surface of the right lobe is opposite the
lower border of the fifth rib in the right mammary line; in the right mid-
axillary line, opposite the seventh rib; and in the mid-scapular line,
opposite the ninth rib; and at the side of the spinal column, opposite the
tenth thoracic spinous process." These lines are determined by per-
cussion and are only approximate, since the liver varies greatly in posi-
tion. The gall-bladder is almost entirely covered by the liver, but the
fundus projects slightly below the anterior margin and is in relation with
the costal cartilage of the ninth rib. The gall-duct passes obliquely
downward and empties at a point slightly to the right and above the
umbilicus. Clinically, there is often found a thickening of the tissues
around the lower end of the duct and the localized hardness can be
plainly felt. There is some tenderness in these cases and the condition
is almost diagnostic of liver disease.

The stomach lies in the left hypochondriac and epigastric regions
and its position is more variable than that of the liver. Its cardiac end
corresponds to a point over the left costal cartilage of the seventh rib
which is about an inch from the sternum. The pyloric end lies about an
inch to the right of the median line and usually beneath the liver and
about three inches from the sterno-xiphoid articulation. Addison says
that the pyloric portion of the stomach is practically bisected by a hori-
zontal plane which passes through the abdomen mid-way between the
supra-sternal notch and the pubic symphysis. The lesser curvature of
the stomach corresponds to a curved line connecting the cardiac and
pyloric ends. The greater curvature corresponds to a line drawn up-
ward from the cardiac orifice to the fifth rib and thence to the pyloric
orifice. When the stomach is empty it lies quite obliquely in the ab-
dominal cavity and is almost entirety covered by the ribs and cartilages
on the left side. When distended, it descends, becomes more nearly
transverse and crosses the median line to a distance of two or three inches.

The small intestines lie in a frame formed by the large intestine. The
duodenum is the part which is of most interest to us in that it is quite
frequently diseased and because it receives the gall-duct. Eisendrath

442 APPLIED ANATOMY.

says: "The duodenum corresponds on the surface, to the right half of
the epigastric region behind the eighth costal cartilage (horizontal por-
tion); the second or vertical portion lies mid-way between the median
line of the body and the vertical line which separates the right hypo-
chondriac from the epigastric region. The third or ascending portion
passes obliquely upward across the body, from the right half of the um-
bilical region to the left half of the same, where it joins with the jejunum
at a point one inch to the right of the median line (duodeno-jejunal
flexure) , at a point about mid-way between the ensiform process and the
umbilicus."

The large intestine is divided into the cecum, ascending colon,,
hepatic flexure, transverse colon, splenic flexure, descending colon, sig-
moid flexure and rectum.

The cecum corresponds to the right iliac and right lumbar region.
The base is slightly below McBurney's point. Its position is variable,
since it is subject to displacement downward. In constipation and in
enteroptosis it often gets into the true pelvic cavity.

The ascending colon extends upward to the liver, at which place it
makes quite a sharp bend to the median line. The transverse colon sags
in the middle and reaches almost to the umbilicus. Its position is also
variable and it is found almost as often below the umbilicus as above it,
especially in cases of intestinal indigestion, constipation and enteroptosis.
The writer examined a case in which the transverse colon was found
partly in the true pelvic cavity. The splenic flexure is in relation with
the spleen, at which point it makes a sharp bend forward and downward.
The descending colon passes almost vertically downward and when near
the pelvic brim makes a turn which is called the sigmoid flexure and
crosses the left sacro-iliac synchondrosis. As it passes into the true
pelvic cavity, it becomes smaller. The large intestine is accessible to
palpation with the possible exception of the hepatic and splenic flex-
ures, and on this account fecal impaction can ordinarily be easily diag-
nosed.

The vermiform appendix corresponds to the middle of the line con-
necting the umbilicus and the anterior superior spine on the right side.
This is called McBurney's point.

The pancreas lies immediately below and behind the stomach. It
crosses the inferior vena cava, aorta and the body of the first lumbar
vertebra. It corresponds to a horizontal line drawn about three inches
above the umbilicus.

APPLIED ANATOMY. 443

The kidneys are in relation with the eleventh and twelfth thoracic
and first and second lumbar vertebrae, and the right is lower than the
left. The surface markings on the abdominal wall are as follows: the
lowest point extends to the lower border of the tenth costal cartilage,
while the upper borders reach to within two inches of a line drawn hori-
zontally through the xiphoid appendix. On account of their depth
and the amount of adipose tissue surrounding them, they cannot in the
ordinary person be palpated from the front. Deaver says: "a trans-
verse plane through the umbilicus passes just below the lower border
of the kidneys, and they are cut in half by a line drawn vertically up-
ward in the middle of Poupart's ligament. "

The external abdominal ring is in the lower part of the aponeurosis
of the external oblique muscle and is in relation with the spine of the
pubis. It is of interest in that it consitutes a weak place in the abdom-
inal wall and hernia often takes place at this point. It is called a ring
because it gives passage to the spermatic cord, the genital branches of
the genito crural nerve and the ilio-inguinal nerve in the male, and in
the female the round ligament of the uterus and the above named nerves.
In hernia, there is to be found a tumor which increases in size whenever
the intra-abdominal pressure is increased, as in coughing and lifting.
The opening can ordinarily be palpated and the diagnosis in doubtful
cases is based on this. The tests for hernia should be made while the
patient is in the erect posture, since the tumor is larger and the impulses
more marked with the patient in this position.

The skin of the abdominal wall is quite closely adherent to the ab-
dominal fascia, especially around the umbilicus. It is broken in cases
of abnormal enlargements as ascites and pregnancy and the lineae albi-
cantes are thus formed. The deeper layer is continuous with the apon-
eurosis of the external oblique muscle at Poupart's ligament, the crest of
the ilium and the lineae alba.

The superficial vessels are the anterior ends of the lower intercostal
and the lumbar arteries and veins. In addition to this are the super-
ficial epigastric, the circumflex iliac, and branches of the internal mammary
artery. The superficial veins of the front of the abdomen are quite num-
erous and are subject to varicosities during pregnancy and other en-
largements. Deaver quotes Schiff as saying that small veins connect
the portal vein with the epigastric veins at the umbilicus. This ac-
counts for the dilatation of them in hypertrophic cirrhosis of the liver.

444 APPLIED ANATOMY.

The lymphatic vessels of the abdominal wall accompany the blood-ves-
sels, those above the umbilicus emptying into the axillary glands and
those below, into the inguinal. The nerves of the abdominal wall are
the lower five or six intercostal and branches of the ilio-hypogastric and
ilio-inguinal, which are from the anterior division of the first lumbar
nerve. The nerve supply to the abdominal wall is of great importance
to the physician in that nearly all abdominal and pelvic visceral dis-
eases cause pain to be referred to these nerves. Eisendrathsays:* "The
spinal segments with which they are connected are also in communica-
tion with the viscera of the abdomen and thorax through the sympa-
thetic system. Hence diseased conditions of the abdominal viscera give
rise to disturbance in the spinal segments with which they are connected,
and the brain, being accustomed to localize pain along the spinal nerves,
makes a mistake and refers the pain along the spinal nerve of the seg-
ment disturbed. Not only is pain referred, but the skin supplied by the
disturbed spinal segments becomes tender, and through a study of these,
Head has been able to localize the visceral centers, thus affording the sur-
geon a means for increased accuracy of location of pain as a symptom in
abdominal diagnosis. " These nerves supply both the integument and the
muscles, therefore a stimulation of them, as in examining the abdomen
with cold hands, will cause the muscles to contract and thus make it
difficult to palpate the viscera beneath. These nerves are connected
with the gangliated cord by means of the rami communicantes. On
this account in irritative disease of the viscera as in appendicitis, the
abdominal wall becomes tender and rigid. These nerves run obliquely
forward and downward, which thing should be remembered in the making
of incisions in the abdominal wall.

The condition of the abdominal wall is of importance in that it is
a fair indication of the condition of the viscera of the abdominal cavity.
Diseases of the abdominal or pelvic viscera are in some way indicated by
changes in the abdominal wall or of the structures immediately beneath.
A contractured abdominal wall is most frequently the result of a chronic
peritonitis. In the cases of chronic intestinal indigestion, the wall is
quite rigid and the abdomen retracted. It is sometimes suggestive of
asthma or other conditions in which the respiration is of the abdominal
or diaphragmatic type. If the tightened or contractured condition is
accompanied by tenderness, it is probably a case of an intestinal indi-
gestion or chronic peritonitis from other causes. In acute peritonitis,

*Clinical Anatomy, Eisendrath, p. 220.

APPLIED ANATOMY. 445

and in cases of distention from accumulation of gas, the abdominal wall
is often very tense. The percussion note is tympanitic and from this
the differential diagnosis is made between these conditions and solid
tumors and cysts in which condition the note is dull.

A relaxed abdominal wall may be the result of over distension or
stretching of it, the accumulation of fat or general weakness. The most
common form is the result of pregnancy in which the walls are in a sub-
involuted condition in which cases, they fail to regain their former tone.
In nulliparae, the relaxed abdominal wall is diagnostic of enteroptosis. The
degree of relaxation of the wall is indicative of the degree of relaxation
of the supports of the intestines. Often the accumulation of fat in the
abdominal wall causes it to relax and gives the patient a pendulous ap-
pearance, and in such cases there is usually a great deal of fat in the
omentum and the intestines. In a general way then, a fat abdominal
wall is indicative of the accumulation of fat around the intestines; a re-
laxed abdominal wall, of a relaxed condition of the supports of the in-
testines; while a contractured abdominal wall is indicative of an
irritation of the peritoneum caused most frequently by chronic catarrh
of the bowel. A localized contracture or hardening of the wall is sug-
gestive of an irritative disease of the part in relation, or a contracture of
the abdominal, or if deep, of the psoas muscles. If the thickening of the
tissues or tumefaction is not superficial, it is indicative most frequently
of an impacted bowel or a congested viscus or in some cases, an enterolith.
The localized relaxation is suggestive of a thinning of the abdominal wall
at that point and predisposes to hernia, particularly if it is near the um-
bilicus or abdominal ring.

The temperature of the abdominal wall should be taken into consid-
eration in the examination of a patient. If the temperature is above
normal, it is indicative of peritonitis, the degree of temperature deter-
mining the degree of inflammation. If this occurs in the lower part of
the abdominal wall, it is indicative of inflammation of the pelvic perito-
neum caused by ovarian or uterine disease. If localized in the right iliac
fossa, it suggests peritonitis from appendicitis. If in the neighborhood of
the umbilicus, it is probably a case of inflammation of the bowels. Only
in incipient peritonitis, is the increase of temperature localized, while a
general rise of temperature is indicative of a diffuse peritonitis. In
children suffering with indigestion, the surface temperature is often in-
creased to a greater degree than that of any other part of the body. By

446 APPLIED ANATOMY.

manipulation of the intestines by which they are lifted or changed as to
position, this temperature can be reduced, often at a single treatment. In
the treatment of children for such a disorder, the abdominal manipula-
tion is the most important of all treatments. A coldness of the abdom-
inal wall, is, according to Dr. Still, the result of a displacement upward
or to one side, of the omentum, which is an apron like flap which sep-
arates the abdominal wall from the intestines, thereby protecting them
against injury and perhaps against change of temperature. In many
cadavers examined by the writer, the omentum was found rolled up and
displaced upward or to one side. The coldness of the abdominal wall is
found in cases in which the vitality, that is, the activity of the intestines
and other abdominal viscera is lessened. In subinvolution of the ab-
dominal wall and pelvic organs, the jtarts feel cold to the touch and often
there is a cold perspiration on the surface.

The areas of tenderness in the abdominal wall are suggestive of a con-
gestion or inflammation of the viscera in relation. This painful condi-
tion is often reflex, but in many cases it is the result of the inflammation
extending by contiguity of tissue, from the visceral to the parietal layer
of the peritoneum. It is practically impossible for tenderness or in-
flammation of a viscus to occur without the abdominal wall becoming
affected, that is, it becoming tender also. A general tenderness of the
abdominal wall is indicative of a diffuse peritonitis, or a general disease
of the intestines as in cases of sudden cessation of the menses or chronic
catarrh of the bowel. A localized tenderness over the pit of the stomach,
that is over the sub-sternal angle, is about as good a diagnostic indica-
tion of gastritis or some other organic disease of the stomach as there is.
In mild cases the tenderness is most marked in the deep structures, while
in acute cases, the integument over this area becomes so tender that the
patient can scarcely bear the weight of the clothing on the part. Tender-
ness between the pit of the stomach and umbilicus, that is, about mid-
way between, is suggestive of an organic disease of the small intestine.
If this tenderness seems to follow a horizontal course, it is in the trans-
verse colon. A tenderness in the right hypochondriac region is sugges-
tive of congestion of the liver or of gall stones. Often there is a localized
area of tenderness just above and to the right of the umbilicus, at which
point the gall-duct empties into the duodenum; this is suggestive of
catarrh of the gall bladder, or of gall stones. In appendicitis, the tender-
ness is over McBurney's point. This may be confused with that from

APPLIED ANATOMY. 447

ovarian disorders, which usually is at a point somewhat lower than this.
Tenderness in the iliac fossae occurs in congestion, inflammation or or-
ganic disease of the peritoneum, tubes, and ovaries. Supra-pubic tender-
ness is suggestive of congestion or inflammation of the uterus or organic

Fig. 134. — Surface markings of the thoracic and abdominal viscera (right side) .
U. L., upper lobe of right lung. L. L., lower lobe. M. L., middle lobe. P., lower
boundary of the lung. 7., lower border of liver. A. C, ascending colon. T. C,
transverse colon. (After Eisendrath).

448 APPLIED ANATOMY.

disease of the bladder. Tenderness of the abdominal wall may occur in
cases of strain of the muscles, hernia, Pott's disease involving the thoracic
vertebra? and fracture or dislocation of the lower thoracic vertebra?. In
the examination for abdominal tenderness, ascertain whether it is super-
ficial or deep, also the degree of it, location and length of standing.

In lesions of the lower ribs, often the pain is referred to the abdom-
inal wall, but in these cases, pressure will not ordinarily increase the
pain. Pseudo-appendicitis is a very good example of this type of dis-
ease and in many cases of supposed ovarian and gastric disorders, the
pain is a referred one.

In many disorders of the abdominal and pelvic viscera, there is a
marked pulsation of the arteries which supply the parts. This pulsa-
tion is due to a constriction of the vessel from a thickening of the walls
or else to a stimulation of the vaso-constrictor nerves supplying the part.
Pulsation at 'the pit of the stomach, is indicative of congestion or inflam-
mation of the stomach, if immediately above the umbilicus, of disorders
of the small intestine. In chronic ovarian disorders, there is pulsation
and thickening of the iliac arteries, which things can be determined in
an average case by palpation over them. The writer has examined many
cases in which the artery could be distinctly palpated, being hard and
large and considerably larger than the corresponding one. In thin people,
care should be taken not to mistake the normal pulsation of the abdom-
inal aorta for an aneurysm or other pathological conditions.

The function of the abdominal wall is to support the abdominal
viscera as well as protect them against injury. If the wall is relaxed it
does not well support or protect, hence displacement of the viscera is the
result. Its function is also disturbed by contracture of the wall whether
from lesions or visceral disease, and the contour of the abdomen is thus
altered. Lesions along the lower thoracic region involving the vertebra?
and ribs, disturb the function of the abdominal wall in that they inter-
fere with the innervation of its muscles. On this account the muscles
will become contractured or relaxed, both of which disturb function.

THE TEMPORO-MAXILLARY ARTICULATION.

The temporo-maxillary articulation is formed by the glenoid fossa
and the edge of the temporal bone or eminentia articularis, and the
condyle of the lower jaw. This articulation is of importance on account

APPLIED ANATOMY.

449

of the frequency of dislocation or injury and the effects on the fifth cranial
nerve. The ligaments are the capsular, which is divided into several
portions such as the external lateral and internal lateral ; the interarticu-
lar cartilage; the spheno-maxillary and the stylo-maxillary. The two
lateral ligaments in addition to holding the bone in place, protect the
internal maxillary vessels and the auriculo-temporal nerve, during move-
ments of the lower jaw. The interarticular fibro-cartilage acts as a
buffer and prevents shocks to the brain, as in the violent closing of the
jaw or blows on the chin, which would otherwise injure the brain through

Fig. 135 — Showing the temporo-maxillary articulation.

the thin bony plate of the glenoid cavity which is in relation with the
middle fossa of the skull. This joint is innervated by branches of the
fifth nerve, and on this account the effects of a lesion would be most
pronounced in the area supplied by this nerve. The movements of the
joint consist of a hinge-like movement with a slight gliding action and
some rotation. These movements are necessary for the proper triturat-

450 APPLIED ANATOMY.

ing of the food. The muscles concerned in the movements of the jaw
are:

Depressors. The platysma myoides, the mylo-hyoid, the genio-
hyoid, the anterior belly of the digastric and the genio-hyo-glossus.

Elevators. The masseter, the temporal and the internal pterygoid.
The lower jaw may be protruded or retracted by the fibro-cartilage and
the condyles gliding forward and backward in a horizontal direction.
The forward movement is produced by the contraction of the external
pterygoid assisted by the masseter and the internal pterygoid. Retrac-
tion is effected by the posterior part of the temporal and a part of the
masseter. The grinding movements are accomplished by the alternate
contractions of the internal and external pterygoid muscles on each side.

In all ordinary movements of the jaw the fibro-cartilage is held in
relation with the condyle, but if the depression of the jaw is marked as in
yawning, the condyle may be dislocated forward. The external pterygoid
muscle has to do with holding the bone out of place, thus the jaw is
locked in its abnormal position. McClellan says: "A proper under-
standing of the mechanism of this displacement is necessary for its
reduction, which demands that the lower jaw be drawn forward,
forcibly depressed and then pushed backward and upward. The dis-
location of the jaw comes most frequently from force applied to the
jaw when the mouth is open, but perhaps more frequently from the spas-
modic action of the external pterygoid muscle in yawning. " The signs
of the dislocation are a widely opened mouth, which cannot be closed,
pain and swelling of the joint and dribbling away of the saliva. A sub-
luxation of the jaw is more common than a complete displacement. It
consists of a slipping forward of the interarticular cartilage upon the
eminentia articularis as a result of rupture or relaxation of the ligaments.
This occurs most frequently in young and delicate people in which the
ligaments are relaxed. In this case the condyles catch and temporarily
lock the jaw, which after loosening cause the jaw to be closed with a
snap. In most cases the two sides of the jaw are not depressed sym-
metrically, that is the symphysis is drawn out of the median line. These
partial dislocations can be diagnosed by noting the character of the
movement, which is best done by placing the hands over both articula-
tions while the patient opens the mouth.

As a result of these lesions, not only is the function of the joint im-
paired but the structures in relation are injured or in 801116 way affected.

APPLIED ANATOMY. 451

These structures are the parotid gland, the fifth nerve and the temporo-
maxillary artery. Often facial neuralgia is the result of a subluxation
at this joint which irritates the fifth cranial nerve. The pain is often
referred to the teeth, or the points on the face at which the nerve is super-
ficial. Some disorders of the parotid gland result from a lesion of the
lower jaw by which the gland is directly injured or affected through its
innervation, and becomes tender and congested and gives rise to symp-
toms similar to those in mumps. The writer has seen many cases of
erysipelas of the face in which the trouble was undoubtedly due to sub-
luxation of the inferior maxilla, since in nearly all of them the condition
was relieved within a short time by correcting this lesion. The possible
explanation is that the vaso-motor nerves to the superficial blood-ves-
sels of the face are in some way affected by a subluxated condition of the
bone, hence the marked congestion which is the first sign of the disease.
In addition to this we should consider the micro-organism which is
supposed to be responsible for the disease in that it is the exciting
cause.

In reducing this lesion it may be necessary to introduce a cork or
the finger wrapped with a towel, between the last molar teeth and then
by using this as a fulcrum and the jaw as a lever, the head of the bone can
be pried back and down into its socket. In cases of subluxation, the
lesion can be reduced by using the angle of the jaw as a lever and pro-
ducing some pressure on the articulation as the mouth is opened.

THE HYOID BONE.

The hyoid bone acts as a stay for the support of the numerous mus-
cles attached to it, therefore its position is dependent on the condition
of the muscles attached to it. It consists of a body and four cornua.
The greater cornua can be palpated just above and to the side of the
thyroid cartilage. Each projects upward and backward and termin-
nates in a round tubercle to which is attached the thyro-hyoid ligament.
This bone is of interest in that injuries to the throat as in choking, dis-
turb its position and consequently disorders of the voice and difficult
deglutition result. In contracture of the hyoid muscles, for example the
omo-hyoid, aphonia often results. Therefore in cases of huskiness of
the voice, loss of voice, chronic hacking cough or even painful condi-
tions of the throat, this bone should be examined, because in these dis-
orders it is often found to be displaced. These effects are explained by

452 APPLIED ANATOMY.

the fact that the muscles attached to it are contractured and that the
nerves in relation are affected, particularly the superior and recurrent
laryngeal. Contractures of these muscles put a tension on the voice-
box, thereby interfering with its function, while in other cases they pull
the bone backward against the nerves in posterior relation, thereby
setting up an irritation of them. In whooping cough, this bone is often
found displaced upward and backward and the severity of the paroxysms
can be lessened to a marked extent by drawing it down into its normal
position. By grasping the cornua and pulling them downward and for-
ward thereby stretching and overcoming the contracture of the tissues
above the bone, the irritation can be relieved or at least lessened in in-
tensity. In some cases the two ends of the bone may not be of the same
length, this giving rise to an irregularity that may be mistaken for a lesion.

. THE STERXO-CLAVICULAR ARTICULATION.

The sterno-clavicular articulation is quite shallow and on this ac-
count the clavicle is subject to displacement. The ligaments permit of
considerable movement when the shoulder and arm are used. It is
frequently slightly displaced and coupled with this is often found hyper-
mobility, so that it is possible, by grasping the middle third of the clav-
icle, to move the sternal end of the bone through a space of half
an inch. The most common lesion of this articulation is a backward
displacement of the sternal end of the clavicle. This is diagnosed by
feeling it in its abnormal position, and noting that it is less prominent
than the opposite side. This sort of displacement may produce dyspnea,
dysphagia or congestion of the head and face from pressure on the
trachea, esophagus or the veins of the neck. Goitre is supposed to be
produced, or made worse by a downward or backward displacement of
this end of the clavicle. In some of these cases, the upward displacement
of the first rib is the real condition rather than a displacement of the
clavicle. The distance between the clavicle and rib is lessened in either
case and would lead to an obstruction of the vessels located between the
two. The effects of this lesion are most pronounced in the veins which
leads to congestion of the throat, thyroid gland and arm. In all cases
of sore throat, exophthalmic goitre or enlargements of the neck whether
from lymphatic disturbances or due to venous congestion, the clavicle
should be examined, because in many of these, it is subluxated back-
ward and downward and thus obstructs the drainage of these parts.

APPLIED ANATOMY. 453

The effects of a lesion of this end of the clavicle are then determined almost
entirely by the degree of pressure on the adjacent blood-vessels. A
displacement of this end of the clavicle will weaken the shoulder in that
the bone acts as a brace to the shoulder. On this account it is torn loose
by strong muscular exertions in which the shoulder and arm are used.

THE ACROMIOCLAVICULAR.

The acromio-clavicular joint is shallow and has a peculiar obliquity.
It is of greater importance to the physician partly on account of the fre-
quency of the subluxation and partly on account of the severity of the
effects. It has the usual capsular ligament and the interarticular fibro-
cartilage which is often imperfect. In all movements of the shoulder
girdle, this articulation is involved. In movements of the arm, forward
and backward and upward past the horizontal plane, this articulation is
involved. The acromial end of the clavicle is most frequently dislocated
upward and backward. As the result of such a lesion, the movements
of the shoulder girdle are imperfect and many movements of the arm
painful or impossible. The arm can be raised to a level of the shoulder
without the movement of this joint, but whenever it is carried forward
or backward as in combing the hair or putting on a coat, this joint is in-
volved. If a lesion exists, these movements are practically impossible,
but in the average case they are only painful so that the patient has
difficulty in backward or upward movements of the arm. This lesion
is often the cause of pain along the groove of the biceps and at the in-
sertion of the deltoid, in which cases, the trouble is usually attributed to
a slipping of the bicipital tendon in its groove. In cases treated by the
writer it was found that in most of them in which a diagnosis of dislo-
cation of the bicipital tendon was made, there was found to be a lesion at
the acromio-clavicular articulation. This lesion not only disturbs the
function of the joint, that is, movements in which this joint is used, but
it seems to affect the circumflex and other nerves in relation. This
gives rise to a referred pain which is felt at the insertion of the deltoid
along the tendon of the biceps and over the top of the shoulder. The
patient often describes it as "rheumatism" of the shoulder on account
of the stiffness and pain. In all cases in which a patient cannot get the
hand to the back of the head or the spine, or cannot extend the arm above
the head, it is well to examine this articulation, since in most of them there
will be found a tenderness and irregularity at the acromio-clavicular

454 APPLIED ANATOMY.

joint. Reduction is as a rule, easily effected by drawing the shoulder
and arm up and back and at the same time applying some pressure over
the acromial end of the clavicle. In cases in which it does not stay in
place, it is well to bandage the joint and strap the arm to the side.

THE SHOULDER-JOINT.

The shoulder-joint is formed by the head of the humerus and the
glenoid fossa of the scapula. It is an enarthrodial or ball-and-socket
joint, and the movements are freer than those of any other articulation.
The glenoid fossa is deepened by the glenoid ligament and even in this
condition, is much smaller than the head of the humerus, which accounts
for the great freedom of movement. The capsular ligament is attached
to the circumference of the glenoid cavity and to the anatomical neck
of the humerus below. It is very loose and large and in fact is large
enough to accommodate the head of the femur. In dislocations of the
humerus, this ligament is ruptured at the lower part, which is the weakest
portion. The coraco-humeral or accessory ligament, seems to be a thick-
ening of the inner part of the capsular ligament which extends from the
coracoid process to the tuberosity of the humerus. The glenoid liga-
ment is a fibro-cartilaginous rim which surrounds the edge of and deepens
the glenoid cavity. It is continuous above with the long head of the
biceps tendon and below with the long head of the triceps. These lig-
aments do not securely hold the head of the bone in position, but the
tendons of the muscles in relation, so reinforce them that the head of
the bone is thoroughly well held in place. The important tendons are
those of the supra-spinatus, infra-spinatus, and teres minor muscles, pos-
teriorly ; the broad tendon of the subscapularis strengthens it on the inner
part; the long head of the triceps below and the long tendon of the biceps
strengthens the upper anterior part of the joint. In addition to these,
the deltoid covers over the entire joint and strengthens and protects
it.

The synovial membrane lines the ligaments of the joint and sends
a reflexion around the long tendon of the biceps and communicates with
the bursal sacs around the tendons in relation. In injury to the shoulder-
joint, the synovial sac often becomes distended with fluid and thus pro-
duces a fluctuating swelling around the joint. This is often followed
by adhesions or dryness of the joints in which there is crepitus. Care
should be taken in the treatment of chronic synovitis of the shoulder-

APPLIED ANATOMY.

455

joint because of the danger of making it worse by the breaking of ad-
hesions.

The blood-supply of the joint is derived from the suprascapular,
anterior and posterior circumflex and subscapular arteries. It is inner-
vated by the suprascapular, circumflex and a few filaments from the
subscapular nerve. McClellan says: "The shoulder-joint is practically
a universal joint and as it depends upon the arrangement and power of
the surrounding tendons rather than upon the mechanical adjustment of
the opposing bony surfaces, the grouping of the muscles in effecting the
various movements should be understood. Extension is effected by the
teres major, latissimus dorsi and the posterior third of the deltoid. These

ACROMIOCLAVICULAR CORACO-ACROMIAL /TRAPEZOID LIST.

1 mm *

Fig 136. — The glenoid fossa, scapula.clavicle, and acromio-elavicular articulation.

are assisted in raising the arm by the teres minor and infraspinatus mus-
cles. Flexion is produced by the coraco-brachialis and the anterior
portion of the deltoid aided by the pectoralis major; abduction by the
deltoid and supraspinatus ; adduction by the pectoralis major, teres
minor, latissimus dorsi and coraco-brachialis."

456 APPLIED ANATOMY.

On account of the shallowness of the glenoid cavity, the powerful
leverage exerted on the joint by the arm as in protecting the body in
falls, the large size and rounded shape of the head and the looseness of
the ligaments, dislocation of this joint is comparatively very common.
It is caused most frequently by forcible extension as in falls on the hand
or elbow and twists of the arm. Sometimes a direct blow on the shoul-
der will dislocate the humerus. The form of the dislocation is deter-
mined by the position of the head of the bone in relation to the glenoid
cavity. Thus, there may be four forms of dislocation; the subcoracoid,
in which the head is forward and slightly downward; the subglenoid,
in which it is directly under the cavity; the subspinous, in which it is
back and the subclavicular, in which it is anterior. The other disloca-
tions are only modifications of these.

The signs of dislocation of the shoulder, depend upon the length of
standing of the case and the character of the injury. In all recent cases
there is swelling, lessened mobility, pain in the joint and along the course
of the arm and no crepitus. There is prominence of the acromian pro-
cess with a depression immediately beneath, a flattening of the shoulder,
a change in the direction of the humerus and on palpation, the head of
the bone is found to be at a place elsewhere than in the glenoid cavity.
The usual tests for dislocation of the shoulder are, the strait edge test
in which a straight edge applied to the shoulder will touch the arm and
acromian process; increased circumference of the joint and limitation of
the movements of the arm, so that when the hand is placed on the op-
posite shoulder the elbow will not touch the chest; and palpation of the
bone in its abnormal. position.

The subcoracoid, is the most common of the displacements of the
shoulder. In this dislocation, the head of the bone is anterior to the
glenoid cavity and under the coracoid process. It is diagnosed by feel-
ing the head of the bone in this position and by noting the prominence
of the tissues caused by the abnormal position. The limb may be short-
ened, but it is in many cases not affected at all as to length. There seems
to be all grades between the subcoracoid and subglenoid displacements,
the latter being the next most common form. The diagnostic points
of this form are, the presence of the head of the bone under the glenoid
cavity, that is, in the axilla, marked depression over the anterior part
of the axilla, lengthening of the arm and quite a large depression be-
tween the head of the bone and the coracoid process.

APPLIED ANATOMY.

457

The other forms of dislocation of the shoulder are very rare. The
most important of the diagnostic signs, is the abnormal position of the
head of the bone, which can be palpated and seen in its changed position.

Most important as well as most constant of the effects of a displaced
shoulder is the interference with the function of the joint, that is, loss or

Fig. 137. — Dislocation of the shoulder with atrophy, paralysis and deformity.
The fingers were stiff, flexion of the wrist impossible and pain in the shoulder-joint,
very great. Under treatment, the pain was relieved but reduction was found impos-
sible on account of the great amount of inflammatory tissue around the joint. (From
photo).

restriction of movement. In order that a joint may have normal move-
ment, the articular surfaces must be in contact and if they are changed,
the disturbance of movement is usually in proportion to the degree of

458 APPLIED ANATOMY.

change. In dislocation of the shoulder the articular surfaces are of course
separated and otherwise changed, hence the limited movement of the
arm. Adhesions occur in many cases as a result of the irritation and in-
flammation, which so commonly accompany a displacement of the hu-
merus. These adhesive bands still further restrict the movements of
the shoulder and often have to be broken up before reduction is possible.
Probably the best way to do this is by repeated stretching and manipu-
lation of them, by which they are gradually torn and absorption hastened.

Atrophy of the muscles of the shoulder occurs in every chronic case,
partly on account of the impairment of the vessels and nerves to these
muscles and partly on account of non-use. The muscles first affected
and in which the atrophy is greatest, is the deltoid. This is on account
of its innervation more than anything else, since it is supplied by the
circumflex nerve, which is the main supply of the shoulder-joint and its
ligaments. In dislocation of the shoulder, the shoulder-joint is injured
and consequently the circumflex nerve, and the above atrophy is one of
the effects. If other nerves of the brachial plexus are involved or if
the arm and hand are held in a fixed position for too great a length of
time, contractures producing deformities will result. In some cases
bandaging of a shoulder or arm will lead to these contractures and de-
formities. These deformities can be prevented in most instances by
proper care, that is, passive movements being resorted to in cases in which
the patient is unable to use the arm. Another effect which is chronic, is
that of repeated dislocations. One dislocation makes it easier for an-
other to occur on account of the relaxation of the ligaments and injury
to the tissues of the joint. This weakness or relaxation may be in part
the result of lesions of the upper thoracic area that interfere with the
nutrition of the joint.

Partial dislocation of the shoulder is a condition in which the lig-
aments that hold the head of the bone in place are so relaxed that they
permit the bone to drop away from its socket or else the bone has been
forcibly twisted in the socket, thereby injuring the ligaments. The first
is the result of a general weakness or local disorder due to lesions of the
upper thoracic area affecting the trophic nerves to the joint, or to a re-
peated dislocation or injury of the shoulder. In recent cases, the head
of the bone may be pulled to one side of the socket, or it may become
twisted, either of which constitutes a partial dislocation. As in the case
of the hip, it seems that the head of the humerus is either in or out of the

APPLIED ANATOMY. 459

socket, but clinically, it is a fact that the head may become twisted in
the glenoid cavity, this interfering with the function of the joint. In
these cases of partial dislocation of the shoulder-joint, only some of the
movements are impaired. The ordinary movements of the arm may be
normal, but if the patient should attempt an exaggeration of any of
these normal movements there will be restriction and pain. The pain
in these cases may be a continuous ache referred to the area of distribution
of one of the brachial nerves, or it may be a sharp pain on certain at-
tempted movements. The sensory disturbance may be confined to the
shoulder-joint in which case it is often called rheumatism of the shoulder.
Some of the trophic disorders of the arm can be attributed to a partial
dislocation of the head of the humerus.

THE ELBOW.

The principal disorder of the elbow consists of a partial dislocation
of the head of the radius. This is characterized by pain along the course
of the nerve in relation, numbness or perverted sensation in the part and
in many cases, by some trophic disorder, such as caries of the bone, or
some eruptive disorder of the skin covering the forearm. It is diagnosed
by locating the head of the bone in an abnormal position, pain over the
part and by restriction of movement. In complete dislocations of the
elbow, both the bones of the forearm are dislocated backward on the
humerus so that the coronoid process of "the ulna is in the olecranon
fossa and the neck of the radius on the eapitellum of the humerus. In
such a dislocation the joint locks whenever extension is attempted and
the olecranon process, that is the elbow, becomes very prominent. An-
other form of lesion of the bones of the forearm consists of an approxi-
mation of the upper ends of the bones. This condition is diagnosed by
palpation by which the distance between them is ascertained, and by
pain and tenderness along the tissues between the bones. In many cases
in which the symptoms and conditions are obscure, it is well to examine
either for a partial dislocation of the radius or an approximation of
these two bones.

THE WRIST.

The principal disorder of the wrist-joint is a sprain, or in some cases
a partial or complete dislocation of the joint is found. This occurs on
account of falls in which the patient attempts to protect the body by

460

APPLIED ANATOMY.

catching himself on the hand. By doing this the movement is carried
beyond the physiological range, therefore the ligaments are either torn
or over-stretched. This results in a thickening and an exudation. In

TROCHLEA

OBLIQUE

ULNA

Fig. 138. — Showing longitudinal section of the elbow-joint.

APPLIED ANATOMY. 461

such cases it is advisable to examine for a fracture of the radius, since
such is accompanied by swelling of the joint, which is identical with that
of a sprain. In partial dislocations of the wrist there will be found slight
irregularity, some restriction of movement and tenderness. The effects
of an injury to this joint are stiffness, or weakness of the articulation,
pain and swelling.

THE HAND.

The carpal bones are seldom misplaced, but the os magnum occasion-
ally is forced backward in extreme flexion of the hand. It is character-
ized by prominence of the bone which may be mistaken for a weeping
sinew, or a ruptured tendon. It seldom produces any trouble further
than that of weakening the hand or producing pain at certain movements
or when a strain is thrown on that part.

The phalanges of the hand are quite often sprained or dislocated,
particularly the thumb. This is the result of direct violence or from
hyperextension. The diagnosis is comparatively easy on account of the
signs, they being abnormal position, swelling, pain and limitation of
movement. The thumb is subject to sprains which result from blows
on the end of it or hyperextension. The principal articulation involved
is the one between the first phalanx and the metacarpal bone. The
effects are hard to overcome, they consisting in the main of a thickening,
congestion and extreme tenderness of the ligaments.

THE UPPER EXTREMITY AS A REGION.

The upper extremity as a region. The skin of the arm is quite thin
and freely movable. On this account the veins stand out in prominence
and cutaneous eruptions are rare. The surface markings of the prin-
cipal arteries and veins and nerves is important, since compression of
the vessels and inhibition of the nerve, can be done to better advantage
if the external markings are well known. The brachial artery is indi-
cated by a line drawn from the inner border of the biceps or posterior
axillary fold, to the center of the elbow. A line from this point to the
scaphoid bone represents the radial, while one drawn to the pisiform,
the ulnar artery. The course of the median nerve is the same as that
of the brachial artery. The posterior circumflex nerve and artery are
in relation with the insertion of the deltoid muscle.

The ulnar nerve corresponds to a line drawn from the lower part of

462 APPLIED ANATOMY.

the axilla or apex, to the internal condyle, thence along the under side
of the arm in relation to the flexor carpi ulnaris tendon. The musculo-
spiral, corresponds to a line drawn obliquely around the upper part of the
arm, it crossing the humerus at the junction of the middle and lower
thirds.

The lymphatics accompany the veins, those from the forearm empty-
ing into the glands at the angle of the elbow, while those of the upper
arm, empty into the axillary glands. The superficial veins form quite
a net work in the integument of the arm and in some people in whom
the skin is thin, the veins are very prominent. In infections of the
hand and forearm, the superficial lymphatic vessels and sometimes the
veins become inflamed and are characterized by red lines that lead up-
ward from the point of infection.

The contour or external configuration of the arm depends on the
age, sex and occupation of the individual. In children and females, it is
about cylindrical on account of the lack of development of the muscles
and the deposit of subcutaneous fat, while in adults in whom the mus-
cles are developed, the arm is flattened from side to side. The devel-
opment of the supinator longus, pronator radii teres, triceps and the biceps
muscles, changes the contour of the arm to a marked degree. The tendon
of the biceps makes a triangular depression in front of the elbow called
the antecubital fossa and is of interest in that the brachial artery and
median nerve are in relation. At the insertion of the deltoid muscle is
another depression at which place pain is usually referred in disorders of
the shoulder- joint or brachial plexus. At the back of the elbow is a
slight depression when the arm is extended, which marks the articula-
tion of the radius with the ulna, and furnishes a landmark in the exami-
nation of this articulation. The prominence of the elbow is formed by
the olecranon process of the ulna. On the inner and posterior side of
of the ulno-carpal articulation is a prominence formed by the styloid
process of the ulna. In dislocations and fractures at or near this joint,
this prominence serves as a landmark in locating the joint and in the
differential diagnosis.

The upper extremity is subject to change in contour from many
diseases. If the nails are abnormally convex, both transversely and
longitudinally, it is symptomatic of tuberculosis. In such cases if the
nails were allowed to grow they would become clawed. If they are
brittle and have white spots in them it is indicative of malnutrition. If

APPLIED ANATOMY.

463

they are very short, it is suggestive of nervousness, since nervous people
often bite the nails, to the quick. If the fingers are clubbed and the nails
short, it is suggestive of organic heart disease. This applies particularly
to children in which the nail is broad and short, and is found especially
in the congenital types of valvular diseases of the heart. A dactylitis is
almost diagnostic of hereditary syphilis or tuberculosis. A dactylitis

Fig. 139. — Showing the condition of the hands and forearms in a marked case of
progressive muscular atrophy. (From photo).

consists of an inflammation of the finger or toe and is characterized by an
enlargement of the joint and often by the formation of a small ulcer.
In the hereditary form, the development of the finger is interfered with
when it appears to be short and stumpy.

If the joints of the fingers are enlarged and the hand everted.it is
suggestive of arthritis deformans. In this disease the deformity very
often reaches a marked degree so that all the fingers are drawn out of
shape. In certain injuries to the palmar fascia, contraction may result

464 APPLIED ANATOMY.

which draws the little and ring fingers into the position of extreme flexion.
This produces a deformity which is quite characteristic and easily diag-
nosed on account of the thickening of the fascia of the palm of the hand.
This is called Dupuytren's contraction. A flattening of the thenar and
hypothenar eminences, is almost diagnostic of progressive muscular
atrophy. If this is accompanied by a softening of the tissues of the hand
and atrophy of the adductor muscles of the thumb, and the hand be-
comes very thin, it is diagnostic of chronic anterior polio-myelitis. The
swelling of one or more joints of the hand occurs in chronic rheumatism
and in gout. The diagnosis is based on the other symptoms.

There are certain motor disorders which are common and fairly diag-
nostic of nervous and other diseases. Spasmodic or convulsive move-
ment of the hand and arm occurs in chorea. This is usually accompanied
by some movement of the head, neck and shoulders. It is usually unilat-
eral but may* -affect both arms. A constant movement of the forefinger
and thumb is suggestive of paralysis agitans. This occurs in the aged.
Athetoid movements of the hand and wrist occur in hysteria and in cer-
tain nervous diseases. They may be the result of infantile cerebral palsy
or of lesions which affect the muscles of the hand. The effects are pecu-
liar in that the fingers assume curious and unusual positions such as
extreme flexion, pronation, extension, tortion and supination.

Intentional tremor is indicative of spinal cord disease especially
disseminated sclerosis. Tremor of the hands and arms is found in Graves
disease, often during senility and in patients suffering from hemiplegia.
Certain forms of nervousness are characterized by tremor of the hand.
Hare says: "There are two sets of movements associated with the
movements of the muscles of the wrist and hand which possess grave
prognostic and diagnostic importance. The first of these is twitch-
ing of the muscles of the forearm (subsultus tendinum). It indicates
severe exhausting disease. The second is picking at the bed clothes.
This is called carphologia. It is a grave symptom and usually is indi-
cative of approaching death." Inco-ordination of the movements of the
hand and arm occurs in some cases of locomotor ataxia. It may result
from a neuritis or upper thoracic lesions, the differential diagnosis being
based on the other symptoms of tabes dorsalis.

Contractures of the muscles and tendons of the hand and wrist and
those of the elbow, result from dislocations of the shoulder and from
trauma. In some cases these are the result of hysteria. Rigidity of the

APPLIED ANATOMY.

465

parts occur in some cases of chronic hydrocephalus. In epileptic spasms,
the clonic contractions peculiar to this disease. Monoplegia or paralysis of
one arm or hand, results from hemiplegia, injury to the brachial plexus or
in certain spinal cord disturbances. The writer has had cases of mono-

Fig. 140. — Showing a lesion at the articulation between the second and third
thoraciCjVertebra. The patient fell from a bicycle, striking on the back of the neck.
In about one year, symptoms of progressive muscular atrophy set in and at the time
of the taking of the photo, the disease was well under way. Note the lateral devia-
tion and break at the point of the arrow. (From photo).

466 APPLIED ANATOMY.

plegia in an upper extremity that were due to upper thoracic lesions.
In other cases, there is found a dislocated shoulder or injury to the
brachial plexus as in obstetric paralysis. Pressure of growths in the
axilla, will also lead to paralysis of the upper arm type which is some-
times called Erb's paralysis. Ordinarily complete motor and sensory
paralysis of one upper extremity, is indicative of injury to the brachial
plexus. If other parts of the body are involved it is suggestive of hem-
iplegia while in some cases, it is the result of upper thoracic lesions. Im-
pairment of movement and weakness of the arm, most frequently result
from upper thoracic lesions and from repeated dislocation of the shoul-
der. If it affects only one side it is probably a shoulder disorder, but
if both sides are involved, it is most probably the result of a disorder of
the spine.

The cutaneous nerves of the upper extremity are the supra-clavicu-
lar, circumflex and intercosto-humeral, internal cutaneous, nerve of
Wrisberg, musculo-spiral, musculo-cutaneous, median, ulnar and small
branches from the principal divisions of the brachial plexus. The deep in-
nervation comes principally from the main trunks of the- brachial plexus,
as the circumflex, musculo-spiral, musculo-cutaneous, ulnar and median.
The upper extremity is subject to many sensory disturbances, some of
which are local and some reflex. Certain visceral diseases tend to pro-
duce pain in the arm, as is the case of cardiac disease in which pain is
referred to the area supplied by the left ulnar nerve. Pain is also re-
ferred to the arm in cases of dislocation of the shoulder, of the acromial
end of the clavicle and from subluxations of the upper thoracic verte-
brae. A lesion of the upper ribs will produce pain or an ache in the
shoulder, this sometimes extending down the arm. The explanation of
most of these referred pains lies in the fact that the sensorium is often
mistaken as to the origin of the sensory impulses carried to it and they
are referred to the periphery of the nerve. In the case of a lesion of the
upper thoracic vertebras, the sensory impulses that arise from it are
carried to the sensorium and the pain is referred to the periphery of
the nerves in relation, that is, to the brachial nerves. Pain along the
tract of any of the brachial nerves may be due to a tumor on the nerve,
or irritation from other causes, as infection, inflammation, or displace-
ment of the shoulder or vertebra with which it is in relation. Neuralgic
conditions, or aches in the nerve, are ordinarily due to congestion of the
nerve trunk and the pain is increased by pressure along the nerve. A

APPLIED ANATOMY.

467

throbbing pain indicates an acute congestion of an area in which the
elasticity of the tissues is lessened. Each beat of the heart forces more
blood into the already congested vessels and thereby the pain is increased
with each heart beat.

Fig. 141 — Showing a subluxation of the third dorsal vertebra. Note the " break' '
at the point of the arrow. The lesion was produced by trauma and in a short time,
symptoms of progressive muscular atrophy began to develop. At the time of the
taking of the photo, three years after the accident, the disease was well developed.
(From photo) .

468 APPLIED ANATOMY.

Parasthesia of the arm, that is perverted sensation in which there
is tingling and numbness, is most frequently due to direct pressure on
the nerve trunk. This comes from a displacement of some of the bones
with which the brachial nerves are in relation, as in the case of the hu-
merus, clavicle, radius and ulna. The writer has treated a few cases
of parasthesia of the arm due to lower cervical and upper thoracic le-
sions. The explanation of the effect is that the displaced bone presses
directly on the nerve trunk or vessels supplying it or else interfere with
the sensory cells of the ganglion on the posterior root. In some forms of
heart trouble there is numbness of the ring and little fingers on the left
side. In hemiplegia, especially in the early stages, the fingers become
numb. In the aged, often there is found a tingling sensation or numbness
of the hand and fingers. This may be due to a change in the arteries or
to trophic disorders of the brain.

The arm is subject to trophic disorders as the result of spinal and
peripheral lesions. The vaso-motor disorders will be considered along
with the trophic since they are related. The trophic and vaso-motor
centers for the upper extremity are located in the upper thoracic spinal
cord. This is determined partly by clinical observation and partly by
physiological experiments on animals. A lesion of the upper thoracic
vertebral articulations and particularly the second and third,will produce
vaso-motor and trophic changes in the arm. The explanation is that the
lesion breaks the line of nerve connection existing between the spinal
cord and the arm or else interferes with the nutrition of the cells con-
stituting these centers. The peripheral lesions consist of dislocations
of the shoulder and elbow. In other cases the nerve may be tornjor
otherwise injured by trauma so that its functions are impaired. Atrophy
of one arm is most frequently the result of a neuritis of traumatic origin
or dislocation of the shoulder. Inflammation and swelling of the arm
are sometimes due to a spinal lesion. In ulcers and eruptions of the
integument and in caries of the bone, examine carefully for subluxations
of the bones with which the various brachial nerves are in relation.
The writer has seen cases of what appeared to be eczema cured by cor-
recting a displacement of the radius.

There are certain secretory disturbances of the upper extremity
that are of diagnostic importance. Hypersecretion of sweat of the palms
of the hands is fairly diagnostic of nervousness, which sometimes occurs
in cases of constipation and the early stages of progressive muscular

APPLIED ANATOMY. 469

atrophy. A localized dryness of the skin is suggestive of a local lesion
such as a lower cervical or upper thoracic subluxation or displacement
of the shoulder. Chaffing of the hands is due in part to disturbance of
sebaceous secretion, that is, it is lessened. This may be a part of a gen-
eral disturbance but often is a local one. These secretory disorders are
dependent to a great extent, upon the amount and character of the blood
circulating through the part.

Fig. 142. — Showing a specimen of dermography. The letters were made by
stroking the skin with a dull pencil. At first, there was a bright, red line followed
by a welt, as shown in the picture. The condition was the result of an attack of
measles in which the rash "went in." (From photo).

THE HIP-JOINT.

The hip-joint is formed by the acetabulum and the head of the femur.
The acetabulum is a circular depression formed by the junction of three
bones, the ilium, the ischium and the pubis. The ilium forms about two-
fifths, the ischium a little more than two-fifths and the pubis the re-
maining one-fifth. It is directed downward, outward and forward but
this varies somewhat in different cases. In the female and in "pigeon-
toed" people, the acetabulum faces somewhat forward thus throwing the
trochanters anterior. The margin formed by the cotyloid ligaments, in-
creases the depth of the socket. The lower side is broken by a notch or
depression called the cotyloid notch. On this account dislocations of
the hip, occur at this point more frequently than at any other. Ossifi-
cation of the bones forming the acetabulum begins quite early but is not
completed until some time after birth. At the age of sixteen, ossification
is usually completed. Anything interfering with this process during
fetal life will often lead to the congenital form of dislocation of the hip.

470 APPLIED ANATOMY.

The head of the femur is hemispherical in shape, quite smooth and
glistening, being covered with cartilage except the part to which is at-
tached the ligamentum teres. The ligaments of the hip-joint are the
capsular and the ilio-femoral which is a part of the capsular, the cotyloid,
the ligamentum teres and the transverse. The capsular ligament com-
pletely invests the joint, being attached above to the edge of the acetabu-
lum and to the neck of the femur below. It is thickest and strongest over
the anterior and external parts of the joint, since the strain on these parts
is greatest, while below it is quite thin and loose. The ilio-femoral lig-
ament, sometimes called Bigelow's or the Y-ligament, consists of a
thickening of the anterior portion of the capsular ligament. It is at-
tached above to the anterior superior spine and passing downward, it
divides into two parts, on which account it is called the Y-ligament, it
having the appearance of an inverted Y. One of these bands, the outer
one, is attached to the anterior inter-trochanteric line near the tro-
chanter, the inner one, to the lower end of this line. This ligament
is seldom broken in the average dislocation and is of importance in that
it acts as a fulcrum around which the movements of the head of the bone
occur, and thus the different displacements are determined. The action
and course of this ligament must be considered in the reduction of hip
lesions.

The cotyloid ligament consists of strong bands of fibro-cartilaginous
tissue which are attached to the edge of the acetabulum. It deepens
and protects the cotyloid cavity and thus tends to prevent dislocation.
The transverse ligament is really a portion of the cotyloid. It passes
across the cotyloid notch and thus converts it into a foramen through
which the vessels to the hip-joint pass. The ligamentum teres extends
from the head of the bone to about the center of the acetabulum. It is
not always present, but when it is, it is broken in dislocation. These
ligaments of the hip-joint are subject to relaxation and contracture as
are the ligaments of other joints. They may so relax that the bone will
drop part way out of the socket, thus lengthening the limb, but this is
not so common as in the case of the shoulder-joint. They do not have
so much to do with holding the head of the femur in the socket as with
limiting the movement of the joint. After section of these ligaments,
air pressure will hold the head of the bone in place. The ligaments of
the hip-joint help to economize the muscular effort in balancing the
trunk.

APPLIED ANATOMY.

471

The muscles in relation with the joint are: in front, the ilio-psoas;
externally, the gluteus minimus and rectus femoris; internally, the ob-
turator externus and pectineus, while the pyriformis, the two gemelli
and the quadratus femoris are in posterior relation. A synovial mem-
brane lines the entire capsule and the cotyloid ligament, and is reflected

ANT INF ILIAC SPINE

ILIO-FEMORAL
LIGT

Fig. 143. — Showing the ligaments of the hip-joint Note the ilio-femoral.

over the articular surface of the head of the femur. In synovitis of the
hip, the capsule becomes distended in cases in which there is much ef-
fusion and thus causes bulging in Scarpa's triangle and backward into

472 APPLIED ANATOMY.

the tissues, thus obliterating the gluteal fold. Movement of the joint is
limited and the thigh tends to assume a position of flexion, inward rota-
tion and adduction, this being the position of rest for the joint.

The arteries that supply the joint are derived from the obturator,
gluteal, sciatic and internal circumflex. These are innervated princi-
pally from the lumbar spinal cord by way of the aortic plexus, which
surrounds the abdominal aorta and sends off filaments with each branch
of the iliac arteries.

The nerves supplying the joint are derived from the sacral plexus,
the obturator, great sciatic and the accessory obturator nerve. The
joint is an enarthrodial one and is capable of all forms of movement,
although they are not so marked as in the case of the shoulder. Flexion,
extension and circumduction are the principal movements. Flexion is
limited by the contact of the neck of the femur with the upper edge of
the acetabuhuri; extension, by the ilio-femoral ligament and circumduc-
tion, by the ligaments and muscles attached. Abduction and adduc-
tion are limited principally by the capsular ligament. Movement is
also governed to a certain extent by the depth of the hip socket and the
condition of the muscles and synovial membrane of the joint. The
pathological conditions which interfere with the movement of the hip-
joint are, dislocation, caries of the joint, non- or imperfect development
of the socket, partial dislocation and painful conditions due to other
causes, such as inflammation or sprain of the joint.

Dislocation of the hip may be either acquired or congenital, that is,
taking place after birth, or incomplete formation of the acetabulum.
The dislocations of the hip are usually classified under four forms: up-
ward and backward or dorsum iliac, sciatic, thyroid and pubic. These
dislocations result from exaggeration of the movements of the hip, that
is, the femur is carried beyond the normal range of movement. In most
cases the thigh is flexed and abducted when the dislocation occurs, thus
forcing the heavier bone against the lower or weaker part of the capsular
ligament. In the iliac form of dislocation, the head of the bone rests
above and behind the acetabulum upon the posterior surface of the ilium.
The lower and posterior part of the capsular ligament is usually ruptured
and the round ligament broken. The glutei muscles and other external
rotators, are usually torn or put on a stretch. These contractures in-
terfere with reduction. The diagnosis of this form of dislocation is
based on the position of the head and trochanter, length of the limb and

APPLIED ANATOMY. 473

the disturbance of mobility. The head of the bone can often be palpated
up and behind the acetabulum and the trochanter is abnormally prom-
inent. The limb is slightly flexed, adducted and the toe turned inward
so with the shortening which accompanies this dislocation the sole of the
foot will rest on the arch of the other foot. The trochanter is usually
above Nelaton's line, but this is not diagnostic of the displacement on
account of the degrees of relaxation of the ligaments of the joint. Ex-
ternal rotation of the thigh is limited or impossible, this depending,
however, on whether or not the Y-ligament is torn. If this ligament is
ruptured the toes are not necessarily inverted nor is external rotation
impossible.

The sciatic form of dislocation is one in which the head of the bone
rests in or just in front of, the sciatic notch. The head of the bone after
being forced backward through the capsule, comes in contact with the
tendon of the obturator internus muscle, which deflects the head into
the sciatic notch, this tendon offering a great obstacle to the reduction
of the dislocation. In this dislocation there is flexion, adduction and
inward rotation, but all less pronounced than in the iliac form. There
is some shortening of the limb, but not so much as in the dorsum iliac
form, except when the patient is in the sitting posture and then the
shortening is quite pronounced. The reason for this is that the head of
the bone is displaced backward more than it is upward, therefore in
flexion of the thigh, the shortening of the limb is exaggerated. Some-
times the head of the bone gets locked in the sciatic notch, thus making
reduction impossible. This form of dislocation is very painful.

In the thyroid dislocation, the head of the bone is displaced down-
ward into the thyroid foramen, it resting upon the obturator externus
muscle. The glutei, ilio-psoas, adductor brevis, pyriformis, obturator
externus and pectineus muscles are either torn or stretched by this form
of displacement. There is eversion of the foot, lengthening of the limb
and internal rotation is limited, or is impossible in some cases. The
head of the bone can be palpated in its abnormal position and the tro-
chanter is turned backward. The peculiar jjosture of the patient is the
result of an attempt to relax the ilio-psoas muscle.

The pubic form of dislocation is rare and it is one in which the head
of the bone rests in relation with the pubic bone. The limb is slightly
shortened, abducted and rotated outward and the head of the bone can
be readily palpated in its abnormal position.

474 APLLIED ANATOMY.

The change in length of the limb in these dislocations is determined
by the position of the head of the bone whether it is below, above or
behind the acetabulum. The degree of eversion and inversion is reg-
ulated by the Y-ligament, it holding the trochanter in position while the
head is displaced forward and downward, or upward. If the head of
the bone is displaced forward and downward, the muscles and Y-liga-
ment hold the trochanten in position thus producing eversion of the
foot. If dislocated upward and backward, this ligament holds the tro-
chanter in place and thus prevents eversion. The pain in dislocations
of the hip is determined by the amount of damage to the tissues, the
degree of inflammation, amount of exudate and the nerves that are im-
pinged upon. Pain is usually present over the sciatic nerve, that is, in
its upper part, partly on account of the traction or pressure exerted upon
it, or through injury to the pyriformis muscle. Pain in the knee is the
result of injury to the obturator or anterior crural nerve. The promi-
nence of the hip is regulated by the position of the trochanter and the
condition of the muscles. Ordinarily there is atrophy of the muscles, this
producing a depression or flattening of the hip. The two sides should
in all cases be compared not only by palpation but by inspection. The
various creases of the hip are changed as to depth and direction, par-
ticularly the crease formed by the buttocks. The flexion lines just below
the buttock are usually obliterated.

Congenital dislocation of the hip is a form in which the acetabulum
is so shallow that the hip-bone is forced out of place from pressure dur-
ing intra-uterine life, or else is forced out of the socket when the child
begins to use the limb. The essential point of difference between con-
genital and acquired forms of dislocation is the degree of development or
depth of the socket, that is, it is always shallow in the typical congenital
form. The hip is usually displaced upward directly across the rim of the
acetabulum, while in the .acquired form it is ordinarily displaced downward
through the cotyloid notch. In the congenital dislocation there is ordi-
narily shortening of the limb and the child walks with a rocking move-
ment. Mobility is usually increased rather than restricted and on in-
spection with the parts exposed, the bone can be seen to pla}' up and
down in the muscles, as the child walks. There is no tenderness and the
limb can be drawn down almost to the length of the sound side on account
of the relaxed condition of the ligaments. Not alone is the acetabulum
imperfectly developed but the head of the bone is often mal-developed

APPLIED ANATOMY. 475

on account of interference with its nutrition, while the angle that the neck
forms with the shaft is greater than in a normal case. Perhaps the
'earliest indication of this type of dislocation is that the child does not
crawl naturally and is backward in walking. The two buttocks are not
the same size, the limb on the affected side is malnourished and the
tissues flabby and the child walks with a distinct limp, and if the condi-
tion is bi-lateral, the gait is a distinctly waddling one. The diagnosis
and prognosis are best made after taking a skiagraph of the hip. The
principal involved in the treating of congenital dislocation is to over-
come the adductor muscles force the head of the bone into the socket,
set up an irritation which would cause an exudate to form, thus holding
the head in place and then abducting the limb and putting on a cast, to
hold it in this position. The object of this abduction is to place the head
of the bone in such a position that the muscles cannot draw it over the
poorly developed rim of the acetabulum. In addition to .this, passive
movement should be begun quite soon after the reduction, that is, the
parts should be treated to better the nutrition of the bone, ligaments
and muscles concerned.

Articular osteitis of the hip, or hip-joint disease, is a lesion of the
joint characterized by inflammation and degeneration of the head of
the femur and the acetabulum. It is usually regarded as tubercular in
character although, as Hilton points out, it is not necessarily the case. It
is associated with traumatism of the hip and sometimes there is a co-ex-
isting displacement, that is, the injury causes a lessening of resistance
which permits the tubercle bacilli to propagate. About the first indica-
tion of this sort of disorder of the hip-joint, is a slight limp. This is more
marked in the morning and it gradually wears off as the day advances.
This limp is due in part to the stiffening of the muscles and to the in-
flammation of the joint. Deformity soon appears which consists usually
of a flexion with abduction and appa.rent lengthening. This is due to
the fact that the child attempts to place the hip in the position of greatest
ease. Atrophy of the glutei muscles takes place so that the contour is
changed, also the gluteal lines are obliterated. Pain or tenderness in
the hip or in the inner side of the knee, are present in most cases. The
child refers the pain to the knee and on pressure the pain is greatest over
the head of the bone. The limitation of motion is perhaps the best
symptom upon which to diagnose this condition. This is the result of
contracture of the muscles and change in the form of the bones that

476 APPLIED ANATOMY.

form the joint. The child often cries out in its sleep. The general
health is often impaired and the child is pale and anemic and usually
has the tubercular diathesis. These symptoms increase in intensity
until an abscess forms which usually appears in front of the joint. The
disease most frequently starts in the head of the femur and then extends
to the acetabulum, and finally there is degeneration of all the parts,
unless the progress of the disease is arrested.

In making an examination for this disorder, the child should be
stripped of all clothing and caused to walk back and forth in order that the
amount of disturbance of function may be the better estimated. If the
limp is due to the disease of the hip-joint, the child will not move the articu-
lation very much in making the step. It tries to protect that side by
throwing most of the weight on the sound hip. The thigh on the af-
fected side is usually considerably smaller, than on the sound side. By
placing the chi'ld in the dorsal posture on the table, it will be found that
in attempting to force the popliteal space to- the table that the lumbar
spine will be arched, it being found impossible to force the popliteal
space and the lumbar spine to the table at the same time if the case is
one of tuberculosis of the hip. By attempted movements of the hip,
it will be found that they are limited on the affected side, which is due to
the condition of the muscles and ligaments of the hip as much as it is
due to the pain. All these passive movements should be given with the
greatest care, especially if the disease has reached the stage of pus forma-
tion, or if the head of the bone is honey-combed, since fracture of the
neck of the femur may be produced if the parts are handled roughly.

Partial dislocation of the hip is a condition in which the head of the
femur is twisted in the socket, or else drawn up against one side of the
acetabulum and held there by muscular and ligamentous contraction.
It is usually the result of abduction of the limb in which the movement
is carried beyond the physiological range, this throwing the head of the
bone against the weak part of the joint. This sort of lesion is more nearly
analogous to spinal lesions than are the dislocations of the hip. Partial
dislocation is characterized by restriction of movement of the hip, lame-
ness and pain at, and swelling of the knee. This swelling assumes the
form of a synovitis of the knee and a puffy enlargement soon forms on
the inner side of the joint soon after the injury. The length of the limb
may be affected and if it is, it is most frequentty slightly lengthened.
The toe is often everted and the limb slightly flexed. The measurement

APPLIED ANATOMY. 477

of the hip, that is, Nelaton's and Bryant's lines, do not show any dis-
placement. However, these lines are unreliable even in the diagnosis
of a dislocation of the hip. It is a well know fact, clinically, that many
cases of lameness characterized by the above symptoms, are due to a twist
of the head of the femur in its socket and that the symptoms can be re-
lieved by treatment directed to restoring normal relations between the
head of the bone and its socket. The pain in the knee as in other lesions
of the hip-joint, is the result of a disturbance of the anterior crural or
obturator nerves. The painful affections, of the hip-joint are the result
of dislocation, sprain, caries and certain sjDinal lesions that affect the
sciatic and other nerves that supply the joint, but especially the sciatic.
The pain may be a referred one, but this is not so common as in the case
of the knee-joint. If it is a referred one, the trouble is most commonly
in the pelvic organs, such as an enlargement of the uterus or other vis-
cus which produces pressure directly on the nerve supplying the hip.
The trophic condition of the hip-joint, especially its degree of develop-
ment, is controlled by the condition of the lumbar spine. If lesions ex-
ist in this area, the nutrition of the hip will suffer, this causing a dis-
eased or shallow socket, weakness of the ligaments of the joint and tend-
ency to tubercular affections. In all trophic and vaso-motor disorders
of the hip, the lumbar spine should be carefully examined since a lesion
in this region will affect the anterior crural, the obturator, the sciatic and
the vaso-motor nerves that supply the hip-joint. These vaso-motor
nerves reach the joint by way of the arteries and are derived from the
gangliated cord. In all tubercular affections of the hip-joint, this part
of the spine should be especially treated, since by so doing the vitality of
the hip is increased.

THE KNEE-JOINT.

The knee-joint is formed by the lower end of the femur, the upper
end of the tibia and by the patella, and is described as consisting of three
articulations: one between each of the condyles of the femur and the
tuberosity of the tibia and one between the femur and the patella. It
is a very large, complicated joint and the surfaces are nearly fiat. It is
classed as a ginglymoid or hinge-joint, but it is not so typical as is the
elbow, since it is much more complicated. On account of the size and
shape, it is regarded as one of the weakest joints in the body, but the
number, size and arrangement of its ligaments, and the strong muscles

478

APPLIED ANATOMY.

POST.
CRUCIAL

/NT.CRUCIAL^.

Fig. 144. — The ligaments of the back of the knee-joint.

with their tendinous expansions around the joint, make it quite strong.

There are many ligaments around this joint but only a few will be
considered here, namely, the patellar and the semi-lunar cartilages.

The ligameiitum patellae or anterior ligament, is the lower end of the
quadriceps extensor tendon. It is very strong, broad and flat. It is of
interest principally in that fracture of the patella results from the

APPLIED ANATOMY. 479

sudden and strong contraction of the quadriceps extensor muscle. This
also has to do with the dislocation of the patella, which condition is not
unusual.

The semi-lunar cartilages are two crescent-shaped cartilages placed
on the top of the tibia. They are wedge-shaped and thus deepen the
cavity. They are of interest in that they are subject to displacement
which results in the locking of the joint. The knee-joint has a very
large synovial membrane which lines the surfaces of the bone except
those covered by the articular cartilage. It also covers the semi-lunar
fibro-cartilages and extends upward several inches under the quadriceps
extensor muscle and laterally to the vasti muscles and is separated from
the patella by a cushion of fat. It is reflected from the patella and thus
forms some of the internal ligaments of the joint. It also assists in form-
ing some of the bursa? in relation to the tendons of the knee-joint. On
account of some of these communicating with the cavity of the joint,
care should be taken in the opening of them when they are distended
with fluid. On account of the extension upward of this synovial mem-
brane, synovitis of the knee is characterized by considerable swelling
above the patella, and often the patella itself is lifted away from the
lower end of the femur.

The arteries of the knee-joint are derived from the anastomotica
magna of the femoral, an- articular branch from the popliteal and the
recurrent from the anterior tibial. The nerve supply is derived from the
popliteal, anterior crural and obturator nerves. The importance of this is
brought out best in cases of dislocation or disease of the hip.

The movements of the joint consist principally of flexion and ex-
tension and some internal and external rotation. Flexion is limited by
contact of the leg and femur. In slight flexion of the leg, all the liga-
ments are relaxed, with the exception of the ligamentum patella?, and on
this account in injuries of the knee, the limb assumes a semi-flexed posi-
tion. The posterior crural and common ligaments, prevent over ex-
tension, hence are injured in all cases in which the knee is forcibly bent
backward. The anterior and posterior crucial ligaments when normal,
prevent the bones from slipping forward or backward, while the lateral,
prevent lateral displacements. The movements of the knee are re-
stricted by disorders of these ligaments of the synovial membranes and
changes of the bone itself. The knee-joint is seldom displaced on ac-
count of the number and size of the ligaments surrounding it. but sprains

480

APPLIED ANATOMY.

of it are not rare and do not readily yield to treatment. The number
of ligaments involved and the extent of the injury, account for this.
When force is applied to the joint, the effect is in the ligament rather than
the articular surfaces and a sprain is the result. In dislocation ofjthe
knee-joint, there will be prominence on the side to which it is displaced

POST CRUCIAL

TRANSVERSE

Fig. 145. — Showing the inferior articular surface of the tibia, and ligaments.
Note the size and shape of the articular surfaces.

while a depression exists on the opposite side. In recent cases there will
be swelling and congestion of the joint. Movement is impaired and
painful. It is differentiated from a sprain by the change in contour of

APPLIED ANATOMY. 481

the bones forming the joint since in sprains, change in contour is due to
the thickening of the ligaments and the effusion around the joint.

The patella quite frequently becomes displaced; the outward dis-
location being the most common. It is the result of muscular action or
trauma applied to the edge of the bone. The contraction of the quad-
riceps extensor is the principal cause. The partial form of dislocation
of the patella, it is due to relaxation of the ligamentum patellae.
When this condition exists, the patella has too great a play and then from
muscular action, it will suddenly slip over one or the other of the con-
dyles, thus causing a locking of the knee-joint. Ordinarily the patient
can press the bone into place and it causes no further trouble until it
becomes displaced a second time.

The dislocation of one or a part of the semi-lunar cartilage is, per-
haps, the most important of all these displacements. The condition is
the result of a sudden twist or wrench of the knee, especially during partial
flexion. This accident is accompanied by a locking of the joint, severe
and sudden pain, swelling and the formation of a prominence on the
side to which the cartilage is displaced. One displacement predisposes
to another so that the cartilage may slip out on the least strain of the
joint. This condition can best be reduced by grasping the cartilage and
exerting pressure on it, while the limb is moved to-and-fro. If the frac-
tured cartilage becomes loosened, it may lock the joint at almost any
time. The patient may be walking along with no impairment when all
of a sudden, the floating piece of cartilage works into the joint and
suddenly locks it.

Swelling of the knee is suggestive of a synovitis or an effusion from
injury to one of the bursa?. If the patella is raised, or if it floats, in which
case it is termed "riding of the patella," it is due to synovitis. If it is
not raised by the effusion, it is in the bursa. Most cases of swelling of
the knee are due to effusions, which, in quite a number of cases, are due
to disorder of the hip-joint. This consists of a slight puffiness on the
inner aspect of the knee, which fluctuates in size and is not particularly
painful. In other cases, it is due to a sprain of the joint or to over ex-
ertion.

In some cases, the enlargement of the knee is due to tuberculosis of
the bone, either the lower end of the femur or the upper end of the tibia,
in which it becomes honey-combed. Usually an abscess forms in such
cases. This breaks above on the inner side of the knee-cap or below and
to the inner side of the joint.

482

APPLIED ANATOMY.

Stiffness of the knee-joint may be due to deposits, synovitis, dislo-
cation or to tenderness due to a sprain. The particular form of stiff-
ness can be diagnosed by noting the contour, degree and form of move-
ment and by getting a history of the case. Pain of the knee-joint is

QUAD EXTENSOR K.

NOVIAL SAC

/PATELLA

POST
CRUCIAL LIGT

Fig. 146. — The right knee-joint from the lateral surface. (The joint cavity and
several bursa? have been injected with a stiffening medium and then dissected out.
(After Spalteholz).

APPLIED ANATOMY. 483

usually the result of hip-joint disease, or some form of dislocation of the
hip. In other cases it is due to direct injury of the knee, as in sprains,
dislocations and synovitis. Crepitus in the knee-joint is very common
but usually causes no trouble further than a creaky sound whenever the
joint is moved. It is usually the result of an old synovitis in which there
were adhesions formed, or it may be the result of fever, over use of the
joint or other conditions in which the synovial membrane becomes af-
fected. There is a lessened amount of secretion of synovia, hence insuf-
ficient lubrication of the joint and particularly that part between the
patella and the femur. Sometimes a portion of the cartilage gets into
the knee-joint, or perhaps some foreign body gets into it, which condi-
tions cause a locking of the joint. Little can be done with such a con-
dition.

A lesion of the tibiofibular articulation is sometimes present, a par-
tial dislocation of the fibula being the most frequent of the pathological
conditions. Normal movements of this joint are slight, consisting of a
slight up-and-down gliding movement. Sometimes the fibula is forced
upward and outward, this not only producing interference with the move-
ment, but affecting the external popliteal nerve, which is in relation. In
addition to the tenderness at the joint, there is usually irregularity, and
if both are found the diagnosis is fairly conclusive. The principal ef-
fects of this lesion are pain along the course of the musculo-cutaneous
and anterior tibial nerves, and a burning sensation at the bottom of the
foot.

THE AXKLE-JOIXT.

The ankle-joint is formed by the lower ends of the tibia and fibula
and the astragulus. The movements of this joint are extension and flex-
ion, which combined reach about seventy degrees. The ligaments of the
joint and the tendo Achillis, restrict these movements. The ligaments
in the front of the joint are weakest of all and on this account, swelling
from injury of the joint occurs first at this point.

The most common lesion of the joint is a sprain which consists of a
rupture to a greater or lesser extent, of these ligaments. In all sprains
there is a partial dislocation of the bones forming the joint. On this
account manipulation, by which this partial dislocation is reduced, is to
be advised immediately after the accident. As a result of this injury
there is pain, swelling and inflammation of the parts, particularly the

484

APPLIED ANATOMY.

synovial membrane and ligaments. The effects of this lesion are re-
striction of movement, swelling and pain. The disturbance of movement
is the result of the effect on the ligament and of the change in position of

NAVICULO-CUNE.IFORM

LONG PLANTAR 'SHORT PLANTAR

Fig 147. — The ligaments of the ankle and a part of the foot. The internal lat-
eral are Involved in sprains of the ankle-joint.

the bones forming the joint. The pain is due to the rupture of, or pres-
sure on, the nerves in relation.

In Pott's fracture, dislocation quite frequently occurs at this joint,
or at least there is a partial dislocation and a sprain which tend to con-

APPLIED ANATOMY.

485

Fig. 148. — The joints of the right foot.

486 APPLIED ANATOMY.

fuse the diagnosis. In elderly people, a fracture should be suspected
in cases of injury to this joint and the examination made accordingly.
Sometimes the astragulus is displaced on its articulations above and
below.

The other bones of the ankle and foot are occasionally displaced.
The first metatarsal bone and the first phalanx are quite frequently
displaced in cases of bunions. In displacements of these small bones
of the foot, there will be pain and disturbance of movement. In one
case seen by the writer, there was a displacement of one of the cuneiform
bones that gave rise to symptoms which simulated hip-joint disease,
at least it was so diagnosed by some physicians. There was a limp and
pain at the bottom of the foot. In most cases, pain in this area is due
to a lesion higher up, but occasionally it is the result of a local lesion.
In many cases of pain in the bottom of the foot, it is due to the displace-
ment of a sesamoid bone. These bones are formed in the flexor tendons
and reach a remarkable size in some instances. In forcible contraction
of the muscles of the foot these bones may be forced out of their grooves
or articular facets and thus give rise to considerable pain on movement
of the foot. Such disorders can usually be diagnosed by palpating the
irregularity and noting the location of the pain.

THE LOWER EXTREMITY AS A REGION.

The skin of this region is thickened at points of pressure as in front
of the knee and the gluteal region. On the inner sides of the knee and
leg it is quite thin and very freely movable. The mobility of the skin
over these parts tends to protect the joint in cuts and contusions in that
the force is directed away from the underlying parts.

The femoral artery and vein correspond to a line drawn from a point
about midway between the anterior superior spine and the symphysis,
to the internal condyle. The popliteal artery lies in the popliteal space
and is subject to pressure at this point in sitting with the legs hanging.
The posterior tibial artery corresponds to a line drawn from the center
of the lower part of the popliteal space to a point just behind the internal
malleolus. The perineal artery lies behind the fibula and is possibly
affected by subluxations and fractures of this bone.

The long saphenous vein corresponds to a line drawn from the internal
malleolus along the inner aspect of the leg and thigh to Scarpa's triangle.
The short saphenous vein corresponds to a line drawn from the outer

APPLIED ANATOMY. 487

side of the tendon of Achilles, to a point immediately behind the knee.

The great sciatic nerve corresponds to a line drawn from a point
midway between the tuberosity of the ischium and the great trochanter,
along the back part of the thigh to the center of the popliteal space, at
which place it usually divides. The peroneal nerve extends from this
point down the leg in company with the peroneal artery. The anterior
tibial corresponds to a line drawn from near the head of the fibula diag-
onally across to a point about an inch anterior to the external malleolus.

The bony prominences which serve as landmarks for the lower ex-
tremity also have to do with the contour of the part. The great tro-
chanter forms a prominence on the side of the upper part of the thigh
and is of importance in locating the head of the femur. The patella is
the principal eminence of the knee. The "shin bone," or the anterior
edge of the tibia, determines the contour of this part of the leg and is
subject to injuries and fractures. A blow at this place is particularly
painful on account of its nearness to the integument, hence has no soft
parts to protect it. The malleoli are the great landmarks of the ankle, and
from them measurements are taken for determining certain forms of
injuries of the lower extremity, such as fractures and dislocations.

The glutei muscles determine the contour of the hip. The vasti
and recti determine the contour of the anterior part of the thigh. The
course of the sartorius muscle is brought into prominence whenever
the thigh is flexed and adducted. The hamstring tendons have to do
with the contour of the back part of the knee, while on the inner side,
those of the sartorius and vasti and pectineus can be palpated. The
calf muscles, that is the soleus and gastrocnemius, determine the contour
of the back of the leg.

The changes of contour of the lower extremity should be carefully
noted in making up a physical diagnosis, since nearly if not all disorders
of the lower extremities are characterized by some change of contour.
Of the hip and thigh, a dislocation of the femur is the most common cause
of change of contour. The change is brought about from displacement
of the trochanter, contracture of some muscles and atrophy of others. In
all cases in which the contour is abnormal, the diseased side should be
compared by inspection, with the sound side. Hip-joint disease will
also change the contour of the hip, principally on account of atrophy of
the glutei muscles. The trochanter in these cases may be also displaced
or the neck destroyed, this altering the contour. Fracture of the

4SS APPLIED ANATOMY.

femur will change the contour of that part on account of change in the
bone and the effect on muscles attached. Fracture of the neck of the
femur often results in an upward displacement of the trochanter which
may be mistaken for a dislocation of the hip. In all such cases in
the aged, an intracapsular fracture of the hip should be suspected.
Change of form of this part results from atrophy or hypertrophy of the
muscles or from edema of the thigh. In athletes, often the rectus muscle
is ruptured, this causing some change in contour. In the various spinal
cord diseases in which the lower limbs are involved, there is a change of
contour from atrophy or occasionally from hypertrophy of the muscles
of the thigh. Change of contour of the knee and leg is more common
than in the thigh.

It is important to understand the surface anatomy of the knee, since
there are so many changes of contour of the part. McClellan says:
"A knowledge of the construction of the joint may serve to interpret
many symptoms and to explain the production of various movements,
but what has been aptly called the language of form appeals to the
judgment and, if properly applied, often determines the diagnosis and
the result of treatment. " Synovitis of the knee invariably produces
enlargement which is most marked on the anterior and inner aspect.
There may be an effusion into the different bursse around the joint, this
producing a unilateral enlargement. Most of these enlargements due
to effusion are the result of disorder of the hip-joint, but in some instances
they are due to direct injury of the knee. Tuberculosis of the knee-joint
produces an enlargement, hence change in contour. The upper end of
the tibia is most frequently involved and often the bone becomes honey-
combed and doubled in size. In cases of emaciation, the knee-joints are
often apparently enlarged on account of atrophy and shrinkage of the
muscles above and below it. Paralysis of the leg leads to atrophy, hence
change in form. In neuritis and progressive muscular atrophy, the calf
muscles are more or less atrophied. In diseases of the hip, such as
fractures, dislocations or hip-joint disease, the muscles of the leg are
atrophied, partly from non-use and partly, from an interference with
nutrition. Fractures of the tibia or fibula change the contour of the
leg, Pott's fracture being the most typical. Edema of the leg is sug-
gestive of heart or kidney disease if symmetrical, but if of only one leg, is
suggestive of a spinal or innominate lesion, which interferes with the
lymphatic circulation from the limb. Usually the edema is worse to-

■ lllh.THORACIC

,12th

-->\

MUSCULO ■

CUTANEOUS

4S5 L.

0 HYPOGASTRIC

IsLLUMBAR

GENITO CRURAL

UIO INGUINAL

I ij SACRAL

SM.SCIATIG2.3.&

EXTCUTANEOUS
2S.iL.

2.5S4 L
OBTURATOR

-INTCUTANEOUS
245 L

-MID CUTANEOUS

StS L.

-PATELLA PLEX.

-PATELLA BRA. Of
USAPHENOUS

-INT.ORLONG
SAPHENOUS
3&4L

SURAL BRA.OF
L. SAPHENOUS

LAT.CUTANEOUS

OR PERONEAL

51. SI. 2. S.

, EXT. SAPHENOUS
I 12. S.

EXT. PLANTAR
U2S

INT.CALCANEAN
IS2 b

-ANT.TIBIAL
4S5L

>INT.PLANTAR4 5LX15>

Fig. 149. The segmental sensory innervation of the lower extremity.

490 APPLIED ANATOMY.

ward evening and especially so, if the patient is on the feet very much.
In chronic cases the swelling pits on pressure and if there is an injury to
the part, it heals slowly. Edema may be the result of milk-leg which in
turn is, I believe, a sequel to innominate lesions which occur during
child-birth, although it is popularly believed to be due to infection.
The edema may also be a sequel to typhoid fever especially if on the
right side. If the entire lower extremity and the external genitalia are
involved it is called elephantiasis. In most of these disorders of the leg
characterized by edema, the trouble is either in the hip-joint or else
there is a subluxation of the innominate. Ordinarily if there is no dis-
coloration the trouble is due to lymphatic obstruction, but if the veins
are involved, there is in all probability some discoloration.

Rheumatoid arthritis often produces a change in contour of the
knees and feet on account of the deposit around the joints. There are
certain nervous disorders called arthropathies, which produce enlarge-
ment of the joints, particularly those of the lower limb.

A sprain of the ankle may result in a deformity which may last for
months on account of the edema and swelling of the injured ligaments.
In those chronic cases a dislocation or fracture should be thought of.
If it occurs in an aged person or one who is mal-nourished, it is possibly
a fracture, but in the young a dislocation is more common than a fracture.

The arch of the foot may be broken down, this producing a condi-
tion called "flat foot." This weakens the ankle and leads to a peculiar
gait. The various forms of talipes, result from contracture of tendons,
alteration in the shape of the bones, partial displacements and from
shortening of ligaments and fascia attached to the foot. If the patient
walks on the toes, which condition is called talipes equinus, it is gener-
ally the result of infantile paralysis, the deformity being the result of a
contraction of the tendo Achillis. Talipes varus is the most common of
the congenital forms on account of the attitude of the fetus in utero.
In the acquired form the os calcis is drawn up by the tendon of Achilles
thus partially displacing the astragulus. Talipes valgus, or flat foot is
the result of breaking down of the arch and occurs in those who are un-
derfed and in people who have to stand on their feet a great deal. It
occurs in some cas.es of improperly cared .for Pott's fracture. In these
various deformities of the foot, the tendinous contractures are prominent
and sometimes they reach such a degree that tenotomy has to be per-
formed before the deformity can be overcome.

APPLIED ANATOMY. 491

The various movements of the limbs, that is the gait of a patient, are
very suggestive of the disease with which the patient is afflicted.
Although the gait varies in normal individuals, yet ordinarily the ap-
pearance of the legs and feet and the peculiarity of the gait, reveal the
fact that there is something wrong with the movements of the limb . If t he
patient has a "heel and toe" walk and has to look where he steps, and
if the arch of the foot is flattened, it is quite suggestive of locomotor
ataxia. This disturbance of movement is due to an impairment of the
muscular sense more than to a weakness of the muscles. There is also
some weakening of the ankle and the patient is unable to stand on his
heels although the muscles of the lower extremities seem to be in a thor-
oughly good condition. In multiple neuritis, there is a peculiar gait
called the "steppage" gait. (The foot is drawn forward and the toe is
raised so that the heel first strikes the ground in much the manner adopt-
ed when one attempts to step over an obstacle). In spastic paraplegia,
the toes seem glued to the floor and the patient has to lean forward in
order to be able to advance the limbs. This gait is explained by the
fact that the flexors of the thigh are weakened, while the flexors of the
leg are shortened. The toes are inverted, the knees adducted and the
patient has what is commonly called a "cross legged progression."

In atonic paraplegia, both feet are dragged, the toes trailing on the
ground. The patient necessarily has to walk with crutches and the
limbs are dragged along. In infantile paralysis in which one limb is
involved, the foot is usually everted and the patient drags it in such a
fashion that the inner side scrapes the floor. Hemiplegia is character-
ized by a dragging of the foot on the paralyzed side in such a way that
the end of the toe and inner side of the sole is worn. This coupled with
paralysis of the upper extremity on the same side makes the diagnosis clear.
This peculiarity of gait is the result of weakness, that is, inability to ad-
vance the limb, hence it is dragged. In children a "waddling gait" is
suggestive of a double displacement of the hip. It is present in congen-
ital dislocation of one hip but less marked. In iliac displacements of
the hip, the toe is turned in and the limb shortened, the body is inclined
toward the affected side. In a thyroid displacement of the hip, the toe is
turned outward and the limb is lengthened and the patient's body is
inclined to the opposite side in order to tilt the pelvis so that the limb
may be shortened. A propulsive gait is indicative of paralysis agitans.
A drunken gait occurs in patients suffering with cerebellar ataxia and in

492 APPLIED ANATOMY.

certain forms of chorea. In cerebellar ataxia there is the intentional
tremor. The patient may, in reaching for an article, stab all around it
and finally gets his hands on it in a manner similar to that of a drunken
person. A stiff gait is often found in disseminated sclerosis, this closely
resembling the gait of spastic paraplegia. In Friedreich's ataxia the
gait is uncertain and if the patient is told to stand with his feet together
there will be swaying of the body. This is due to inco-ordination and
loss of muscular sense.

The various limps are due to painful conditions of the hip, knee or
foot , or possibly of the spine. By examination, the cause is usually very
easily ascertained, and by knowing the different forms of disorder of the
gait and movements of the limbs, the cause can more easily be located.

Pain in the hip-joint is suggestive of displacement, caries, sciatica,
or lesions of the various bones with which the sensory nerves to this
part are in relation. Pain in the knee-joint comes most frequently from
partial displacement of the hip, or other disorder of this joint. It may be
due to a synovitis of the knee, a loose cartilage, or a displacement of the
bones forming the joint. Ache or pain along the femur, comes most
frequently from an inflammation or congestion of the sciatic nerve.
This, in turn, comes from pelvic disorders, spinal cord diseases or a lesion
of the spine or innominate bones. Pain in the leg is the result of pressure
on the nerve supply at some point or it may be referred from visceral
disease such as inflammation of the pelvic organs. Pain in the foot may
be the result of the displacing of any of the joints with which the sciatic
nerve or its branches are in relation, or it also may be the result of a vis-
ceral disorder from which the pain is referred.

In most painful disturbances of the leg not due to inflammation or
trauma, there is some lesion of the joints in relation with the sciatic
nerve which has most to do with supplying sensation to the lower limbs.
It is a good plan to examine first the joints in relation with the pain and
then successively all the joints between the point of pain and the spinal
cord. Perversion of sensation, such as numbness or tingling of the
nerves of the lower extremity, is most frequently due to pressure on the
trunk of the nerve. This is illustrated by the fact that by sitting
on a high chair and suspending the legs, they will go to sleep. Numb-
ness may also be due to cerebral disorders. In all these affections the
spinal column should be examined, since a lesion of any of the lumbar
vertebras will in all likelihood, intercept the passing of sensory impulses

APPLIED ANATOMY. 493

from the lower extremity to the spinal cord, thus the perversion of sen-
sation.

The most common vascular disorder of the lower limb is a varicos-
ity of some of the superficial veins. The vein most frequently affected
is the long saphenous and especially that part, in relation with the ankle.
The superficial veins are affected because their walls are not reinforced
by muscular contraction, and the part farthest away from the heart and
subject to greatest pressure would be affected most, hence the varicosi-
ties are found on the inner side of the ankle. The vaso-motor centers
for the lower limbs are located in the lumbar spinal cord. The impulses
from these centers pass out over the nervi efferentes into the aortic
plexus, thence along the plexuses around the arteries which go to the
lower limbs. This line of communication between the spinal cord and
the gangliatecl cord and the various vessels of the lower extremities, must
be kept open or else there will be some effect in the parts supplied. A
lesion of the lumbar vertebral articulations, will in some way interfere
with this communication, because the displaced bone produces pressure
on the nerves over which these impulses pass. On this account in all
vascular disorders of the lower extremity such as congestion, inflamma-
tion, varicosity or coldness, the spinal column should be examined. In
other cases, a dislocated hip or diseased condition of the pelvic viscera
will produce vascular disorders of the lower limb. All the blood from
the limb passes up through the pelvis and any pelvic enlargement would
tend to interfere with the drainage of the limb. In fibroid tumors,
congestive hypertrophy of the uterus and in pregnancy, the lower limb
is affected as to its circulation. The trophic impulses seem to go hand
in hand with the vaso-motor. In non-development of the acetabulum,
lack of development of the femur, or other bones of the lower extremity,
in atrophic conditions of the limb or even in caries, the spinal column
should be examined since lesions of the lumbar portion, interfere with the
passing of vaso-motor and trophic impulses from the spinal cord to the
parts below.

In tuberculosis of the hip and knee, the principal treatment is
directed to improve the nutrition of the part. This is accomplished by
spinal treatment, in addition to the constitutional. Therefore in trophic
and vascular disorders of the lower extremity, examine especially the
lumbar vertebra, innominate bones and the hip-joint. The secretory
disorders of the lower extremity consist of excessive or lessened perspira-

494 APPLIED ANATOMY.

tion. Sweating of the feet is the most common. In some cases this
perspiration is markedly acid and the writer has known of cases in which
the patient would rot out a pair of shoes in a month or so as the result
of this disturbance of the secretion of sweat. This may be the result
of a constitutional disorder, yet in some cases, at least, it is due to af-
fections of the sweat centers on account of lesions in the lower thoracic
and lumbar area. Dryness of the lower extremities is more suggestive
of kidney disorder than of anything else. However, if it is a local one,
the cause is along the course of the nerves that have to do with connecting
the sweat centers with the periphery.

THE CRANIAL NERVES.
THE OLFACTORY.

The olfactory nerves consist of roots, tract, bulb and about twenty
fine non-medullated nerve fibers that are distributed to the mucous
membrane of the nasal cavity. This nerve is the special nerve of smell
and is stimulated by volatile, odorous substances. It acts as a sentinel
to warn the body against bad air and the ingestion of improper foods.
The stimulation of this nerve seems to reflexly affect the secretion of
saliva. On this account food that has a pleasant odor is more palatable
and more easily digested than that which has an unpleasant odor.

This nerve is seldom affected directly, but may be disturbed through
fracture of the cribiform plate or tumors of the brain. In most cases of
disorders of the sense of smell, anosmia being the most important, the
fifth cranial nerve is involved and consequently there is a lessened or
hyper-secretion of mucous from the membrane lining the cavity. Le-
sions of the cervical articulations, especially those of the axis and the
third, and of the upper thoracic vertebrse, disturb the functions of this
nerve by affecting the fifth cranial and the vaso-motor nerves supply-
ing the nasal mucous membrane. The explanation is that the lesion
affects the vaso-motor nerves at their origin or along their pathway and
thus interferes with the circulation through the mucous membrane lining
the nasal cavity, that is, it produces a catarrhal condition of the nose.
In other cases the turbinated bones become diseased or polypi form in
the nose. These disorders affect the sense of smell by interfering with
the normal secretions rather than by directly affecting the olfactory
nerve, In hysterical individuals there may be hyperosmi-a, while in
epileptics, aura often start in the nose.

APPLIED ANATOMY. 495

THE OPTIC NERVE.

The optic nerve rises from the quadrigeminal body and the optic
thalamus and is connected with the occipital lobe. The two tracts con-
verge to form the optic chiasma or commissure, from which the optic
nerves are formed. The nerve is directed forward and outward, pierces
the dura mater and escapes from the cranial cavity through the optic
foramen and it spreads out to form the principal part of the retina. It
is in relation with the ophthalmic artery and is pierced by the central
artery of the retina.

The function of the nerve is that of vision. This function may be
disturbed by disorders of the blood, pressure from hemorrhage or intra-
cranial tumors, fractures of the skull and in certain spinal cord diseases
and spinal lesions. The most common lesions affecting the optic nerve
are in the upper cervical and upper dorsal regions. These lesions dis-
turb the circulation and nutrition of the nerve since the vaso-motor
centers for the ophthalmic arter}' are as low as the third thoracic seg-
ment of the spinal cord. The impulses pass out over the anterior nerve
roots into the gangliated cord, thence upward and into the superior cerv-
ical ganglion. Then they are conveyed by the cavernous plexus directly
to the optic nerve with the central artery of the retina. It is a clinic
fact that spinal injuries produce atrophy of the optic nerve. Writers
on the subject do not agree as to the explanation of this effect, some lean-
ing to the view that they are the result of a trophic disturbance, while
others assume that they result from an ascending meningitis, while others
contend that these injuries produce a fracture of the base of the brain.
From an osteopathic viewpoint, the effect, that is, that of optic atrophy,
is explained on the theory of vaso-motor disturbance which is the re-
sult of spinal injury, in cases in which the injury is above the fourth
thoracic vertebra. Gifford, in the American Text-Book of Diseases of
the Eye, states "that the numberless cases of optic nerve atrophy in
various forms of spinal disease also led to the belief at one time preva-
lent, of a trophic connection between the spinal column and the optic
nerve; and because the disc in many of these cases (though by no means
in all) was of a grayish hue, it was common to speak of gray or spinal
atrophy. The spinal affection in which atrophy is most commonly
observed is tabes. " The explanation of this connection as given is
that the vaso-motor and possibly the trophic impulses to the optic nerve,

496 APPLIED ANATOMY.

arise as low in the spinal cord as the third thoracic segment. Spinal
cord diseases or lesions of the vertebral articulations at or above this
point will affect the function of the optic nerve.

In kidney disorders particularly the interstitial form of nephritis,
the optic nerve is usually affected, thus producing some form of blind-
ness. In artero-sclerosis, the central artery of the retina or the opthal-
mic artery, may be involved and consequently disturbance of function
of the optic nerve occurs. In the condition known as "choked disc,"
there is usually present a brain tumor producing pressure on the chiasma.
The nature of this condition is not well understood, but according to
some it is clue to the cerebro-spinal fluid, under increased pressure,
forcing its way into the optic sheath and so compressing the veins as to
produce a true congestion or edema, which may be accompanied by in-
flammation.

Most of'the causes of disorders of the optic nerve are extra-cranial
and are especially found in the upper part of the neck and back. They
produee disturbances of the nerve principally through vaso-motor af-
fects on the brain, such as congestion, tumefactions and malnutrition of
the centers of vision or the optic tract.

The blood supply for the center of vision, that is, the central lobe,
comes principally from the vertebral artery. Possibly the best explana-
tion of the connection existing between the lesion and the optic nerve
is through the disturbance of the vertebral artery and plexus.

THE THIRD.

The third cranial nerve has its origin in the gray matter underneath
the fissure of Sylvius. Brubaker says that this nerve "consists of about
fifteen thousand peripherally coursing nerve fibers which serve to bring
the nerve cells from which they arise into relation with a large portion
of the general musculature of the eye." It passes through the caver-
nous sinus and enters the orbit through the sphenoidal fissure. As it
enters the orbit it divides into two branches, the superior and inferior,
the superior supplying the superior rectus and the levator palpebrse
superioris muscles, while the inferior supplies the internal and inferior
recti and ends in the inferior oblique muscle. This nerve communi-
cates with the cavernous plexus, the ophthalmic division of the fifth
and sends a branch to the ciliary ganglion which is called its motor or
short root.

APPLIED ANATOMY. 497

The function of this nerve is to transmit nerve impulses to all the
muscles of the eye except the external rectus and the superior oblique.
As the result of a lesion paralyzing or inhibiting the action of this nerve,
there will be ptosis, strabismus, double vision, some dilatation of the
pupil, loss of power of accommodation and sometimes vertigo and
photophobia. These effects may be produced by intra-cranial disorders,
such as cerebral tumors or hemorrhage, or by extra-cranial affections,
such as lesions in the upper cervical region. It is a well known fact
that lesions of the upper cervical vertebra; will produce disturbance of
the third nerve. The writer has seen and treated cases of this sort in
which there was no doubt but that the lesion produced the effect, ptosis
being the most common and pronounced. It is difficult to explain why
such a lesion will affect the third cranial nerve, unless we do it through
the vaso-motor connections. So far as we can ascertain from the liter-
ature, writers in general, claim that no motor impulses from the spinal
cord pass upward into this nerve, but one author states that some pass
from the medulla upward into it and are distributed to parts supplied
by the nerve.

Vaso-motor impulses for the vessels which supply the part of the
brain from which this nerve arises, apparently come from the upper
thoracic area and pass by way of the gangliated cord and its branches
around the carotid artery through to the blood-vessels of this part of the
brain. This is disputed by some, but it appears to be the most reason-
able explanation of the relation between the cause and effect. The
lesion interferes with the nutrition of the cells, or perhaps the nerve
itself, since nutrition is governed to a great extent, by the vaso-motor
nerves.

The lesions that are most commonly found in affections of the third
cranial nerve are: subluxations of the second and third cervical ver-
tebra. These act as predisposing causes, while the exciting causes that
are usually given, act the more readily. If the effect on the nerve ap-
pears to be the result of intra-cranial disorder, such as a hemorrhage,
the cause of this is extra-cranial, that is, in the neck. The condition of
the cranial viscera is controlled by the spinal cord and therefore the
communication between the two parts should be free.

498 APPLIED ANATOMY.

THE FOURTH.

The trochlear or pathetic us nerve arises below the grey matter sur-
rounding the aqueduct of Sylvius. It has a long course before it makes
its exit from the cranial cavity and is distributed to the superior oblique
muscle. It receives a branch from the cavernous plexus and from the
ophthalmic division of the fifth nerve. The sympathetic carries to it
vaso-motor fibers, while the fifth cranial, gives to it the muscle sense
fibers. It is motor and trophic in function. In cases in which this
nerve is involved often the patient holds one side of the head slightly
elevated. Lesions of the neck may affect this nerve through the vaso-
motor connections. The disturbances of it are rare.

THE FIFTH.

The fifth cranial nerve is similar to a spinal nerve in that it arises
from two roots, a motor and a sensory, and has a ganglion. The motor
root is derived from the floor of the fourth ventricle. The large sensory
posterior root, according to Landois, receives fibers " (1) from the gray
matter of the sensory nucleus of the trigeminus, situated to the side of
the motor nucleus, and the analogue of the posterior horn. (2) From
the gray matter of the posterior horn of the spinal cord down to the
second cervical vertebra. (3) From the cerebellum, fibers passing through
the crus." The origin of the sensory root, is connected with the motor
nuclei of all of the nerves arising in the medulla oblongata, with the ex-
ception of the abducent. This fact explains the various reflex effects.

The trigeminus divides into three principal divisions, the ophthalmic,
superior and inferior maxillary. These nerves through their ganglia,
connect with most of the other cranial nerves. The ophthalmic divi-
sion communicates with the third, fourth and sixth cranial nerves in the
cavernous sinus. Through the spheno-palatine and otic ganglia, the
fifth nerve communicates with the seventh cranial nerve, and with the
ninth nerve through the otic ganglion. It also has a very free connec-
tion with the cavernous and carotid plexuses and receives from them
most of its vaso-motor impulses. This nerve is principally sensory in
function although it transmits motor, vaso-motor, secretory and trophic
impulses. On account of the wide area of distribution and the import-
ance of the parts supplied, as well as the character of the impulses, this
nerve is very important and is connected with nearly all diseases of the
head and face.

APPLIED ANATOMY. 499

This nerve, like the other cranial nerves, is subject to disturbance
from intra-cranial growths, congestion of the head, while it is particularly
liable to disturbance from caries of the teeth and various disorders of
the nasal cavity, mouth, ear and throat. In addition to these, this
nerve is affected by lesions in the cervical and upper dorsal regions and
subluxations of the lower jaw. A lesion of a cervical vertebral articu-
lation will affect this nerve in one of two ways. First, this lesion will
intercept the passage of impulses from the spinal cord to the nerve and
second, it will interfere with the nutrition of the descending root of the
nerve by pressure on the veins and arteries that drain and supply the
segments of the cord in which this root is found. Lesions of the upper
thoracic area will affect the fifth cranial nerve by intercepting the
passing of vaso-motor and other impulses from the upper thoracic spinal
segments into the gangliated cord, or it will interfere with the nutrition
of the nerve cells that give rise to the vaso-motor impulses that pass
to the head and face and are distributed by means of the fifth
nerve. These lesions also interfere with the circulation, that is, nutri-
tion of the fifth nerve and its cells, since they disturb the circulation to
the brain. A lesion of the lower jaw will affect the nerve by direct
pressure or injury, since it sends a filament to the temporo-maxillary
articulation. One or all of the functions of the fifth nerve may be af-
fected by these lesions and in our clinic work, it is very common to find
the cervical lesion responsible for most of these disturbances.

The fifth cranial nerve is motor to the azygos uvula muscle through
the posterior palatine nerve, to the tensor palati and tympanum muscles,
the digastric, mylo-hyoid and the muscles of mastication, which consist
of the temporal, the two pterygoid and the masseter.

The motor impulses for the dilators of the pupil come immediately
from the ophthalmic division of the fifth and indirectly from the cervical
sympathetic. Although it has not been definitely demonstrated that
motor impulses pass from the spinal cord to the head and face, yet it is
to be presumed that they do, this presumption being based on clinic
results. Cervical and upper thoracic lesions, affect the muscles of the
eye, this having been demonstrated in many cases treated by the writer.
Assuming that no motor impulses pass from the spinal cord to these
muscles, the effects can be explained through the vaso-motor and trophic
connections that undoubtedly exist between the spinal cord and parts
supplied with motor impulses by way of the fifth cranial. These im-

500 APPLIED ANATOMY.

pulses arise in the upper part of the thoracic spinal cord and pass by way
of the gangliated cord and its ascending branches to the ophthalmic
division of the fifth. Lesions along the course of these fibers inter-
cept or otherwise interfere with this connection and consequently there
is an effect in the parts supplied.

Landois says: "Anastomotic fibers pass from the second cervical
nerve downward through the lateral columns of the spinal cord to the
cilio-spinal region and thence through the three or four uppermost

thoracic nerves into the cervical sympathetic In the dog and

in the cat, at least, these fibers do not pass through the ciliary ganglion,
but directly along the optic nerve to the eye, all passing through the
Gasserian ganglion, the first division and finally through the long ciliary
nerves. "

The fifth cranial nerve is sensory to nearly all the dura mater, the
eye-ball and its appendages, the mucous membrane lining the cavities
of the head and face, the integument of the face and side of the head,
the teeth, tonsils, two-thirds of the tongue, mastoid cells, the various
glands and articulations of the lower jaw. Pain in any of these parts is
due to an irritation of this nerve either at its periphery, along its course
or in the cranium. Since neither the nerve cells nor the course of the
nerve is in relation with the spinal cord, it is somewhat difficult to ex-
plain why lesions of the cervical vertebrae affect the sensory function of
this nerve. That such lesions do affect the functions of this nerve is a
well demonstrated clinic fact. There are two ways of explaining the
effects of a cervical lesion on this nerve. First, the long or sensory root
comes from as low in the spinal cord as the second or even the third
cervical segments, while second, the nerve, and the parts to which it is
distributed, receive their trophic and vaso-motor impulses from the spinal
cord and these are affected by -the lesion, since they come from the spinal
cord. Pain is defined by Baruch as "the prayer of the nerve for pure
blood. " There may be anemia of the nerve or other vascular disturb-
ances, in which there is either abnormal pressure on, as in contracture of
muscles or stimulation of the nerve filament, from the toxic products
of the stagnated blood, which things affect the nutrition of the nerve.
These, according to the above definition of pain, produce pain.

The fifth cranial nerve supplies about three-fourths of the dura
mater with sensory impulses, the vagus being the other important nerve
to this part. In most cases of headaches the dura mater is affected

APPLIED ANATOMY. 501

through the disturbance of the fifth nerve. A lesion in the neck will
produce headache by causing a congestion of the brain and this in turn
produces pressure on the meninges, probably the most sensitive struc-
ture in the cranial cavity, hence the ache is actually due to pressure on
the branches of the fifth cranial nerve from increased amount of blood
in the unyielding cranial cavity. The throbbing type of headache is
the result of this pressure being increased with each pulsation of the
heart, hence the pain is synchronous with the heart beat. Stooping,
increases the blood pressure in the cranial cavity and thus increases the
intensity of the ache. Exercise of any sort which causes an increased
rate in the heart beat, will cause the pain to become more severe and the
throbbing is harder and more frequent. In such a case, exercise increases
the heart rate and as a result, the blood pressure in the brain is propor-
tionately increased and since there is a pathological congestion already
existing, the increased pressure produces pain in the meninges. In the
other types of headache, the fifth cranial nerve is irritated by the toxic
material in the blood. This may come from retention of the menses,
liver or gastric disorders, kidney disease, cystic degeneration of the ovary
and from cervical lesions that impair the quality of the blood circulating
through the brain by lessening the rate of flow. So soon as the current
slows, the blood deteriorates in quality, and in passive congestion, toxic
products are formed which, in turn, stimulate the sensory nerves. The
most common lesions that affect the sensory innervation of the dura
mater and thus have to do with the production of headache, are at the
second and third cervical, fourth, fifth, seventh, eighth and ninth dorsal
and the fourth and fifth lumbar, that is, the headache may be due to
disturbances of the vaso-motor supply to the brain, affection of the heart,
disturbances of the quality of the blood through diseases of the liver and
kidneys and reflexly, through diseases of the uterus.

Pain in the eye-ball is the result of some disorder of the fifth cranial
nerve which supplies it. This is explained through the vaso-motor and
trophic nerves, which receive their impulses from points below, and on
account of which a cervical lesion will affect the eye. The aching of
the eye-ball is most frequently the result of a congestion of it either from
overuse, catching of cold, or neck lesions affecting the vaso-motor sup-
ply to it.

Pain in the various cavities lined with mucous membrane, is usually
the result of congestion of these mucous membranes, the pain being the

502 APPLIED ANATOMY.

result of pressure on the nerve as a mechanical stimulation, or chemical
stimulation, as in the case of toxic matter in the blood.

Pain in the different parts of the face at which points the fifth cranial
nerve becomes superficial, is ordinarily the result of congestion of the
nerve itself, as is demonstrated by the pain on pressure over the supra-
orbital nerve when the patient has a cold in the head. Toothache is most
commonly the result of irritation of the fifth nerve from decay of the
tooth. A lesion of the lower jaw may cause the pain to be referred to a
tooth that is apparently sound, while a neck lesion may interfere with
the nutrition of the nerve, on which account pain will be referred to its
area of distribution, that is, the teeth.

The soft palate, the uvula, tonsil, salivary glands and two-thirds of
the tongue receive their sensory innervation by way of the fifth cranial,
hence, in pain in these areas the fifth nerve is at fault. The trouble
m y be a peripheral one, or it may be a referred pain, since it is a well
known fact that an irritation of one part of the fifth nerve often produces
a pain in another part, which is ordinarily called a sympathetic pain.
A good illustration of this is that a decayed tooth will produce earache.

Facial neuralgia, one of the most painful affections, is the result of
congestion or inflammation of the fifth cranial nerve. This comes most
frequently from a neck lesion, which disturbs the vaso-motor supply of
the blood-vessels of this nerve. Some palliative effect can be obtained
by the application of heat to the affected part or from pressure along the
course of the nerve.

The fifth cranial nerve is more closely connected with the sympa-
thetic nervous system than any other cranial nerve, perhaps on account
of the numerous ganglia in relation with it. On this account, many
visceral disorders cause pain to be referred to the area supplied by the
fifth nerve, and particularly the coverings of the brain and the eye.
Often in uterine displacements or inflammation, pain is referred to one
eye or to other parts supplied by the fifth nerve. In nearly all those
cases in which the pain is a referred one, there are local lesions that dis-
turb the nutrition and circulation of the nerve and are in the main, re-
sponsible for the referred pain. Thus in the various types of reflex
headaches, there are ordinarily, lesions of the upper cervical vertebral
articulations.

The fifth cranial nerve receives its vaso-motor impulses from the
superior cervical ganglion, that is, they pass through this ganglion.

APPLIED ANATOMY. 503

They pass upward over the plexuses around the carotid arteries and
through the Gasserian ganglion, thence over the divisions of the nerve
and especially the ophthalmic or first division of the nerve. Although
parts of the head and face receive their vaso-motor impulses directly
from the superior cervical ganglion, yet most of them pass through the
fifth nerve.

Nearly, if not all, the vaso-motor impulses to the blood-vessels of
the eye and its appendages, pass through the ophthalmic division of the
fifth, the parts to be especially mentioned are the iris, choroid and the
retina. Since the vaso-motor impulses to the parts supplied by the
cranial nerve are derived from the spinal cord, especially the upper
thoracic segments, it is readily seen why lesions of the cervical and
upper thoracic vertebra?, would produce vascular disturbances of the
above areas.

The secretory impulses that pass through to the lachrymal, mucous,
salivary and sweat glands, come from the spinal cord by way of the cer-
vical sympathetic and the fifth cranial nerves. The lesions of the cer-
vical region will increase or decrease the secretion of the lachrymal
gland. This is explained through either the secretory or vaso-motor
nerves, since secretion seems to depend to a great extent, upon the
amount and quality of blood. The condition in which there is an ex-
cess of secretion, is called the "weeping eye'" and in cases seen by the
author, there were lesions in the neck that were responsible.

The mucous glands lining the nasal and oral cavities, the throat, and
those covering the tongue, receive their secretory impulses from the
spinal cord by way of the fifth nerve. As in secretion in other parts of
the body, the vaso-motor nerves are to be considered. The best example
of a neck lesion producing secretory disturbances of the mucous mem-
brane, is an ordinary cold. Invariably in these cases some sort of neck
lesion is present such as contracture of muscles, and congestion of the
deep tissues, due primarily, in the average case, to subluxations of one
or more of the cervical vertebra. Pressure over the articular processes
is productive of pain or at least soreness. Sitting with the back of the
neck in a draft will cause these muscular lesions to form and within a
few minutes the coryza will develop. The lesions affect in some way,
the passing of vaso-motor and secretory impulses to the mucous glands
located in the nose and thus the effect.

The salivary glands receive their impulses from the upper thoracic

504 APPLIED ANATOMY.

segments of the spinal cord, they passing by way of the cervical sympa-
thetic cord, superior cervical ganglion, cavernous plexus and the max-
illary divisions of the fifth nerve. A lesion of any vertebral articulation,
at the origin or along the course of these nerve fillers, will stimulate or
inhibit the passing of impulses over them, thus an increase or decrease
in the amount of saliva secreted. Most, if not all, the secretory nerves
of the sweat glands of the head and face come from the spinal cord by
way of the cervical sympathetic and the fifth cranial. There may be
excessive sweating of the head, dryness of the parts or localized disturb-
ances. The writer has treated cases of hemidrosis in which the cause
was located at the articulation between the second and third cervical
vertebrae. A cure was effected in these cases by the correction of the
lesion, which is at least indicative of the fact that secretory impulses pass
from some point below in relation with this articulation, and were af-
fected by the lesion.

An oily condition of the skin of the face is most frequently the re-
sult of impairment of the sweat, as well as the sebaceous glands. The
amount of sweat is lessened, hence the sebaceous secretion is not dis-
solved, diluted or washed away by the sweat, therefore remains in the
pores of the skin. In such cases the affected parts of the face never
sweat. The lesion is sometimes found in the neck and is the possible
cause of this disorder. There is an increased secretion of sebaceous
matter when the patient becomes heated from exertion and the face
becomes quite oily but no perspiration is visible. This condition is worst
in warm weather.

It is as yet a disputed point as to whether trophic impulses pass over
the trigeminus or whether certain effects in parts innervated by the fifth,
are not due to vaso-motor disturbances. If the nerve is divided, there
will be, within a few days, inflammation and finally necrosis of the eye-
ball, and trophic disorders of the other parts supplied by the fifth cranial
nerve. In such experiments the eye becomes anesthetic and thus is
unable to expel dust or any irritant that may get into the eye. The
organ is not conscious of an injury and makes no effort to remove the ir-
ritant. The reflex secretion of tears is wanting and thus the foreign body
remains in the eye and finally sets up an inflammation which is the re-
sult of loss of sensation, rather than an interference with the trophic
nerves. At any rate there are trophic disorders that are of importance
as a result of affections of the fifth cranial nerve. Among these disturb-

APPLIED ANATOMY. 505

ances are falling of the hair, grayness and splitting of the hair, eruption
on the face, dryness of the skin and keratitis and other disorders of the
eye characterized by malnutrition.

The fifth cranial nerve furnishes to the muscles of the face what is
called by Landois "muscle sense." In lesions impairing this nerve, the
delicacy of movement of the muscles of the face is impaired in conse-
quence of the absence of the muscle sense.

THE SIXTH.

The abducens nerve arises from a nucleus with large cells that cor-
responds to the anterior horns of the spinal cord. This nucleus is located
in the floor of the fourth ventricle in relation with the deep origin of the
oculo-motor. Landois says: "Probably some oculo-motor fibers arise
from the abducens nucleus and from the left, those fibers of the right
oculo-motor that rotate the right eye inward. (This explains the syner-
gistic action of the two eyes in lateral movement)." This nerve passes
out of the cranial cavity through the sphenoidal fissure and supplies the
external rectus muscle. While in the cavernous sinus it receives branches
from the cavernous plexus that convey to it vaso-motor impulses and
branches from the ophthalmic division of the fifth nerve. The sympa-
thetic communicating branches in all probability, carry motor impulses
to the nerve from the spinal cord. Landois says, that in the cat, the motor
fibers for the external rectus pass in part through the dorsal nerves,
from the first to the fifth. In man, according to Klumpke and Oppen-
heim, the communicating branch of the first dorsal nerve is the path for
the motor impulses to the unstriated muscles of the eye and the external
rectus muscle. A lesion at the origin of or along the course of these
nerve impulses to the external rectus muscle, will affect the activity of
this muscle, hence strabismus. If the lesion is irritative, there will be
external strabismus but if it is paralytic, internal strabismus will result.
Again, cervical and upper thoracic lesions, disturb the vaso-motor in-
nervation of this nerve which is followed by weakness and a resultant
squint. Clinically, these lesions seem to be responsible for the acquired
cases of strabismus, while in the congenital form there is some disturb-
ance of the muscle itself such as contracture or shortening. Perhaps the
best explanation of why spinal lesions produce disturbances of the ab-
ducens nerve is that it, according to Landois, receives motor impulses
by way of the cervical sympathetic, and the above mentioned lesions
affect the cervical sympathetic nerves.

506 APPLIED ANATOMY.

THE SEVENTH.

The facial nerve has its deep origin in the pons under the floor of
the fourth ventricle. It is described by Morris as a mixed nerve having
a sensory and motor root, the former consisting of the pars intermedia.
This intermediate part arises from the medulla in connection with the
nucleus of the glosso-pharyngeal, and sends most of its fibers to the facial
and the remainder to the auditory. In company with the auditory
nerve, the facial enters the internal auditory canal and the aqueduct of
Fallopius. It then makes a sharp bend at which is located the genicu-
late ganglion, which is supposed to be analogous to the ganglion on the
posterior nerve roots of the spinal nerves. While in the internal audi-
tory meatus, the seventh, gives filaments to the eighth nerve, the
auditory artery and perhaps the temporal bone. It gives off along
its course, the -great superficial petrosal, the chorda tympani, motor nerve
to the stapedius muscle, branch of communication to the small super-
ficial petrosal nerve, a filament to the vagus and the external superficial
petrosal, which connects the geniculate ganglion with the sympathetic
plexus surrounding the middle meningeal artery. After it escapes from
the skull through the mastoid foramen, it divides into the posterior
auricular, lingual, muscular to the posterior belly of the digastric and the
stylo-hyoid. In the substance of the parotid gland it divides into the
two terminal divisions, the temporo-facial and the cervico-facial, branches
from which form a plexus called the pes anserinus. This nerve com-
municates with the fifth, eighth, ninth, tenth cranial, great auricular
from the cervical plexus and with the sympathetic plexus around the
middle meningeal artery.

The principal function of this nerve is that of supplying motor im-
pulses to the muscles of the face. It also transmits vaso-motor, secre-
tory and gustatory impulses. Langley considers the seventh and ninth
nerves together and states that the two together probably supply with
autonomic fibers the whole of the mucous membrane of the nose and
mouth. *"The fibers run in the several branches of the fifth nerve sup-
plying the respective glands for stimulation of these branches causes
secretion and after section of any one branch, stimulation of the seventh
and ninth nerves has no longer an effect in the region to which the cut
branch runs." It has been shown that the seventh nerve sends vaso-

*Schafer's Phys. Vol. II. p. 660.

APPLIED ANATOMY. 507

motor impulses to the salivary glands, to the tongue, mucous membrane
of the floor of the mouth and to the soft part of the palate. These im-
pulses pass into the seventh nerve by way of the sympathetic plexus
around the middle meningeal artery, which in turn receives its vaso-
motor impulses by way of the superior cervical ganglion. This furnishes
an explanation of why a cervical lesion will affect the parts supplied by
the seventh nerve.

The chorda tympani nerve contains secretory and vaso-dilator fibers
for the sublingual and submaxillary glands and also gustatory fibers for
the margin and tip of the tongue. The gustatory fibers of this nerve
probably originate in the glosso-pharyngeal and enter the facial through
the pars intermedia. This nerve also contains fibers to the anterior
lateral portion and tip of the tongue. It is possible that the facial also
receives sensory impulses from the vagus. Muscle sense fibers are
furnished to the facial by the trigeminus.

The principal lesions affecting the seventh cranial nerve are growths,
fracture of the base of the brain, diseases of the ear, forceps pressure,
and bony and muscular lesions of the neck. The most important dis-
ease of this nerve is Bell's paralysis, which consists of a paralysis of the
lateral half of the face. This is usually a motor paralysis, although in
some cases there may be pain. The eye on the affected side cannot be
entirely closed, food gets in between the teeth and the cheek, patient
cannot pucker the lips as in whistling or expectorating, and the voice is
muffled. The wrinkles are smoothed out on the affected side, the mouth
is drawn toward the sound side and the tongue cannot be pro-
truded in the median line. The extent and degree of the paralysis is
best brought out in attempted movements of the muscles of the face as
in laughing or crying. In some cases there is tightening of the ear-
drum which produces some disorder of the sense of hearing, while in other
cases the chorda tympani branch of the facial is affected and is followed
by some loss of taste. In the author's practice, most of the cases of
Bell's paralysis resulted from cervical lesions such as contracture of
muscles and displacement of vertebrae. Exposure to a draft, the catch-
ing of cold and injury from any cause will bring on an attack in some
cases. Perhaps the best explanation of why a cervical lesion produces
a paralysis is, that the vaso-motor supply to the cells of origin of the
seventh nerve and the nerve itself and the parts supplied b)r the nerve, are
impaired by the lesion, since the impulses pass up by way of the gang-

508 APPLIED ANATOMY.

liated cord and on this account are subject to disorders. A contrac-
tured condition of the muscles of the neck in a similar way produces the
effect.

As stated above the vaso-motor nerves from the superior cervical
ganglion pass into the seventh nerve by way of the plexus around the
middle meningeal artery. It has not been demonstrated as yet that motor
impulses pass from the spinal cord up through this nerve, but judging
from the short interval of time existing between the production of the
neck lesion and the paralysis, one would infer that there is a direct motor
connection which is broken by the lesion.

There are other disorders of the seventh nerve such as blepharo-
spasm. It may be due to direct irritation of the facial nerve, or as Bru-
baker states, it may be caused by stimulation of the ' ' sensory nerve of
the eye principally in connection with scrofulous inflammation of the
eye, or in consequence of excessive irritability of the retina. " Often
one unconsciously blinks when brought into a strong light. In path-
ological conditions in which there is photophobia, there often results a
clonic spasm of the eye-lids. There may be other forms of spasm of the
muscle supplied by this nerve in which there is fibrillary twitching, ab-
normal winking or histrionic spasms. As stated in connection with
Bell's paralysis, these motor effects may result from a direct disturbance
of the motor impulses, but since this is not definitely proven, it is better
to explain the effects through vaso-motor and trophic disorders. In
addition to these neck lesions it is recognized that intra-cranial disorders
such as hemorrhages and tumors and injury of the periphery of the nerve,
will produce disorders of the seventh, but back of these exciting causes
there will be found in most instances, a neck lesion which is primary to
the disorder, the exciting cause then acting the more readily. The
writer has treated cases of facial paralysis due to mastoid abscess, in-
flammation of the middle ear and to polypi of the ear.

THE EIGHTH.

The auditory nerve is the nerve of the special sense of hearing.
Gowers says that the deep origin is still involved in uncertainty. Its
attachment to the medulla, (at the junction of this with the pons) is by
two roots, one of which winds around the restiform body, (inferior cere-
bellar peduncle) while the other passes into the substance of the medulla.
The nerve thus formed by the junction of these roots, is directed outward

APPLIED ANATOMY. 509

to the internal auditory meatus in company with the facial nerve. The
pars intermedia sends some filaments to the auditory nerve, but as to
the kind of impulses carried by them, we are in doubt. It is supposedly
trophic and vaso-motor.

The auditory nerve while in the meatus, divides into an upper or
vestibular branch and a lower or cochlear nerve. The vestibular nerve,
according to Landois, is essentially connected with the gray matter that
is in relation with the cerebellum and probably subserves the purpose of
maintaining the equilibrium. The cochlear nerve supplies the saccule,
the posterior semicircular canal and is continued through the labyrinth
as the cochlear nerve and is distributed to the organ of Corti. The
auditory nerve then has two functions, namely, that of hearing and that
of maintaining the equilibrium of the body. From this there may arise
two sets of diseases one characterized by loss of, or interference with,
the sense of hearing, and the other characterized by vertigo or disturb-
ances of equilibrium.

The sense of hearing may be increased, decreased or lost. Stimu-
lation of the nerve whether from a local condition or the result of a general
nervous disorder as in hysteria, will produce a condition called hyper-
acusis. Tinnitus aurium, or ringing in the ears, is quite often due to a
hypersensitive condition of the auditory nerve. In other cases, it is
due to derangement of the mechanism that transmits the sound, which
has been described before. The roaring in the ears from the taking of
quinine is the result of congestion of the labyrinthine arteries, "which
may increase to the degree of causing rupture of the vessel." It is also
due to the poisonous effect of the drug. Deafness is more commonly due
to a disturbance of the mechanism conveying the sounds than to a dis-
order of the apparatus that receives the impulses, that is, the auditory
nerve. Deafness due to paralysis of the nerve, is diagnosed by inability
of the patient to hear when the vibration is applied to the mastoid pro-
cess, or other parts in which the medium is bone or other tissue. The
other forms of disorder of the auditory nerve are characterized by ver-
tigo, staggering gait, vomiting, roaring in the ears which symptoms
make up the so-called Menieres' disease. The nerve in this disease may
be affected reflexly, or it may be affected as the result of increased at-
mospheric pressure. Menieres' disease has been produced by forcible
injections into the ears of rabbits and in addition to the vertigo, there
was nystagmus and rotation of the head toward the affected side.

510 APPLIED ANATOMY.

Some have attempted to prove that seasickness was due to a de-
rangement of this nerve, but as yet no definite proof has been presented.

The lesions that involve the auditory nerve are those which pro-
.duce direct pressure on it or those that interfere with its nutrition or
circulation. Abscesses and diseases of the bone with which it is in re-
lation, will produce a direct effect on it, while cervical lesions will affect
its nutrition and vaso-motor supply.

The vaso-motor supply to the blood-vessels that supply the cells of
origin of the nerve, seem to follow up the vertebral artery from the upper
thoracic and lower cervical regions. Other vaso-motor impulses pass
by way of the superior cervical ganglion and over the cavernous plexus
either by way of the facial or glosso-pharyngeal nerves, the former by
way of the pars intermedia, the latter by way of the tympanic plexus.
Deafness is often caused by a subluxation of some of the upper cervical
vertebrae. In 'most of those cases the tympanum and middle ear are
involved. Occasionally a case is found in which the auditory nerve is
involved as the result of a cervical lesion, but I believe it is an excep-
tional condition.

That the auditory nerve bears a close connection to vertigo, is indi-
cated by the fact that it cannot be induced in deaf mutes, or in animals
in which the labyrinths have been destroyed. The heart also has some-
thing to do with vertigo, and this tends to prove that the circulation of
blood also has something to do with the production of the disorder, be-
cause in cases of weakness of the heart, or anemia of the brain, there is
at least a tendency toward vertigo.

THE NINTH.

The glosso-pharyngeal nerve arises from nerve cells situated below
the floor of the fourth ventricle. The filaments unite to form the nerve
which emerges from the medulla between the olive and restiform bodies.
The ninth is a mixed nerve but the afferent fibers predominate. The
sensory descending root is from the fasiculus solitaris. Cunningham
says: "It begins at the upper limit of the medulla, and can be traced
downwards through its whole length. Its precise point of termination
is not known but it is believed that it is carried for some distance down-
ward into the upper part of the cord, viz., to the level of the fourth cer-
vical nerve according to Kolliker. " This tract is formed principally
by the glosso-pharyngeal, while a few of the afferent fibers of the tenth
enter it.

APPLIED ANATOMY. 511

The nerve thus formed, passes out of the cranial cavity through the
jugular foramen in company with the pneumogastric and spinal ac-
cessory nerves, but in a separate sheath of dura mater. It then passes
downward between the hyoid bone and the lower jaw, is in relation with
the carotid artery and ends in the tongue.

In the jugular foramen there are two enlargements or ganglia, the
jugular and petrous. The petrous ganglion gives off the tympanic branch
which with branches from the sympathetic filaments around the carotid
artery, form the tympanic plexus. This plexus supplies the mucous
membrane of the tympanum, the mastoid cells and the Eustachian
tube. It in addition, communicates with the superior cervical ganglion,
the auricular branch of the pneumogastric and sometimes with the
ganglion on the root of the vagus. In the neck it gives off a branch that
supplies the stylo-pharyngeus muscle and pharyngeal branches that
innervate the muous membrane of the pharynx. There is a tonsillitic
and a lingual branch.

Functionally, the ninth nerve is the gustatory nerve of the posterior
third of the tongue and a part of the soft palate; the motor nerve for the
stylo-pharyngeus muscle; the sensory nerve for a part of the tongue,
epiglottis, tonsils, pharynx and the soft palate; secretory to the parotid
gland and vaso-motor to the posterior part of the tongue, and the parotid
gland. Langley states that sympathetic fibers pass to the posterior
part of the tongue, the pharynx, and the larynx by way of the glosso-
pharyngeal nerve, the pharyngeal and superior laryngeal branches of the
vagus. Most of these impulses are derived from the spinal cord and
reach the nerve by way of the cervical sympathetic and the branch
of communication existing between the superior cervical ganglion and
the glosso-pharyngeal.

Disorders of this nerve have not been accurately determined on ac-
count of the connection with the pneumogastric, thus making experi-
mental study of the nerve quite difficult. Lesions of the neck affect the
nerve by interfering with the passing of vaso-motor impulses to it and
by disturbing the nutrition of the parts supplied by it. Diseases of the
tonsils, parotid glands, tongue, and mucous membrane of the throat are
predisposed to, or produced by, the lesion affecting the ninth nerve.
Deglutition and respiration may also be affected since the nerve exerts
an inhibitory influence on these acts. The writer saw one case in which
there was marked pain in the posterior part of the tongue which resulted

512 APPLIED ANATOMY.

from a lesion of the axis. The pain would come on in the form of a
paroxysm accompanied by increased secretion of saliva. Certain kinds
of food as well as sudden changes of temperature, would bring on the
attacks.

THE TENTH.

The vagus nerve has its cell origin, in relation with that of the ninth
and eleventh cranial nerves, in the floor of the fourth ventricle. Some
of its fibers come from the solitary bundle of longitudinal fibers that
extend down to the second cervical spinal segment. A motor nucleus
called the nucleus ambiguus, which is situated further inward and is a
continuation of the grey matter of the anterior horn, of the spinal cord
gives off some fibers. The origin of the vagus and glosso-pharyngeal
cannot be sharply separated and thus it is difficult to rightty interpret
the various symptoms that arise from disorders of these nerves. The
sensory fibers have their cells of origin in the ganglia situated outside of
the medulla, viz., the petrosal and jugular ganglia.

The nerve thus formed passes out of the cranial cavity in company
with the ninth and eleventh and in the same sheath with the spinal ac-
cessory. In the foramen, it has a ganglion on it called the ganglion of
the root, and immediately after the accessory part of the eleventh joins
it there is another ganglion called the ganglion of the trunk. It then
descends in the neck in relation with the internal carotid artery and in-
ternal jugular vein, all of which are surrounded by a common sheath.
The nerve can be reached at this part of its course, which is taken advant-
age of in certain palliative treatments for nausea and cardiac dis-
orders. The two nerves differ so'mewhat in their thoracic relations but
this is of no practical importance. It terminates in the various abdom-
inal plexuses.

The first branch given off is the meningeal, which is distributed to
the dura mater around the lateral sinus. It is sensory in function and
in addition, may carry vaso-motor impulses. It may be affected directly
in congestion of the brain, tumors and fractures of the base of the skull,
and indirectly by cervical lesions that interfere with the nutrition of its
cells and parts supplied by it. The principal effect of disturbance of it
is headache in the back and side of the head. In cases in which there is
pressure on it, there may be almost any sort of reflex disurbance such as
nausea and throat disorders such as a chronic cough.

APPLIED ANATOMY. 513

The auricular branch is distributed to the posterior and inferior
part of the external auditory meatus, back of pinna, and according to
Morris it also "supplies twigs to the osseous part of the external audi-
tory meatus and to the lower part of the outer surface of the membrana
tympani. " It is called the nerve of Arnold. It communicates with
the posterior branch of the facial and receives a branch from the petrosal
ganglion of the glosso-pharyngeal nerve. It is supposed to supply the
facial with sensory fibers at the point at which it crosses it, and with muscle-
sense fibers. It is sensory to the parts of the ear which it supplies. Irri-
tation of this nerve from foreign bodies in the external auditory canal, or
accumulation and desiccation of the cerumen will produce in some cases,
vomiting, coughing, cardiac disturbances and according to Landois,
irritation of the auricular nerve will cause reflex contraction of the ves-
sels of the ear. In some of the writer's cases, attacks of asthma could be
induced by stimulation of this nerve. Dr. Still has suggested that a
hardening of the wax in the auditor}- canal will affect the throat as in
cases of croup. In his Philosophy of Osteopathy he says: "I began to
think more about the dry wax that is always found in cases of croup, sore
throat, tonsillitis, pneumonia, and all diseases of the lungs, nose, and
head. "

In speaking of a case of croup, he says: "On examination, I found
the ear-wax dried up. So I put a few drops of glycerine and after a
minute's time a few drops of warm water, in the child's head, and kept a
wet rag corked into its ear at intervals for twelve hours and gave it
osteopathic treatment. At the end of twelve hours all signs of croup
had disappeared. " As to the explanation of the functions of the ear
wax and the effects of its desiccation he seems to think that it has to do
with nutrition of certain parts of the body such as the nerves, since in
paralytics, the wax on the affected side is found in great quantities that is,
not absorbed for the nutrition of the nerves. Possibly the auricular
branch of the vagus has something to do with the secretion of the cer-
umen and a hardening will cause reflex effects on parts supplied by the
pneumogastric, viz., the throat and lungs. Neck lesions may affect this
nerve by interfering with its nutrition and by affecting the secretion of
ear-wax.

Fibers of unknown function pass from the superior cervical ganglion
to the ganglia of the pneumogastric. It is supposed that they carry
vaso-motor impulses from the ganglion to the vagus. A lesion of the

514 APPLIED ANATOMY.

upper cervical vertebrae will affect this communicating filament and
thus produce some disorder in some part supplied by the vagus.

Morris says: "Two twigs pass from the eleventh nerve to the
ganglion of the root of the vagus, and at a lower level the accessory part
of the eleventh nerve joins the ganglion of the trunk of the tenth. The
majority of the fibers of the accessory part of the eleventh nerve merely
pass across the surface of the ganglion of the trunk and are continued
into the pharyngeal and superior laryngeal branches of the vagus, but
a certain number blend with the trunk of the vagus and are continued into
its recurrent laryngeal and cardiac branches. " These filaments transmit
motor fibers for the larynx, cardiac inhibitory, and possibly motor
fibers for the pharynx, esophagus and the stomach. There are also
anastomotic fibers between the vagus and the facial, the ninth, the twelfth
and the loop between the upper two cervical nerves. The function of
these connecting branches is unknown. These fibers are subject to in-
jury in lesions of the atlas and axis and thus whatever function that they
may possess will be impaired. The lesion affects them particularly
by tightening the tissues in which they are located, while in some in-
stances by direct pressure on them.

The pharyngeal branches of the pneumogastric nerve together with
the pharyngeal of the glosso-pharyngeal and the superior cervical gang-
lion, form the pharyngeal plexus. The vagal branches are motor to the
constrictor muscles of the pharynx, palato-glossus and palato-pharyngeal,
and the elevator of the veil of the palate; sensory to the mucous mem-
brane of the pharynx from the veil of the palate down. These sensory
branches of the vagus take part in the reflex process of deglutition, and
vomiting can be induced by irritation of them, as is demonstrated by the
introduction of the finger into the throat. Disease of this nerve is
characterized by difficulty in swallowing or pain in the throat. The
food entering the pharynx from the mouth, lodges there instead of pass-
ing on down the esophagus. In some cases liquids may enter the larynx
and cause spasms characterized by coughing or choking. Lesions of
the neck affect the sympathetic filaments of the pharyngeal plexus and
thereby induce symptoms that are attributed to a disease of this nerve.
Spasm of the pharynx results from irritation of this nerve and is often
associated with globus hystericus.

The superior laryngeal nerve is a branch of the lower part of the
ganglion of the trunk and passes downward in relation with the carotid

APPLIED ANATOMY. 515

arteries to its destination, the larynx. It divides into an internal and
external branch, the internal supplying the mucous membrane of the
epiglottis, the larynx, the mucous membrane of the cricoid cartilage anp
communicates with the recurrent laryngeal. The external branch is dis-
tributed to the crico-thyroid muscle, a part of the mucous membrane of
the larynx, and sends a branch to the heart which joins with one of those of
the cervical sympathetic. It also furnishes a branch to the inferior con-
strictor, the pharyngeal plexus and receives a communicating branch
from the superior cervical ganglion. The superior laryngeal nerve before
dividing, receives a vaso-motor filament from the superior cervical gang-
lion. The external branch also receives vaso-motor impulses from the
same source and is motor and sensory to the part supplied by it. The
internal branch is the sensory nerve to the epiglottis, a part of the root of
the tongue and to almost the entire larynx. Lesions of the neck will
affect this nerve by interfering with the passing of vaso-motor impulses
to it which are derived from the spinal cord by way of the superior cer-
vical ganglion. These lesions will produce anemia or congestion of the
larynx, hence sensory and motor disturbances. Coughing is one of the
most common of these disturbances. It is a reflex process resulting from
stimulation of some of these sensory branches of the pneumogastric.
The impulses thus generated are carried to the cough center, which is
supposed to be situated near the ala cinerea. This is a warning to the
organism that there is something in the throat that should be expelled.
The center may be stimulated by irritation of the nerve along its course,
as well as by foreign bodies in the larynx which irritate the peripheral
nerves. The center receiving the impulses, refers them to the throat it
being mistaken as to their source and thus a cough is produced which
consists essentially of contraction of the laryngeal muscles in order to
expel the supposed foreign body. Thus irritation of any sensory branch
of the pneumogastric may induce coughing, such as irritation of the ex-
ternal auditory canal, the nasal mucous membrane and the abdominal
viscera. There are other afferent pathways to the cough center as is
evidenced by the fact that stimulation of the uterus, ovary and mam-
mary gland will often produce a cough. The important point to con-
sider here is the fact that a lesion of the first rib and particularly the
upper cervical vertebrae and the hyoid bone, will either directly irritate
the superior laryngeal nerve by exerting pressure or traction on it, or
indirectly affect it by interfering with the vaso-motor impulses to the

516 APPLIED ANATOMY.

mucous membrane of the larynx. Landois quotes Hedon as finding in
the superior laryngeal nerve vasodilator and secretory fibers for the
mucous membrane of the larynx, and Kokin, in both laryngeal nerves
secretory fibers for the mucous glands of the larynx and trachea.

The inferior laryngeal branches of the pneumogastric differ slightly
in their course and distribution on the two sides. It is in relation with
the trachea, the arch of the aorta and the esophagus and hence is likely
to be affected in diseases of these structures. Functionally, it is the
motor nerve of the larynx, supplying all the muscles with the exception
of the crico-thyroid. These motor fibers are supposed to be derived from
the spinal accessory nerve. It also supplies the esophagus, the trachea,
inferior constrictor of the pharynx and gives off a cardiac branch, and
twigs of communication with the inferior cervical ganglion of the sym-
pathetic. The lesions that affect this nerve are located in the cervical
and upper thoracic area, especially the lesions of the upper two ribs.
These subluxations, especially affect the nerve through the vaso-motor
supply of the larynx. Since the larynx is the organ of voice and is sup-
plied by the laryngeal nerves with motor, sensory, vaso-motor and pos-
sibly secretory impulses, lesions, affecting the cells of origin, exit or
course of these nerves, produce disorders of the voice, ranging from
hoarseness to aphonia.

The cardiac branches of the pneumogastric are supposed to carry in-
hibitory impulses to the heart which a're thought to be derived princi-
pally from the spinal accessory nerve. Some writers claim that stimu-
lation of this nerve will produce acceleration of the movements of the
heart, especially if the irritation is a feeble one. It is supposed also
to carry sensory and vaso-motor impulses. Landois cites the following
experiment in support- of the existence of vaso-motor fibers in the cardiac
branches: "Persistent irritation of the peripheral stump of the vagus
causes extravasation of blood into the endocardium (long continued
poisoning with digitalin or strychnin had a similar affect) in consequence
of spasmodic contraction of the endocardial vessels with secondary par-
alytic relaxation and rupture. " The accelerator function of the vagus
in reference to the heart, is supposed to be derived from the sympathetic
fibers. Clinically, these cardiac branches are of no great importance
to us since it is the exception for lesions in the neck to affect the heart.

The pulmonary branches of the vagus help to form the anterior and
posterior plexuses and supply sensory and motor fibers to the trachea

APPLIED ANATOMY. 517

bronchi and lungs. They also are supposed to supply vaso-motor nerves
to the pulmonary vessels. Lesions of the upper ribs, from a clinic point
of view, seem to affect these nerves more frequently than do cervical
lesions. Possibly this is through direct connecting filaments or through
sympathetic fibers that help to form the pulmonary plexus. The
writer has made several dissections in which there was found branches
running from the upper thoracic sympathetic ganglia directly across into
the pneumogastric. The principal diseases associated with this nerve
are asthma and chronic cough. Asthma is probably the result of vaso-
motor disturbances of the mucous membrane of the bronchi from le-
sions of the upper thoracic vertebrae and ribs. Coughing is most fre-
quently due to lesions higher up, especially of the first and second ribs
and the cervical vertebras. I am inclined to believe that most of these
disorders result from vaso-motor disturbances of the blood-vessels sup-
plying the parts to which these nerves are distributed, thus making the
effect the result of a peripheral irritation instead of stimulation along
their course. The inhalation of certain gases, the entering of food into
the larynx and trachea, and congestion of the bronchi produce cough.

The esophageal branches of the vagus convey motor and sensory im-
pulses to the esophagus. They first enter the plexus gulas which is
formed by branches from the splanchnic nerves before they reach the
solar plexus, and these branches of the vagus. Dysphagia is the prin-
cipal effect of involvement of these nerves. The writer has seen a few
cases of pain in the lower part of the esophagus during deglutition which
seemed to be the result of swallowing too large a bolus of food, some
foreign body or clue to hasty swallowing.

The abdominal branches of the vagus which supply the stomach,
spleen, liver, kidney and the greater part of the intestinal tract carry
motor, vaso-motor, secretory and sensory impulses. The principal
function is that of conveying motor impulses to the gastro-intestinal
tract. Stimulation of the nerve excites contraction of the stomach, es-
pecially the right half and secretion from the gastric glands. Clinically,
it seems that the function of the abdominal branches of the pneumogas-
tric is controlled by the sympathetic nerves of the part, since diseases of
these parts seldom result from neck disorders but from lesions in the
middle thoracic area. Occasionally neck lesions are found which are
responsible for the disorder of the abdominal viscus, but this is the ex-
ception rather than the rule, hence we conclude that the function of the

518 APPLIED ANATOMY.

abdominal branches of the pneumogastric is controlled by the sympa-
thetic nerves derived from the middle thoracic ganglia and the spinal
cord, since the lesions are found here.

The vagus nerve contains depressor fibers which on stimulation, re-
flexly inhibit the heart's action, dilate the peripheral arteries and pro-
duce a fall of blood pressure. Some writers seem to think that all
sensory nerves contain both pressor and depressor fibers. Landois says,
"Irritation of depressor nerves, particularly if intense and long contin-
ued, causes dilitation of the vessels in the areas innervated by them.
Pressor fibers are present in the superior and inferior laryngeal nerves,
the fifth cranial and cervical sympathetic. Irritation of this nerve will
produce a pressor effect." Congestion of the lungs produces an acceleration
of the heart beat through the action of the depressor nerve. Quainsays
in his summary of the pneumogastric nerves: "They convey fibers to
the voluntary muscles of the soft palate, (with the exception of the tensor
palati) pharynx and larynx, these being in part, at least, derived orig-
inally from the spinal accessory,to the unstriped muscle of the alimentary
canal — esophagus, stomach and intestine (with the exception of the
rectum) and of the air passages — trachea, bronchi and their divisions in
the lungs. Sensory fibers are furnished to the pharynx, esophagus and
stomach, to the larynx, trachea and bronchial ramifications as well as
to the dura mater, external ear and the pericardium. The vagi also
supply nerves to the heart, both efferent (inhibitory — also received from
the spinal accessory) and afferent (depressor) and possibly inhibitory
dilator fibers to the vessels of the intestine. Lastly, pneumogastric
fibers pass either directly or through the solar plexus and its offsets to
the liver, pancreas, spleen, kidneys and suprarenal bodies. Each
pneumogastric nerve is connected with the following cranial nerves: the
spinal accessory, glosso-pharyngeal, facial and hypo-glossal; also some
spinal nerves; and with the sympathetic in the neck, thorax and ab-
domen. "

Physiologically, the pneumogastric is connected with the centers
in the medulla and controls at least in part, some of the most important
functions in the body. It is connected with the vaso-motor center,
which is situated in the medulla, by way of the pressor and depressor
nerves. Respiration is partly under the control of the vagus through
the pulmonary and laryngeal nerves, which connect with the respira-
tory center in the medulla. The vomiting center is stimulated by af-

APPLIED ANATOMY. 5] 9

ferent impulses passing over the vagus. The cardiac centers are in con-
nection with this nerve and thus the pulse rate is in a measure governed
by the impulses passing over the vagus. The secretion of the pancreas
is to a great extent under the control of the pneumogastric while Bernard
says that irritation of the pulmonary branches causes a reflex increase
in the formation of sugar in the liver, perhaps through the intermedia-
tion of the hepatic branches.

Experimentally, many and varied reflexes can be obtained by stim-
ulation of the vagus nerve. It is the seat of much referred pain, espec-
ially in the head and neck. Schafer says: "Referred pain by way of
the vagus occurs in part of the region of the fifth cranial nerve and of the
upper cervical nerves; hence, we must suppose that the roots of the
vagus have intimate connections with the roots of the fifth and of the
upper cervical nerves. Certain deep structures of the head such as the
iris, tooth pulp, tongue, cause referred pain in the skin region of the fifth
nerve, and, taken together, in the whole region of the fifth. " Coughing,
asthmatic attacks, spasms of the larvnx, of the glottis, angina pectoris,
and other cardiac disturbances, vomiting and vaso-motor disorders are
quite frequently produced reflexly on account of the wide distribution,
many connections and intimate relation of the vagus with the centers
in the medulla.

Clinically, the vagus is affected by lesions of the cervical vertebra?,
hyoid bone, upper thoracic vertebra?, upper ribs, by muscular contrac-
tures in these areas, and peripherally by foreign bodies in, or disease of,
the mucous membrane lining the various cavities supplied by the vagus.

THE SPINAL ACCESSORY.

The eleventh cranial, arises from two sources. The medullary or
bulbar portion arises from the nucleus ambiguus in connection with
fibers that form the pneumogastric. The fibers thus formed pass for-
ward and emerge from the medulla with the roots of the vagus. The
accessory portion of the nerve arises from the cells in the anterior horns
of the gray matter of the spinal cord as low as the seventh cervical seg-
ment. The fibers thus formed pass out of the spinal cord between the
anterior and posterior roots of the cervical nerves, and form into a trunk
that ascends through the foramen magnum andunites with the medullary
portion to form the common trunk. The nerve then emerges from the
crania] cavity through the jugular foramen in the same sheath with the

520 APPLIED ANATOMY.

pneumogastric. Cunningham says: "In the jugular foramen the ac-
cessory portion of the nerve (after furnishing a small branch to the
ganglion of the root of the pneumogastric nerve) applies itself to the
ganglion of the trunk and in part joins the ganglion, in part, the nerve
beyond the ganglion. By means of these connections the pneumogas-
tric receives viscero-motor and cardio-inhibitory fibres. " This branch
soon enters the pneumogastric and eventually supplies the pharyngeal
and laryngeal muscles, the latter through the recurrent laryngeal
nerve.

The spinal or accessory portion, passes into the neck in relation with
the carotid artery and internal jugular vein, communicates with the sec-
ond, third and fourth cervical nerves and supplies the sterno-mastoid
and trapezius muscle.

Spinal lesions will affect the functions of this nerve, especially the
accessory portion by interfering with its nutrition. This is the result
of tightening of tissues and pressure on the blood-vessels that supply and
drain the cervical spinal cord.

The principal effect of a lesion involving this nerve is torticollis.
This will follow both an inhibitor and a stimulating lesion, the first pro-
ducing a paralysis of the muscle, while in the latter case there will be a
spastic or clonic effect with structural changes of the muscle. In addi-
tion to these effects there may be, as a result of the effect of the lesion on
the spinal accessory nerve, impairment of deglutition on account of
weakening or paralysis of the constrictor muscles of the larynx, disturb-
ance of the heart, disturbance of the vocal cords and some form of re-
spiratory disorder, especially shortness of breath, on account of effect on
the muscles.

THE HYPOGLOSSUS.

The hypoglossal nerve has its deep origin in the floor of the fourth
ventricle from cells that are continuous with those of the anterior horns
of the spinal cord. The fibers are arranged in two bundles that unite
to form the nerve before it makes its exit from the skull through the
anterior condyloid foramen. It passes downward and forward across the
carotid artery, is in relation with the great cornu of the hyoicl bone and
enters the tongue by passing between the mylo-hyoid and hyo-glossus
muscles. At its origin it is a purely motor nerve but through its con-
nections, receives sensory and other fibers.

APPLIED ANATOMY. 521

The nerve is motor to the intrinsic muscles of the tongue, the hyo-
glossus, genio-hyoid, genio-hyo-glossus, thyro-hyoid and possibly some
of the infra-hyoid muscles although they in all probability receive most
of their motor impulses from the cervical nerves.

It receives its sensory fibers from the vagus and the upper cervical
nerves. (Dana). Muscle sense fibers pass into the nerve from the pneu-
mogastric.

Vaso-motor impulses pass into the nerve from the superior cervical
ganglion, which in turn are derived from the spinal cord. This is proven
experimentally, since division of the hypoglossal is followed by redness
of the same side of the tongue. Lesions of the upper cervical vertebrae
affect this nerve principally through its connections, especially through
the superior cervical ganglion.

The most common of the disorders of this nerve are manifest by
motor effects on the tongue. Disorders of articulation, deglutition and
mastication are not unusual. Stammering is sometimes the result of
disease of the lingual muscles but in most cases is the result of a habit.
The same is true of stuttering. The writer has treated cases of spasms
of the tongue due to lesions of the axis which undoubtedly affected the
hypoglossal nerve. Bulbar disease and neuritis, will produce hemia-
trophy of the tongue. In such cases the cervical lesions that are usually
present, interfere with the nutrition of the medulla and the nerve itself.

All the cranial nerves are more or less affected by lesions of the
cervical and upper thoracic vertebra?. The best explanation is that all of
them receive directly or indirectly, vaso-motor impulses from the spinal
cord and the circulation and nutrition of the nerves and their nerve cells
depend on the condition of the vaso-motor nerves that pass into the
brain from the spinal cord principally by way of the cervical sympathetic.
Lesions in the above mentioned regions interfere with, in some way, the
formation and passing of vaso-motor impulses to the parts above, hence
the disorders of the cranial nerves. These lesions affect the vaso-motor
nerves by lessening the size of the intervertebral foramina through which
pass the nerve fibers and blood-vessels that nourish the cells in that part
of the spinal cord from which these fibers arise. Clinically, there is no
doubt about the statement that cervical and other bony lesions affect
the cranial nerves, since it has been so often absolutely demonstrated.

522 APPLIED ANATOMY.

THE BRAIN.

The brain or encephalon is that portion of the central nervous sys-
tem that occupies the cranial cavity. No detailed description will be
attempted here but only those parts that are frequently diseased will be
discussed. Most disorders of the brain arise from extra-cranial causes
while some come from causes acting from within. It is our purpose to
explain, if possible, the various symptoms that arise from affections of the
brain from an anatomical viewpoint, that is, showing that its diseases,
like disorders of other parts of the body, result from anatomical dis-
placements.

The cerebrum constitutes over eighty per cent of the weight of the
entire brain. It is divided into two parts, by the longitudinal fissure,
which parts are connected by the corpus callosum. Its surface presents
an undulated. appearance, the indentations or depressions are known as
fissures and the prominences, as convolutions. The principal fissures
are, the fissure of Sylvius, of Rolando, parieto-occipital, calloso-marginal
and the calcarine fissure. These fissures are of interest to us in that they
divide the cortex into lobes and convolutions and serve as landmarks
for the locating of the various cortical centers. The principal lobes of
the brain are the frontal, parietal, occipital, the temporo-sphenoidal and
the island of Reil.

The frontal lobe includes that portion of the cerebrum that lies in
front of and above the fissure of Sylvius and in front of the fissure of
Rolando and on the inner side, that part above the calloso-marginal fis-
sure. The function of this lobe has been fairly well ascertained from
experiments on monkeys and by clinical observations in cases of injury
to the part. Gowers includes in his description of the frontal lobe the
anterior part of the parietal. He states that destruction of it produces
hemiplegia on the opposite side, with secondary degeneration of the
pyramidal tract, and rigidity of the limbs; a partial lesion affects face,
arm, or leg according to its position. "Partial lesions are very common
first, on account of the wide extent of the central region; and secondly,
because the region is supplied by different arterial branches and soften-
ing from their occlusion is frequent." The leg and arm are more fre-
quently affected than the face and monoplegia is often due to disease of
the cortex.

Irritating diseases of this area will produce convulsion, of the face,

APPLIED ANATOMY. 523

arm or leg. In some cases there are some sensory disturbances as a re-
sult of disease of the central part of the cortex of this lobe. It is the ex-
ception for any motor effects to follow a disease of the anterior portion
or what is called the prefrontal lobe. The principal effect is on men-
tality and the movements of the head and eyes. "A large number of
cases are on record of disease and injury of various kinds in this part, in
which psychical disturbance was the only symptom."

The parietal lobe includes that portion of the outer and inner por-
tion of the surface of the hemisphere which is bounded anteriorly by the
fissure of Rolando, below by the fissure of Sylvius and posteriorly by
the parieto-occipital fissure.

Disease of the anterior and superior part of this lobe produces dis-
orders of the movements of the limbs. Ptosis results from disease of the
lower part, while if the posterior part of the lobe is affected, some form
of eye disorder may result such as hemianopia, crossed amblyopia or
there is an interference with the "visual percejDtion of words." The
center for general sensation is probably in part situated in the parietal
lobe.

The occipital lobe embraces the posterior part of the cerebrum.
The important point associated with it is that in it are located the cen-
ters for vision. If only one side is involved there will be hemianopia.
Dana says: "The special senses have two centers — the primary and
the secondary. The primary are situated in the ganglia at the base of
the brain; the secondary, are in the cerebral cortex." The occipital
lobe is the secondary center for visual impulses from the corresponding
half of the retina of each eye.

The temporo-sphenoidal lobe lies below and behind the fissure of
Sylvius. The primary center for hearing is located in this lobe. Each
center controls the sense of hearing on the opposite side.

These various lobes are affected by pressure, as in fracture of the
cranial vault, congestion, extravasation of blood as in hemorrhage and
by the lodging of emboli. Nutrition may be affected by other means
which will be discussed later.

The corpus callosum is a great transverse commissure, considerably
arched from before backward, that connects the hemispheres. It is
composed entirely of white fibers that connect the cortex of one side
with the gray matter of the opposite hemisphere. Since its function
seems to be that of furnishing a connecting tract between the hemi-

524 APPLIED ANATOMY.

spheres, the destruction of it would not materially interfere with the
independent action of either side. Gowers says: "We do not yet know
of any symptoms that are the result of the damage to the callosal fibers. "

The internal capsule consists of a band of white matter that embraces
the inner side of the lenticular nucleus, hence the name capsule, and sep-
arates this nucleus from the caudate. Brubaker says: "It consists of
nerve fibers which associate histologically and physiologically all por-
tions of the cerebral cortex with the optic thalmus, pons, medulla, spinal
cord and cerebellum." The corona radiata converge from the cortex
and are condensed to form a part of the capsule. Motor impulses pass
by way of the capsule to the muscles of the opposite side of the body.
Afferent impulses from "skin, mucous membrane, muscles, and special
sense organs," pass through the internal capsule. The motor tract lies
in the posterior third of the anterior part and the anterior two-thirds of
the posterior segment. The sensory tract occupies the posterior third
of the posterior segment, the optic and auditory tracts being located in
the extreme part. The anterior part is supposed to contain psychic
paths to the frontal lobes. On account of the number and character of
impulses transmitted by the capsule and the numbers of cases in which
it is diseased, it is one of the most important parts of the central nervous
system viewed from a pathological standpoint. Lesions of the anterior
part" ordinarily produce few if any disorders, of the middle portion motor
effects, while if the posterior part is destroyed there will be sensory par-
alysis of the parts supplied by the fibers destroyed by the lesion. On
account of the proximity of the fibers composing the capsule, a small
lesion will produce a wide effect as is demonstrated by hemiplegia.

The corpus striatum consists of a large mass of gray matter, hence
called a ganglion, that lies at the base of the hemisphere beneath the
lateral ventricle. It is divided into two parts the caudate, and the lenticu-
cular nucleus. *Dana says: "This ganglion is in close relation with
the cerebellum and with nuclei in the pons. It is also in connection with
fibers that come up from the muscle-sense tract in the spinal cord. Its
functions are then probably connected with securing co-ordinate and
purposeful movements. Destruction, however, of this ganglion in the
human brain produces no definite symptoms, and local lesions of it can-
not be diagnosticated. It is therefore called a "latent region." It is
believed that axons of cells in the frontal lobe pass to the corpus striatum.

*Text-Book of Nervous Diseases, p. 377, 1901.

APPLIED ANATOMY. 525

Schafer in speaking of the function of this ganglion says that it is gen-
erally believed to act as a center for the higher reflex movements and to
be in close association with the Rolandic area, but the experimental
grounds for this belief are still lacking.

The optic thalami consist of two masses of gray matter located in
the lateral walls of the third ventricle. It is connected with the various
lobes of the brain, that is the various sense centers, b}r means of its pro-
jection fibers. The fibers that go to the occipital lobe are connected
with the function of seeing while those that connect with the temporal
lobe, have to do with the function of hearing. In injuries of the optic
thalami, no definite symptoms occur if the lesion is confined to the an-
terior part and the internal capsule is not involved. If the posterior
part is involved, the eyes are generally affected, a crossed blindness or
hemianopia being the result. It also has to do with co-ordination, facial
expression and possibly with the special sense of touch, taste, smell,
hearing and muscle-sense. The centers for complex reflexes and the
reflex center for the secretion of tears are supposed to be located in the
optic thalami. The principal effect of a lesion of the optic thalami is
some sort of eye disorder, blindness being the most common.

The corpora quadrigemma consist of masses of gray matter which
are in relation with the posterior part of the corpus callosum, the third
ventricle and the aqueduct of Sylvius. The function of these bodies is
not well understood but they are supposed to have to do with vision,
ocular movements, equilibrium and hearing. Isolated disease of them
is rare but they are affected by congestion and hemorrhage. They are
also associated with station and locomotion and Ferrier states that in
these bodies "sensory impressions, retinal and others, are co-ordinated
with adaptive motor reactions such as are involved in equilibrium and
locomotion." The various cervical lesions will affect the nutrition and
circulation of these bodies since in all probability, the vaso-motor nerves
to the blood-vessels of these parts come from the superior cervical gang-
lion, or admitting that the blood-vessels of the brain have no vaso-motor
nerves, the blood volume and circulation are dependent on the cervical
ganglia, consequently disorders of the neck will affect the circulation of
the brain as has ofttimes been demonstrated clinically.

The crura cerebri are situated between the pons and the cerebrum.
They are composed of white matter arranged in layers, the ventral and
dorsal portions. These parts are separated by a layer of gray matter

526 APPLIED ANATOMY.

called the substantia nigra. The ventral fibers are to a great extent,
derived from the pyramidal tracts and are continuous with those of the
pons and the medulla. These fibers are motor in function. The dorsal
portion of these fibers, often called the tegmentum, are continuous with
the fibers that pass upward from the medulla, pons and the superior
peduncles of the cerebellum. These fibers transmit sensory or afferent
impulses. Lesions of the crura cerebri are, therefore, characterized by
hemiplegia of the face and limbs of the opposite side, which is often com-
plicated by sensory paralysis of the same parts, if the lesion involves the
dorsal portion of the crura. On account of the proximity of the third
nerve, it is also involved in some eases of disease of the crura which is
followed by paralysis of the eyelid on the same side. The nuclei of other
cranial nerves may be involved if the lesion is a deep one.

The pons Varolii is situated between the medulla below, the crura
cerebri above and the cerebellum posteriorly. It is composed of white
and gray matter and serves as a medium through which impulses pass
both from below upward and from above downward. The posterior
surface of the pons forms the floor of the fourth ventricle and consists of
gray matter that gives rise to the fifth, sixth, seventh and eighth cranial
nerves. The fifth, sixth and seventh cranial nerves traverse the pons
in their course from their nuclear to their apparent origin. On account
of this, a lesion occurring in the pons will affect one side of the body, and
the opposite side of the face, if it falls on the facial roots before they decus-
sate and this is the rule. Such a paralysis is called a crossed or alter-
nating paralysis. The tracts that are always affected are the pyramidal,
and paralysis of the opposite side of the body is the result. If the upper
or posterior parts of the pons are affected, there will be a sensory as well as
a motor paralysis, since the sensory tract lies in this part. If this part is in-
volved, the motor nucleus of the sixth nerve is affected and there will be
a conjugate deviation of the eyes toward the side of the lesion, that is
away from the paralyzed side.

The speech-paths which lie in the posterior part of the pyramidal
tract, may be affected by a lesion of this area and speech disturbances
follow. In some, the oculo-motor and fifth nerves are involved by the
lesion. Church says "A lesion which cuts the sensory root-fibers of the
fifth, induces anesthesia in the face on the same side and crossed paralysis
in the limbs through injury to the pyramidal tract. Rigidity, spasm,
and choreic movements in the limbs are sometimes encountered, and

APPLIED ANATOMY. 527

convulsions in acute diseases are common. If the middle cerebellar
peduncle is affected, vertigo, vomiting, and tinnitus are usually present,
and deafness on the same side may ensue." Lesions of this part are not
unusual and can in many cases be traced to subluxations in the cervical
region that disturb the trophic and vaso-motor impulses to the blood-
vessels of the part.

THE MEDULLA OBLONGATA.

The medulla oblongata which is a continuation upward of the spinal
cord, lies on the basi-occipital bone in front of the cerebellum and below
the pons into which it merges. It is composed of gray and white matter.
The gray matter is continuous with that of the spinal cord but the arrange-
ment of the cells is different. It forms the various centers located in the
medulla which have so much to do with the vital, and other functions of
the body. The white matter is arranged in columns that are really con-
tinuous with those of the spinal cord. The anterior part or pyramids
of the medulla "serve to conduct volitional efferent nerve impulses from
higher portions of the brain to the spinal cord. " The dorsal part of the
medulla, transmits sensory or afferent impulses from the spinal cord to the
brain above. Transverse section of the motor tract will be followed by
motor paralysis of all muscles receiving their supply through them.
Section of the afferent tract on one side is followed by complete loss of
sensation on the opposite side of the body.

There are located in the medulla many centers that reflexly control
important functions of the body. The spinal cord centers are controlled
to a great extent by the predominating centers in the medulla. These
centers are affected by many things but the most important is the blood,
its quality and amount. Any pathological change in the character and
amount of the blood circulating through it will affect the function of
these centers. In all reflex processes there must be a stimulation an
afferent nerve, a center for receiving the impulse and an efferent tract.

The center for sneezing is stimulated by impulses that reach it by
way of the fifth nerve, its nasal branch, and possibly by way of the olfac-
tory. The efferent impulses thus stimulated, pass to the expiratory
muscles, and a spasmodic contraction of them completes the act. This is
nature's method of ridding the body of a foreign object or what is sup-
posed to be injurious to the respiratory tract. I believe it to be nature's
method of "throwing off" a cold. If a person who has contracted a cold

52ft APPLIED ANATOMY.

can sneeze freely, I believe, from eases seen, that it can be aborted.

Congestion of the nasal mucous membrane is the most common of
the irritations that produce activity of the center. In hay fever, the
nasal mucous membrane is intensely congested even to the point of
capillary hemorrhage. This produces attacks of sneezing that are almost
uncontrollable. Pressure on the upper lip or lower part of the nasal
septum will ordinarily stop sneezing. Lesions of the neck both muscu-
lar and bony, produce congestion of the nasal mucous membrane and in
acute cases, will produce sneezing.

The cough center is reached principally through the sensory branches
of the pneumogastric. The efferent impulses pass over the expiratory
nerves. The usual point of irritation is in the throat from congestion
of the mucous membrane. Irritation of other branches of the
vagus will in some cases, produce cough. Disorders of the stomach,
uterus, rectum, bronchi, intestines and the external auditory canal often
refiexly produce coughing. Lesions of the cervical vertebra?, upper ribs,
and hyoid bone are the important ones to be considered in the usual
cases. Like other reflex processes, an irritation of the afferent nerves,
center or efferent nerve will produce a cough. In upper rib lesions es-
pecially, the cough center is mistaken as to the source of the impulses,
they coming from the trunk of the nerve instead of the periphery. This
gives rise to a chronic, hacking cough. Cervical lesions often produce
a cough by producing a peripheral congestion in the mucous membrane
of the respiratory tract.

The secretion of saliva is a reflex process with the center in the
medulla. Landois says: "Irritation of the medulla oblongata when the
chorda tympani and the glosso-pharyngeal nerves are preserved, causes
active secretion of saliva; a lesser amount of secretion when these nerves
are divided; and, finally, none at all when the cervical sympathetic also
is destroyed." Lesions of the cervical vertebrae affect the secretion of
saliva by disturbing the above nerves, especially the cervical sympathetic,
and by disturbing the circulation to the medulla.

The respiratory center, which consists of two areas, the inspiratory
and the expiratory, is located in the medulla. Its activity in the normal
case is governed by the condition of the blood. If the blood is properly
oxygenated respiration will be slow, but if imperfectly aerated, as during
violent exercise, the center will be excited by the venosity of the blood.
The center may be affected by stimulation of the afferent 'nerves as in

APPLIED ANATOMY. 529

pain, by a peripheral disorder as in asthma,but most commonly by changes
in the blood circulating through the medulla. A lesion of an upper
cervical vertebra will affect the circulation through the center and thus
produce respiratory disturbances. This center co-ordinates the muscles
of respiration, which is a decidedly complex process. The vagus is the
most important of the nerves that connect with the respiratory process,
which is determined by the effects of stimulation and section of it. If
one of these nerves is cut, the respiration becomes slowed while if both
are severed, the breathing becomes markedly abnormal and the injury
will result fatally after a short while.

A cardiac center is located in the medulla which exerts an acceler-
ator influence on the heart's action by way of the spinal cord, and the
upper thoracic sympathetic nerves, and an inhibitor action, through the
spinal accessory part of the pneumogastric. This center is closely re-
lated in function with the respiratory, so that venous conditions of the
blood that stimulate the respiratory, will also increase the heart's action
through the accelerators.

Disease of the medulla, as in bulbar paralysis, produces enormous
retardation of the pulse-beat. Functional disorders sometimes result
from lesions of the upper cervical vertebrae that impair the nutrition and
circulation of the medulla, thereby affecting the activity of the cells that
give rise to the above named nerves. Lesions of the upper thoracic ver-
tebra?, will interrupt the passing of impulses between the cardiac center
in the medulla and the centers in the upper segments of the thoracic
spinal cord and the heart.

The predominating vaso-motor center for the blood-vessels of the
body is located in the medulla. It is in constant action maintaining the
tone of the arteries and perhaps that of the veins. It is not only affected
reflexly by blood changes, but by the condition and amount of blood cir-
culating through the medulla. Since lesions of the upper cervical ver-
tebras affect the circulation through the bulb, it follows that the vaso-
motor center will be affected by these lesions. These lesions also interfere
with the connection that exists between the predominating center in
the medulla and the secondary centers situated in the spinal cord. On
this account, the passing of impulses from the spinal cord to the medulla
is interrupted, and the center is not kept well informed as to the condition
of the subsidiary centers, or else the passing of impulses from the higher
center to the subsidiary center is impaired and thus the subsidiary cen-

530 APPLIED ANATOMY.

ters are left to act independently of the bulbar. Blood pressure can be
lessened by inhibition in the suboccipital fossa, this being determined
from clinical observations. The probable explanation is that the activ-
ity of the predominating center in the medulla is lessened or rather the
excessive activity of it is lessened by the treatment, since it temporarily
relieves or removes the cause of the irritation of it.

Deglutition is a reflex process and has its center on the floor of the
fourth ventricle. Afferent impulses reach it over the sensory branches
of the fifth and pneumogastric nerves, that supply the palate and pharynx.
The efferent pathway is through the motor branches of the pharyngeal
plexus. Dysphagia may follow neck lesions that interfere with this re-
flex process by disturbing the periphery as in congestion and inflamma-
tion of the throat, the afferent nerve, the center or the efferent nerve.
These parts are in relation with the cervical vertebra? and would be
directly or indirectly affected, by a cervical lesion.

The vomiting center is situated in the medulla, the afferent impulses
reaching it over the branches of the pneumogastric. The efferent tract
is by way of the expiratory muscles, that is the nerves that control ex-
piration. The intercostal nerves are the important ones concerned in
vomiting since it can with difficulty, if at all, take place if the abdominal
muscles are paralyzed. Contraction of only the abdominal muscles is
sufficient to produce vomiting, which is determined by experiments in
which the other muscles are paralyzed. Clinically, lesions that affect
either the afferent or efferent nerves will tend to bring on an attack, but
the most common form is due to peripheral irritation resulting from the
presence of a foreign body in or abnormal condition of, the alimentary
tract. Since the efferent impulses pass almost entirely through the
thoracic spinal cord and out over the upper thoracic nerves, pressure,
that is inhibition, applied to these points will often intercept the motor
impulses and thus relieve the vomiting.

The center for hiccough is a part of the respiratory apparatus and is
affected by disturbances of the nerves that control respiration. The
stimulation is usually at the periphery, that is at the diaphragm or along
the course of the phrenic nerve. The lesions are found in the lower ribs
the clavicle, first rib and the cervical vertebras. It is the exception for
the center to be directly affected but it is possible for a lesion to so affect
the blood supply to the medulla, that this center will be affected. The
effect of such a lesion is most marked on other parts of the respiratory
apparatus.

APPLIED ANATOMY. 531

Mastication and sucking are reflex processes that have their centers
in the medulla. The afferent nerves are the fifth and glossopharyngeal.
The motor impulses pass out over the facial, hypoglossal and the tri-
geminus.

Closure of the eyelids is a reflex process, the center being in the
medulla. The fifth cranial nerve transmits the afferent, while the facial
carries the motor impulses. Intense light or a foreign body in the eye,
are the important sources of irritation. In Bell's jjaralysis, this reflex
process is impaired so that particles of dust and other irritants enter the
eye and there set up an inflammation. The secretion of tears is also a
reflex process and serves to keep the eye bathed, thus washing out par-
ticles of dust that collect in the eye. These processes are impaired by
neck lesions that affect the center the fifth or the seventh nerve.

Dilatation of the pupil is also a reflex process and in normal cases is
governed by the amount of light that enters the eye, shutting off the
light stimulating the center. The most common lesion that affects this
center or process, is found in the upper thoracic region. The writer has
seen cases in which the pupil could be dilated by pressure at the third
thoracic spine. In another case the pupil could be voluntarily dilated.
The condition of the blood circulating through the medulla and other
tracts in relation that have to clo with the eye, is the most important
factor in cases in which there is some disorder of the pupil. In cerebral
hemorrhage and certain forms of poisoning, the pupil is affected. In
some forms of spinal cord disease, the pupil is changed as in tabes dor-
salis, i. e., narrowed by means of paralysis of the cervical sympathetic.

The sweat center situated in the medulla, is an automatic one and
is the dominating center for the secretion of sweat for the entire surface
of the body. The condition of the blood, activity of the heart and the
cervical lesions are factors that determine the activity of this center.
It can possibly be stimulated to increased activity by manipulation in
the upper cervical region, which treatment is often resorted to in fever
cases. Cervical lesions will produce a unilateral stimulation of this
center, it being bilateral, and thus produce a hemidrosis.

At the junction of the medulla and the pons, there is a spot which,
when stimulated, produces a spasm, it being called the spasm center.
This center is affected Iprincipally through venosity of the blood.
(Landois). Anemia if sudden, will also bring on a convulsion. Clin-
ically, there is found in most of the cases of spasms, a lesion of an upper

532 APPLIED ANATOMY.

cervical vertebral articulation that disturbs the circulation through this
part of the medulla. In such lesions the blood in the center becomes
venous in character and the center is thus stimulated into activity, the
degree of the spasm depending on the amount of toxic matter in the
blood. Spasms can often be checked by treatment applied to the sub-
occipital fossa especially if applied in the beginning of the attack. This
treatment consists of freeing up the drainage of the medulla by relaxing
the contractured muscles and by adjusting the vertebrae, an approxima-
tion being the common form of derangement. In epileptic attacks,
strong pressure applied to the sub-occipital region, will in most cases stop
the attack. It has been ascertained that "irritation of sensory nerves
may cause both sudden contraction as well as dilatation of the cerebral
vessels." If this condition takes place in the medulla, anemia or transi-
tory congestion will result, either of which will produce convulsions
in that such conditions irritate the medulla. This is particularly true
of epileptiform convulsions.

The functions of the medulla are affected by local lesions, that is
in the upper cervical region, that interfere with the circulation to, and
nutrition of, the medulla and by other lesions that impair the quality of
the blood. Even those lesions that impair the quality of the blood need
not necessarily affect the medulla, unless the local lesions are present
which further increase the venosity of the blood by causing a congestion
of the vessels of the medulla.

CEREBELLUM

The cerebellum is situated below the posterior part of the cerebrum and
rests in the inferior fossa of the occipital bone. It is separated from the
cerebrum, by a partition of dura mater called the tentorium cerebelli.
The cortex is composed of grey matter which surrounds the white matter
within. It is partially divided into hemispheres, each one of which is
connected by peduncles, the superior, middle and inferior, which con-
nect respectively with the cerebrum, pons, medulla and spinal cord.
The function of the cerebellum is that of co-ordinating and harmonizing
the action of the muscles that control the equilibrium of the body. In
experiments performed in which the cerebellum is totally removed, there
is no loss of sensation or weakness of the muscles, but inco-ordination of
the muscles is the principal effect. The maintaining of equilibrium is
through the connections with the other parts of the brain. Landois

APPLIED ANATOMY. 533

says: "Through the lateral cerebellar tracts stimuli are conveyed to
the cerebellum and these serve as guides to the position of the trunk.
Connections of the vestibular nerve with the cerebellum have a similar
effect with respect to equilibrium. The cerebellum may influence the
motor nerves of the spinal cord through fibers that pass downward through
the restiform body into the lateral tracts of the spinal cord. The cere-
bellum itself is insensitive to injuries. " It also has to do with the strength
of voluntary movements, tone of muscles and the rhythm of the motor
impulses. Diseases of the cerebellum are characterized by disorders of
co-ordination, such as a staggering or drunken gait, vertigo, ataxia and
malnutrition of muscles. The disease may extend upward from the
spinal cord or may be the direct result of lesions that affect the nutri-
tion of it.

The brain is divided into several areas that have to do with partic-
ular functions, namely: the motor, sensory and those of special sense.
This is important in that the exact spot that is affected can be de-
termined by the symptoms, since cerebral localization is now a fairly
exact science. The motor areas are grouped around the fissure of Ro-
lando, so that in motor paralysis of central origin the exact location of
diseased area is made possible. This area is also sensory to a certain
extent and has been called sensori-motor, since it has been determined
that sensory fibers from the skin terminate in this area. The lower part of
the Rolandic area is the motor center of the neck, head and face, the
middle portion, for the arm and that portion around the upper part of
the fissure, is the motor center for the leg and trunk. These motor
centers control the action of the muscles on the opposite side of the body,
but if the hemorrhage involves the pons before the fibers of the facial
decussate, the muscles on the same side of the face will be paralyzed,
this constituting a crossed paralysis. The auditory area is located by
Ferrier in the upper part of the central sphenoidal convolution. That
for vision, in the occipital lobe, while the speech center is supposed to be
in the frontal lobe on the left side which is called, in honor of its dis-
coverer, Broca's convolution.

These various areas are connected with the parts of the body by
certain tracts. The motor tracts are divided into the direct or volun-
tary, and indirect. The direct motor tract originates from cells in the
Rolandic area, the fibers from which converge into a narrow band that
pass through and form the posterior part of the internal capsule.

534 APPLIED ANATOMY.

They pass on into the pons Varolii and medulla, at the latter point most
of them cross over to the opposite side forming the pyramidal tract.
While in the medulla, some fibers cross to the nuclei of certain of the
cranial nerves. The fibers that do not cross in the medulla form the
direct pyramidal tract. The indirect motor tract contains fibers that
pass into the internal capsule, that are in relation with those of the direct
tract but in addition, connect with the optic thalamus. They pass on
through the cerebral peduncles into the pons. They then cross the median
line into the cerebellar peduncles and thence into the cortex of the cere-
bellum. This tract is concerned in co-ordination of the muscles per-
forming the finer movements of the body and the automatic action of
these muscles as in walking, or the use of the hands in the playing of
musical instruments, etc. The direct motor tract is concerned in all the
voluntary movements and Dana says that when the anterior horn cells
of the cord "are cut off from it by disease, there is a special form of paraly-
sis. The' sensory tract is also divided into a direct and an indirect. The
direct tract includes the fibers that carry impulses from the skin. These
pass into the posterior spinal ganglion, across the posterior columns of
the cord, into either Gower's tract or the anterior ground bundle, the
medulla and pons and finally into the optic thalamus. It then sends
out terminal branches to the cortex that forms sensory areas. The in-
direct sensory tract, according to Dana, carries impulses which originate
in muscles, joints and viscera. These pass through the posterior roots
into the spinal cord, thence up the posterior column of the cord on the
same side. They decussate then to the opposite side and go to the cortex
of the cerebellum, while others terminate in the red nucleus and the optic
thalamus. Still others pass up into the cells of the column of Clark,
thence through the direct cerebellar tracts to the cerebellum. Dana
says: "The direct sensory tracts carry for the most part, the sense of
touch, pain and temperature. The indirect sensory tracts are concern-
ed with sensation from the muscles and joints which have to do with co-
ordination and also with visceral sensation. It is through the indirect
sensory and indirect motor tracts that the automatic and psycho-reflex
acts are performed. " These tracts are of interest to us in that hem-
orrhages, emboli and diseases from other causes, affect them and thus
the location of the disorder can be determined.

The brain is surrounded by three membranes which are named from
their structure and supposed function, the dura mater, araclmoid and pia

APPLIED ANATOMY. 535

mater. The dura mater is the outermost covering, forms the periosteum
of the bones of the skull, divides into septa which separate the cavity
into compartments, and forms the venous sinuses of the skull. It is the
strongest of the membranes and perhaps the most sensitive. Nine-
tenths of its sensory nerves are derived from the fifth cranial, while the
remaining posterior portion is supplied with sensation by the pneumo-
gastric.

The arachnoid is a thin, fibrous, non-vascular, spider-web-like mem-
brane that lies between the dura and the pia mater. There is a space
between this layer and the dura mater called the sub-dural-araclmoid
space, and the cavity thus formed resembles a serous cavity, since it is
lined with epithelium. The space between the arachnoid and the pia
mater is called the sub-arachnoid cavity. These spaces contain a ser-
ous fluid called the cerebro-spinal fluid. This layer is non-vascular and
has no sensory nerves.

The pia mater is the nourishing layer as its name indicates, since it
supplies the outside of the brain with blood. It is continuous with the
pia mater of the spinal cord and is in close relation with the folds of the
brain. From it are formed vascular folds from which is derived the
choroid plexus that supplies some of the ventricles of the brain. Dana
says that it has vaso-motor, but no sensory nerves.

The functions of these membranes are: first, to furnish a cavity
that contains the cerebro-spinal fluid by which the intra-cranial pressure
is regulated; second, to serve as a protection against injury, congestion
or other diseases of the brain, the membranes being very sensitive and,
third, to furnish nutrition and blood to the brain. In nearly all head-
aches that are intra-cranial, the pain is the result of pressure against these
membranes from congestion of the brain. Prolonged headache on one
side is a prodromal symptom of apoplexy, it being the result of increased
amount of blood and increased blood pressure. These membranes may
be stimulated by other causes such as toxic material in the blood and by
growths producing direct pressure. The intra-cranial type of headache
is characterized by increase of pain when the blood pressure is in-
creased as in stooping, or by exertion by which the action of the heart is
increased, which aggravates the congestion. Lesions that produce con-
gestion of the meninges of the brain or increase the amount of blood in the
cranial cavity by obstructing the drainage, inhibit the vaso-motor
centers or increase the heart's action, will produce headache. Over-

536 APPLIED ANATOMY.

use of the centers in the brain will produce congestion which is frequently
followed by headache. This is best illustrated by cases of weakness of
the eyes or overuse of them, invariably producing headache. Riding
on the train, especially if the patient attempts to read or watch the near-
by passing objects, will increase the activity of the centers for sight and
thus produce a congestion. The painful effect is explained by the fact
that this abnormal amount of blood produces a painful pressure on the
coverings of the brain.

The subject of the blood supply of the brain's membranes and the
conditions affecting it are of vital importance to the osteopathic prac-
titioner. Upon the disturbance of this depends most disorders of the
brain, that is, such disorders as arise from causes without, rather than
from causes within the cranial cavity, although in some cases there may
be abuse of function or pressure of the skull from injury. The arterial
blood is derived from the external and internal carotid, and the vertebral
arteries.

The meninges are supplied almost entirely by the external carotid.
The posterior meningeal branch, which comes from the occipital, supplies
the dura mater of the posterior fossa of the skull. The ascending pharyn-
geal gives off meningeal branches that are distributed to the dura mater
in the posterior and middle fossa? of the skull. The internal maxillary
artery, through its largest branch, the middle meningeal, supplies the
greater part of the dura mater.

Perhaps the most important branches of this artery from a path-
ological point of view, are those that supply the Gasserian ganglion. It
is possible that the branches which enter the Gasserian ganglion also
supply the different divisions of the fifth cranial nerve. The vaso-motor
impulses that supply these branches are derived, so far as can be deter-
mined, from the upper thoracic spinal cord and pass by way of the su-
perior cervical ganglion and its internal branches to the carotid plexus,
which gives off secondary plexuses that surround its branches. Judg-
ing from clinical observation, a lesion along the course of these nerves
will produce a vascular disturbance in the parts supplied by the above
named arteries. Some seem to doubt the existence of vaso-motor nerves
n the blood-vessels of the brain. Dana says the blood-vessels of the
brain probably have vaso-motor nerves. Landois makes a similar state-
ment while Langley claims that they are not demonstrated physiologically
but are histologically. Whether they have or not, undoubtedly cervi-

APPLIED ANATOMY. 537

cal lesions produce constriction and dilatation of the blood-vessels and I
believe these results are through vaso-motor nerves. At least it has been
demonstrated that the meningeal vessels have nerves. From this it
follows that any lesion that inhibits or stimulates the passing of vaso-
motor impulses to the meningeal branches of the external carotid, or
especially to the branches that supply the Gasserian ganglion, will pro-
duce vascular disorders in the above named parts. It isn't so much a
question that spinal lesions affect the circulation of the brain as how it
affects it, the first being conceded, the second, not clearly demonstrated.

The internal carotid artery supplies the anterior and upper part of
the brain. Its branches that have to do with supplying the brain are
the anterior meningeal, posterior communicating, anterior cerebral,
middle cerebral and anterior choroid, Gasserian, cavernous and pituitary.

The meningeal branch of the internal carotid supplies the dura mater
of the middle fossa and anastomoses with the small and middle men-
ingeal from the internal maxillary.

The posterior communicating artery comes from the internal carotid
near its termination. It supplies branches to the optic tract, the inter-
peduncular region, cms cerebri and the uncinate convolution of the
brain. It also sends a branch to the optic thalamus.

The anterior cerebral artery supplies the greater part of the anterior
portion of the brain and the basal ganglia. It gives off large branches to
the frontal and parietal lobes. The anterior communicating artery is
a transverse trunk that connects the two anterior cerebral and is of in-
terest in that the ganglion of Ribes is on this artery. The ganglionic
branches supply the caudate nucleus. The commissural supply the
corpus callosum. The cortical or hemispherical branches of the anterior
cerebral, supply the olfactory buib, the frontal convolutions, the marginal
convolution, the lamina cinerea and the quadrate lobe. Undoubtedly
these arteries have vaso-motor nerves that are derived from the cervical
sympathetic, since lesions of the cervical vertebra? affect this part of the
brain. Since the glanglion Ribes is in such close relation with the an-
terior cerebral artery, it certainly seems reasonable that it has something
to do with its innervation, that is, it furnishes either vaso-inotor or
trophic impulses to it, or probably both.

The middle cerebral is the larger of the two terminals of the internal
carotid, and divides into the cortical and central branches. The cortical
branches are given off while the artery is in the fissure of Sylvius in re-

538 APPLIED ANATOMY.

lation with the island of Reil. These branches supply the frontal,
parietal, the external part of the occipital and the temporo-sphenoidal
convolutions. They anastomose with each other to only a slight degree.
They pass to the surface of the cerebrum at almost a right angle to the
surface, hence few would be injured in a stab wound. The central or
ganglionic branches are of pathological interest in that they are the ones
most frequently ruptured in apoplexy. These vessels have received
various names . Cunningham divides them into the internal and external
striate arteries. The internal, supply the internal capsule, and the an-
terior portions of the caudate and lenticular nuclei. The external are
divided into the lenticulo-striate and the lenticulo-optic. The lenti-
cuio-striate supply the lenticular nucleus, internal capsule and the
caudate nucleus. One of these striate arteries, on account of the fre-
quency of rupture has been called by Charcot, the "artery of cerebral
hemorrhage."- The lenticulo-optic supplies the lenticular nucleus and
terminates in the optic thalamus. The nerve supply of the middle cere-
bral, comes from the carotid plexus which surrounds the internal carotid
artery and sends off branches with each division. In hemiplegia, le-
sions of the upper cervical vertebra? are invariably found, which in itself
is pretty good proof that there is some connection between the neck and
the middle cerebral artery. The better proof is that correction of these
lesions is quite frequently followed by marked improvement unless the
hemorrhage has been a severe one. The nutrition of the walls of these
arteries is also affected in hemiplegia, partly as a result of the neck le-
sion and partly as a result of other causes, especially dissipation and hard
mental strain. On account of the fact that these arteries do not anas-
tomose, the absorption of a blood clot is a slow process. Also if the clot
is not absorbed within a short time, softening or degeneration of the
brain tissue will ensue on account of lack of nutrition.

The anterior choroid artery helps to form the choroid plexus and
supplies the optic tract, crus cerebri the hippocampus major and the
internal capsule. It receives its nerve supply from the plexus around the
internal artery. The Gasserian branches are small twigs that supply the
Gasserian ganglion. The cavernous, supply the walls of the cavernous
sinus and the third, fourth, fifth and sixth cranial nerves. This is of im-
portance since it helps to explain certain disorders of these nerves re-
sulting from central and spinal lesions. Derangement of the cervical
sympathetic will in all probability affect these blood-vessels, and thus

APPLIED ANATOMY. 539

produce disorders in the above named cranial nerves on account of this
derangement. The pituitary branches supply the pituitary body. The
function of this body is not well known but it is supposed to furnish an
internal secretion that increases the contraction of the heart and arteries,
and influences the metabolism of the bones and nervous system. Ex-
perimentally, its removal in a dog produces (1), diminution of body-
temperature; (2), loss of appetite and lassitude ; (3), muscular twitchings,
tremor and spasms; (4), dyspnea. (Raymond). Lesions of the neck pro-
duce in some cases, similar effects and possibly through disturbances of
this body.

The vertebral artery with the basilar, give off the posterior cerebral,
the posterior inferior, anterior and superior cerebellar, posterior menin-
geal, transverse or pontal and the internal auditory.

The posterior cerebral artery divides into central and cortical
branches. The central, supply the optic thalamus, the walls of the third
ventricle, eras cerebri, choroid plexus and the corpora quadrigemina.
The cortical branches supply the occipitotemporal, uncinate, and the
lingual lobes. Although the blood does not pass directly from the ver-
tebral to the posterior cerebellar, it going through the circle of Willis, it
seems that the nerve filaments that surround the vertebral pass on to the
branches of the basilar. Clinically, an impairment of the vertebral
arteries will affect the eyes. One explanation is that the blood supply
of the cells of origin of the optic nerve is affected by such a lesion through
disturbances of the vertebral artery from spinal or other lesions.

The posterior inferior cerebellar, is the largest branch of the vertebral.
It supplies the vermiform process, medulla, fourth ventricle, the cortex
of the cerebellum and furnishes branches to the choroid plexus. Upon
the condition of this artery depends the nutrition of the above named
parts. The condition of the artery is determined by the amount of nerve
impulses passing to it. Since they come from the vertebral plexus and
this is subject to injury in lesions of the upper vertebra?, it follows that
such lesions produce disorders of the medulla and cerebellum.

The anterior cerebellar is a branch of the basilar. It is distributed to
the front of the cerebellum and sometimes sends a branch to the pons
and the cms cerebelli. The superior cerebellar supplies the valve of
Vieussens, pineal gland, choroid plexus, optic lobes and the cerebellum.
These branches of the basilar, receive their nerve supply from the verte-
bral plexus and as pointed out above, would be affected by a lesion in

540 APPLIED ANATOMY.

the upper cervical region. The posterior meningeal, is a small branch of
the vertebral that supplies the bone and dura mater of the posterior fossa
of the skull. The transverse or pontal branches of the basilar, supply the
pons and the adjacent parts of the brain. The auditory branch accom-
panies the auditory nerve and supplies it and the internal ear. These
branches are also subject to impairment from neck lesions on account of
the innervation. *Morris in his summary of the cerebral arteries says:
"It will be seen therefore, that the middle cerebral supplies the motor
region, both central and cortical, except a part of the leg centre. It
also supplies the region of the cortex that subserves cutaneous sensibil-
ity, the cortical auditory center and in part the higher visual centre.
It likewise supplies all the cortical regions concerned in speech processes
in the left hemisphere. The anterior cerebral supplies only a small part
of the motor region; namely, the part of the leg centre that occupies the
paracentral lobule and the highest part of the ascending frontal convo-
lution. The posterior supplies the visual path from the middle of the
tract backwards, and the half vision in the occipital lobe. It supplies
also the corpora quadrigemina and the sensory part of the internal cap-
sule. "

The veins of the brain are peculiar in that they form sinuses and
have few, if any muscle fibers in their walls. The meningeal veins form
a net-work in the dura mater with free anastomosis. They do not fol-
low the arteries so closely as do other veins, and do not increase in size
as they approach their terminations. The veins of the cortex ascend
and empty into the superior longitudinal sinus. Gowers says: "The
course of the surface veins is important because it helps to explain the
frequency with which clots form within them. Elsewhere the blood
from ascending arteries passes into descending veins, so that the feeble
pressure through the capillaries is supplemented by the influence of
gravitation." On account of ascending arteries emptying into ascend-
ing veins it is pointed out that the pressure would be lessened to such a
degree that the flow would be retarded in both veins and arteries.
Gowers further says: "Moreover, in the erect posture, the anterior part
of the longitudinal sinus has also an ascending course, while the trabe-
culse that occupy the lumen of the sinus must offer some hindrance to
the movement of the blood. These circumstances help us to understand
the readiness with which clots form in the cortical veins and longitudinal
sinus, when other circumstances favor the coagulation of the blood. "

*Human Anatomy, Morris, p. 533.

APPLIED ANATOMY. 541

The central veins enter into the sinuses. There are fifteen sinuses
of which the important ones are, the longitudinal, the lateral, the straight,
the petrosal, the occipital, and the cavernous. They eventually empty
into the internal jugular vein. The various cerebral veins have no
valves and few, if any muscle fibers in their walls.

Fig. 150. — Showing the veins of the neck and head. (After Quain). Note that
muscular contractures in the neck would obstruct the drainage of these parts.

542 APPLIED ANATOMST.

Some of these sinuses communicate with the veins that are external
to the skull. "Veins from the nose enter the anterior extremity of the
superior longitudinal sinus." The facial vein communicates with the
cavernous sinus. On account of these outlets, epistaxis will often re-
lieve a congestive headache since a great part of the blood comes from
the cavernous and superior longitudinal sinuses. These sinuses when en-
gorged with blood, exert a painful pressure on the meninges which are
quite sensitive and thus the ache is produced. Lesions of the neck tend
to obstruct the jugular vein through tightening of the tissues.

In such cases the blood retained in the sinuses becomes very dark in
color and ladened with toxic materials.

The veins of the cerebellum empty into the lateral, occipital and
petrosal sinuses and the great vein of Galen. Those from the pons,
empty into the basilar and cerebellar veins and into the superior petrosal
sinus. The veins of the medulla drain into the anterior and posterior
median and radicular veins which empty into the occipital, inferior
petrosal and basilar sinuses. Most of these veins are continuous with
those of the upper part of the spinal cord. It does not take a very great
force to materially obstruct these veins since the pressure is not so great
as in other parts of the body. Contracture of the muscles of the neck
and other cervical lesions are the most important of active causes. The
grey matter of the brain is very vascular, it ranking "in richness of blood
supply with the lungs and liver. "

Disturbances of the function of the brain are indicated by many signs
and symptoms. Some of these are dependent upon other causes, hence
are not diagnostic of organic disease, while others are fairly constant and
can be relied upon in the diagnosis of the disorder of the brain. These
indications of cerebral diseases vary in degree from a slight headache to
profound motor paralysis. The disorders themselves vary in degree from
a slight vascular change to extensive destruction of the brain tissue as
in softening. On account of the importance to the practitioner, of a
knowledge of the various indications of cerebral disease, we will consider
in a general way the phenomena that are at least suggestive of such dis-
ease.

A child with a very small head, a condition called microcephalus,
has ordinarily an undeveloped brain. Such a condition will be charac-
terized by idiocy, usually a vicious disposition, some form of motor par-
alysis and other indications of non-development of, or pressure on, the
substance of the brain. These symptoms of course, vary with the

APPLIED ANATOMY. 543

amount of pressure and the degree of development. Ordinarily, a his-
tory of a very hard labor or instrumental delivery is to be expected in
such cases. Although microcephalus is regarded as a congenital dis-
order, I am of the opinion that at least some cases result from injury to
the neck of the child at or immediately after birth. The fontanelles close
early and the ossification of the cranial bones is completed soon after
birth. The above signs and symptoms occurring in a child, are diag-
nostic of disease of the brain, the particular form of disease being non-
development of, or pressure on, the brain substance.

The opposite condition, that is enlargement of the head, is also in-
dicative of disease of the brain. This is called chronic hydrocephalus.
Most of these cases begin at or soon after birth, hence the increase in size
of the head is of diagnostic importance only in the young. If the head
gradually increases in size from birth, the fontanelles and sutures refuse
to close, if the forehead bulges and pressure shows fluctuation, the case
in all probability is one of hydrocephalus. The face does not grow in
proportion to the skull and as a result, the child's face has a triangular
appearance. As this condition progresses, the growth of the body is
retarded, the child does not learn to walk, is unable to support the head
and pressure symptoms soon develop, the symptoms of which vary from
strabismus to convulsions. This enlargement of the head is due to the
gradual accumulation of serous fluid in the ventricles of the brain, which,
in my opinion, is more often the result of injury to the child's neck at
birth, than of all other causes combined. The above mentioned neck
lesions possibly produce this condition through irritation of the meninges
or obstruction of the foramen which connects the serous cavity of the
brain with that of the spinal cord.

Unilateral enlargements of the head are suggestive of exostoses from
injury, but not necessarily of diseases of the brain, or of the mental de-
velopment of the person. Only in a general way are the various prom-
inences of the head indicative of the condition of the part of the brain in
relation.

Impairment of the mental condition is suggestive of brain disease,
which may be due to congestion of a localized area, softening of the brain
tissue or pressure from a tumor or depressed bone. In chronic cases,
insanity invarably carries with it the idea of softening of the brain, which
condition is practically incurable. In children, idiocy, drooling from
the mouth, non-development of the teeth, or early decay and crumbling

544

APPLIED ANATOMY.

of the teeth soon after they are ruptured, inability of the child to learn to
talk or control the movements of the limbs there being a spasticity, are
all indicative of disease of the brain. In such cases the child is usually
overgrown, nutrition good, and ordinarily the child has a craving for
sweetmeats, and organic life is usually good and the child often escapes
many of the diseases of infancy and childhood. Little's disease is the
name applied to such cases.

Complete unconsciousness, if it occurs suddenly, is indicative of

SUP. OPHTHALMIC VEIN ^--_
TENDON OF SUP.OBUQUE — — ^8%.
L'ACHRYMAL GLAND
SUP RECTUS MUS. CUT
EYEBALL
EXT. RECTUS
LACHRYMAL ARTERY
SUP. RECTUS-CUT
INEOPHTHALMIC VEIN
SUP.0PHTHALM1C VEIN
COMMON OPHTHALMIC VEIN

OPTIC NERVE
I NT. CAROTID
OPTIC COMM1S.

Fig. 151. — Showing the veins of -the eye. Since they also drain the appendages
of the eye, any affection of these veins 'would affect both. (After Morris.)

apoplexy. If it comes on gradually, it is usually the result of pressure,
or acute toxic conditions of the blood. Cerebral anemia, whether from
neck lesions, hemorrhage, or from diseases of the heart, often bring on a
gradual unconsciousness. Stupor is often suggestive of cerebral disorder
especially if the patient sleeps a great deal and is hard to awaken out of

APPLIED ANATOMY. 545

slumber. The stupor may be indirectly due to disease of the viscera
which have to do with purifying or forming the blood, and the effect on
the brain being secondary as a result of the toxemia. Coma is often the
result of injuries to the head that produce hemorrhage or concussion of
the brain substance. It also may be the result of certain poisons. In
diagnosing these various conditions of coma, the odor of the breath, con-
dition of the pupil, character of respiration, urinary changes, color and
the condition of the skin, the pulse and temperature should be taken into
consideration. Delirium, consists of mental excitement usually accom-
panied by hallucinations. It is most frequently the result of a toxemia
from alcoholism and fever. Dementia is indicative of organic disease of
the cerebral cortex.

Convulsions that are epileptiform or chronic in character, are usually
due to disease of the cerebral cortex. Hare says: "The clonic variety
of convulsions are represented by idiopathic, traumatic, reflex and syphili-
tic epilepsy, hysterical convulsions of an epileptic type, uremic con-
vulsions and those convulsions that arise from the presence of growths
or other sources of irritation in the cerebral cortex. " It may be added
that some forms of neck lesions produce irritation of the cortex through
derangement of the circulation. In Jacksonian epilepsy, the convul-
sions are local with progressive extension to adjacent muscles with little
or no involvement of the mind. This form is usually caused by a pressure
either of a tumor, or fracture of the cranium. Spasms that are general
point to diseases of the brain. Forced movements and intentional tremor
also point to a central origin. Vertigo is usually suggestive of a vascu-
lar disturbance of the brain and is only a symptom. It is a symptom
of disease of the labyrinth, cerebellum, cerebellar peduncle and of general
anemia of the brain. In disorders of the heart, vertigo is often found as
a complication. Vertigo is also a premonitory sign of an epileptic at-
tack and of disseminated sclerosis. All the forms of vertigo are pri-
marily dependent upon the vascular changes in, and condition of, the
blood-vessels of the brain. Persistent headache in one localized area of
the head, is symptomatic of congestion which may lead to apoplexy.
Pressure from other causes such as tumor, fracture with displacement of
a portion of the cranial vault, thrombosis and congestion of the meninges
produce headache, and therefore these things should be considered in de-
termining the cause. Headache, like vertigo, is only a symptom of dis-
ease and, like it, is dependent on changes in the quality and quantity of
li

546 APLLIED ANATOMY.

the blood in the brain tissue. Headache may be the result of congestion,
anemia or toxemia of the brain. The forms of headache that point to
disease of the brain are those that are localized and prolonged, moving
about or stooping making it worse; and those accompanied by vertigo,
spasm, affections of the eye, such as amaurosis, ptosis and ordinarily
those accompanied by vomiting as in tumors of the brain. This particu-
lar type of headache can partly be diagnosed by the elimination of causes
outside of the skull that are responsible for many cases of headache.

The condition of the pulse is in some cases, suggestive of brain dis-
ease. If the medulla or the center for the pneumogastric nerve is in-
volved, there will always be some cardiac disorder. In tumors of the
brain, cerebral abscesses or pressure from other causes, the pulse rate is
often lowered, it sinking to as low as thirty beats per minute. In some
cases this is so marked that the temperature may be quite high and still
the pulse rate slow. Certain disorders of respiration come from brain
disease, especially affections of the medulla in which are located the re-
spiratory centers. The Cheyne-Stokes respiration occurs in cases in
which there is pressure on any part of the mechanism which controls
respiration, such as hemorrhages, tumors and aneurisms. In this respira-
tion, the breaths become more rapid and deeper until they reach a climax,
which is followed by a stage of apnea. The cycles continue for a short
while when the patient either gets very much better or it terminates
fatally, which is the usual ending.

Apoplexy is diagnostic of disease of the vessels of the brain. This
disease is usually one of hardening of the blood-vessels, on account of
which there is loss of elasticity, so that any change of pressure more
readily affects these walls, thus producing rupture with its consequent
hemorrhage. This rigidity of the arteries or atheromatous condition,
is the residt of alcoholism, high living, excesses, kidney disease, mental
strain and bony lesions of the neck. Church says: "The strongly
acting heart drives the blood column through the rigid aorta and carotids
and its full force falls upon the arteries arising from the Circle of Willis.
These are of comparatively small caliber and, not having outlets by
anastomosis, oppose a dead wall of resistance to the directly received
cardiac impulse. Surrounded in turn by parivascular spaces and not
supported by firm parenchymatous tissues, their walls weaken by age
or infection and yielding at numerous points to the formation of sacular
dilatations, arterial rupture naturally follows." A person is said to

APPLIED ANATOMY. 547

have the "apoplectic build," when the complexion is florid, that is, the
superficial capillaries of the skin quite markedly dilated, is obese and
short of stature. In such people hemorrhage in the brain may follow
from exertion or from emotional causes.

Hemiplegia is diagnostic of disease of the brain. It usually results
from hemorrhage, but may result from pressure from other causes, such
as a tumor, embolus, and depression of the cranial vault. The degree of
hemiplegia is fairly indicative of the degree of cerebral disorder. If the
paralysis is only partial, it suggests a hemorrhage that is not extensive,
but from which the patient usually recovers. If the hemorrhage is ex-
tensive, there will be complete paralysis, which is usually permanent.
The hemiplegic state is characterized by sensory, as well as motor disturb-
ances of the lateral half of the body. In the upper extremity, the flexors
draw the fingers in the palm of the hand, flex the wrist, pronate the arm
and the elbow is fixed at aright angle. The arm is carried close to the
body and there is to all intents and purposes ankylosis of the joints. The
hand is cold a great deal of the time, the skin like that of a baby, and a
clammy perspiration is present. In the lower limb, there is loss of move-
ment so that the leg is dragged and the toe of the shoe is worn off on ac-
count of the dangling of the foot. When the patient attempts to take
a step, the body weight is thrown forward and the toe describes an arc
around the other foot. Contractures sometimes develop which are most
common in the tendons behind the knee. If there is crossed paralysis,
the face on the same side as the lesion, is paralyzed. In ordinary cases,
only the lower half of the face is impaired, which affects the mouth, nose
and chin, particularly the lips. This differs from Bell's paralysis in that
in the latter, the upper as well as the lower part of the face is involved.

Some cases of monoplegia are the result of disease of the cortex.
The seat of the lesion is in the internal capsule in such cases. Hemian-
esthesia, which is partial or complete, comes from a central cause. If
it comes on suddenly, it is suggestive of apoplexy but usually the condi-
tion is associated with motor paralysis. In disseminated sclerosis,
hemianesthesia is sometimes found. In cases of apoplexy, Church says:
"Only in those cases in which the lesion destroys the sensory pathway in
the posterior third of the posterior limb of the capsule do we have per-
sistent hemianesthesia corresponding to hemiplegia. "

Ataxia may be the result of disease of the brain as is demonstrated
in cerebellar ataxia. Oppenheim says diseases of the sensory centers

548 APPLIED ANATOMY.

and conducting tracts may also cause ataxia in the extremities of the
outside of the body.

Ptosis is indicative of disease of central origin especially if it comes
on suddenly. Back of this are found neck lesions that seem to be re-
sponsible for the effect, in that correction of them in some cases seen by
the writer, resulted in the curing of the disease within a short time after
the treatment was given. In these cases the lesion affected the vaso-
motor or trophic nerves to the center of the brain, in which is located the
origin of the occulo-motor nerve. Ptosis may be the result of causes
other than brain disorders, but if it is chronic and accompanied by hem-
iplegic symptoms, and if it comes on suddenly, the chances are that it is
of central origin.

Conjugate deviation of the head and eyes is quite indicative of cere-
bral disease. This deviation is usually toward the side of the lesion and
is most marked in the beginning of the hemiplegic state. If the hem-
orrhage is quite low or in the pons, the eyes will be turned away
from the lesion while the head will be drawn in the opposite direction.

Disturbances of vision such as atrophy of the optic nerve, optic
neuritis and choked disc, are usually the result of central disease. Hem-
ianopsia also results from central lesion. The rolling of the eyes or
nystagmus, occurs in certain forms of brain disorder. Very marked
prominence of one eye is suggestive of a cerebral tumor which is forcing
the eye out into prominence. Often the size of the pupil is affected in
brain disorders. In tumors, the pupil is usually contraced. §g

Certain disorders of the speech such as aphasia is indicative of dis-
ease of the brain. Aphasia consists of an impairment of the ability to
express thoughts or ideas with words or signs and to comprehend spoken
or written language. There are different forms of this which depend
upon the extent of the lesion. Broca's convolution, is usually the seat
of the lesion in this disorder. A slow, scanning speech is characteristic
of Friedreichs' ataxia. A hesitating, halting speech in which the patient
mutters and mumbles in an indistinct and blurred manner, is found in
paretic dementia. In a very indistinct speech in which the patient has
trouble in pronouncing the letters in which the lips are used, disease of
the medulla is to be expected. This is called glosso-labia-pharyngeal
paralysis.

Agraphia is the loss of power to write his own ideas but can copy per-
fectly. The insertion of wrong words, that is, when a patient attempts

APPLIED ANATOMY. 549

to name an object and is conscious of having called it wrongly, is called
paraphasia. These conditions are indicative of some central lesion in
cases organic in character and in others, only functional from vaso-motor
disturbances. If a patient has a staggering gait, intention tremor,
if he reaches for an object and the hand moves all around it and finally
the object is suddenly seized, if there is nystagmus, slow, scanning speech
called a syllabic speech, it points to disseminated sclerosis. If vomiting
occurs that is independent of the taking of food and is most marked in
the morning and there are other indications of cerebral disorder such as
vertigo, chronic headache, slow pulse, choked disc, it points to disease
of the brain.

In the average case of brain disorder, lesions are present in the neck
that act as predisposing or as exciting causes. The explanation is that
in the neck are centers that regulate the amount of blood that passes to
the brain and these vaso-motor centers are affected by lesions of the
upper cervical vertebrae. Not only is the arterial supply to the brain
interfered with, but the drainage obstructed by the contracture of tissues
with which the veins are in relation. Another point to be considered in
the production of cerebral disorders especially functional disturbances,
is the condition of the heart. If the heart is irritated, too much blood
will be forced into the cranial cavity and thus produce a cerebral con-
gestion. This condition is the more important, if there are neck lesions
that affect the vaso-motor nerves that govern the cerebral circulation.

Disease of the kidneys predispose to brain disorders, by affecting
the nutrition of the blood-vessels. Worry, over-work or prolonged ap-
plication to any one subject, tend to produce vascular changes in the
brain that often become pathological. Each compartment of the brain
has its function to perform. When it is performing its function, that is,
when the center is active, more blood is sent to the part. If the part is
over-worked, the congestion may become pathological and the function
of the part be lost or suspended. Many a case of insanity, is the result of
overuse of a certain part of the brain to the exclusion of other parts, and
degeneration of the part is the result. The cerebral circulation should be
equalized by using the different parts, that is by changing the thoughts
and thus shift the activity from one part to another. For example, a
student along any line should devote a part of his time to relaxation of
the mind by change of subject or by physical exercise in which there is
competition, so that the mind is taken entirely off from the persons'

550 APPLIED ANATOMY.

hobby. By doing this every day, the mind gets its rest and the cerebral
circulation is the better equalized. It is all the more important in cases
in which the circulation through the brain is impaired by cervical or other
lesions. The writer's hobby is that all parts of the body are in some
way connected with the spinal cord. This includes the brain. Spinal
lesions impair this connection, hence predispose to cerebral disease.

THE EYE.

The eye, the most important of the organs of special sense, is of
pathological interest in that it is often diseased and particularly in that
it is a fairly accurate index as to the general physical condition. If a
person is exhausted, the condition is at once manifest in the eye. Sick-
ness and suffering are depicted in the eye. On account of the eye being
such a reliable index as to the condition of the body, the various pathol-
ogical signs -and symptoms of which the eye is a part, will be taken up
separately with the idea of anatomically explaining these effects.

A localized prominence of one eyelid is indicative of a Meibomian
cyst. The Meibomian or tarsal glands, occupy the middle of the tarsal
cartilages. They empty their secretions by means of slender ducts that
extend to the inner and anterior edge of the eyelids. The openings of
these ducts, there being about thirty in each lid, are characterized by
minute apertures arranged in rows. A stopping of these ducts will lead
to the formation of a retention cyst, called a Meibomian cyst. They can
be removed by manipulation by which the tumor is grasped and com-
pressed. In none of the cases treated by the writer was it necessary to
resort to an operation. They are harmless but mar the beauty of the
eye.

A red, angry condition of the inner surface of the lid is diagnostic
of conjunctivitis. This condition is the result of many causes of which
the lesions of the neck are the most important. These lesions, as pointed
out before, affect the eyelid through the innervation of the blood-vessels.
The vaso-motor impulses that innervate the blood-vessels of the eyelids
are derived from the spinal cord, pass up through the superior cervical
ganglion, thence along the cavernous plexus to the ophthalmic artery
and its branches, some of which supply the eyelid. Contractures of the
neck muscles will in a very short time, produce a redness of the eyelids.
This is called "catching cold in the eye" but really it should be called
"contracture of the muscles of the back of the neck."

APPLIED ANATOMY. 551

A thickened condition of the eyelids is suggestive of disease of the
hair roots, especially if there is marked redness and a turning in of the
eye-lashes. In some cases, this reddened, thickened condition of the
lid is due to gonorrheal infection.

Twitching of the eyelids is symptomatic of nervousness, chorea, his-
trionic spasm and disorders of the third and seventh nerves. Unless the
condition forms a part of a general nervous affection, neck lesions are
invariably found in such cases. Such lesions affect the nutrition of the
muscles and nerves involved and thus render them more irritable. Eye
strain, is an important cause in children, of twitching or spasmodic wink-
ing. It is suggestive of weakness of the eyes or some refractive disorder.
Blepharospasm is nearly always the result of lesions of the upper cervical
vertebra?. In nervous, hysterical people, a quivering of the eyelid is a
fairly constant symptom. In feigned unconsciousness, this quivering of
the lids is nearly always present. Some forms of spasmodic contraction
of the lids are due to central lesions.

Ptosis is nearly always the result of a lesion of the brain. Back of
this are lesions that impair the circulation to the brain and thus are re-
sponsible for the paralysis.

A sty or hordeolum, seems to be the result of infection of a hair fol-
licle. If the dead root of the hair is removed at once, the sty can often
be aborted. Vascular and nutritive disorders of the eyelid, predispose
to their formation. These result from overuse of the eye, congestion of
the brain and lesions in the upper cervical region especially at the second
and third vertebral articulations.

A puffy condition around, but especially below, the eye is sugges-
tive of either heart or kidney disease. The explanation of the phenome-
non is not very clear but it is supposed to be due to the character of the
tissues of this part, they being loose and flabby. For the same reason
an injury to any part in relation, will cause a black eye, on account of the
extravasation of blood into these tissues.

Dark rings under the eyes are due to exhaustion of the patient. In
the female they are indicative of menstruation. They are not diagnostic
of any special disorder, but are suggestive of female weakness. These
rings are most pronounced in the dark complexioned.

The escape of tears is the result of excessive secretion, stopping of the
lachrymal ducts or to weakness of the eye so that any exciting cause pro-
duces an increase of secretion. If the eyes "water" on exposure to the

552 APPLIED ANATOMY.

wind, it is almost diagnostic of weakness of the eyes. Lesions of the
neck affect the lachrymal gland and if irritative, increase the amount of
tear secretion.

A flattened eyeball is diagnostic of far sightedness or hypermetropia.
A bulging, convex eyeball is indicative of near sightedness or myopia.
These conditions are usually easy to diagnose if at all typical but if only
slightly marked, they may be overlooked.

If the eyeball is red and inflamed, or if it is "blood shot," it is in-
dicative of conjunctivitis or a hemorrhage from rupture of some of the
blood-vessels of the eyeball. The catching of cold in the eye, will pro-
duce an engorgement of the small vessels to such an extent that it be-
comes intensely red in appearance. Rupture of the blood-vessels, re-
sults from trauma or intense straining as in a paroxysm of whooping
cough. In such cases there is extravasation of blood into the tissues
around and in the eyeball which gives it the extremely red, angry ap-
pearance. Usually the eye clears up in a few days but in the wTorst cases
it may take several weeks. If there is only an engorgement and no
rupture of the vessels, the neck lesions are the most important causes
and by applying the proper treatment to the neck, the congestion can be
relieved in a short while.

If there is a localized area of engorgement of the superficial vessels
of the sclerotic coat, with a "peculiar fleshy mass of hypertrophied con-
junctiva" it is called a pterygium. It most commonly starts from the
inner canthus and gradually advances across the eyeball in the horizontal
meridian. It sometimes reaches and crosses the cornea and pupil, in
which cases the eyesight is affected. Aside from irritating particles that
act as exciting causes by producing congestion, the neck lesions, espec-
ially those of the axis, are the important causes of pterygium in that they
inhibit the passing of the vaso-motor impulses from the spinal cord to
the blood-vessels of the eye. These impulses seem to originate in the
upper part of the thoracic spinal cord and pass to the eye by way of the
cervical sympathetic ganglia and the ascending branches that form the
cavernous plexus. This plexus innervates the ophthalmic artery and
all its branches hence the vessels of the eyeball get their vaso-motor sup-
ply from this source. Ordinarily this disorder is treated by attempting
to counteract the effect by ligating or removing the vessels with the
fleshy-like mass. Some cases appear to be cured by the treatment but
in many, the pterygium re-appears since the primary cause, that of the
disordered nerve supply to the arteries, is still active.

APPLIED ANATOMY. 553

The size of the pupil should be considered in the examination of the
eye in brain and spinal cord diseases. If it is contracted, it is indicative
of congestion of the iris, paralysis of the fifth cranial and the sympathetic
supply to the eye, cerebral tumor (early stages), hemorrhage of the brain,
and spinal cord disease especially the part above the third dorsal segment.
Certain drugs and poisons, produce contraction of the pupil and should
be borne in mind when making a diagnosis. Opium and morphine,
when used in large doses, will produce marked contraction of the pupil
to the extent of pin-point contraction. If the pupils are large, it is sug-
gestive of ocular disease such as glaucoma, irritative lesions of the upper
part of the spinal cord, anemia of the brain, syncope, extensive brain
lesions, tumor of the brain, especially the later stages, and of fright,
neurasthenia, a depressed nervous condition, and emotional disturbances.
It also occurs in forced respiration, vomiting and from the use of certain
drugs called mydriatics. Cocaine and atropine and its allied alkaloids,
are the most commonly used in securing dilatation. In cases of uncon-
sciousness in which the pupils are affected, be on the lookout for cerebral
disorder such as apoplexy. If the pupils are of unequal size, it is very
suggestive of brain disorder if the patient is unconscious. In other
cases of eye disease, if the pupil does not respond to the stimulus of light
but the focus remains normal, it is suggestive of spinal cord disease as ■
in tabes dorsalis. This is called the Argyll-Robertson pupil.

A milky appearance of the pupil is indicative of cataract, which is
characterized by opacity of the crystalline lens. Cataract has been
classified in various ways by the different writers, the simplest being into
soft, hard and secondary. The opacity may be in the capsule or the
lens. It is essentially a disease of old age and is the result of mal-nutri-
tion. Lesions of the upper cervical vertebra? will predispose to the forma-
tion of cataract as do diabetes mellitus, wasting fevers, over-work of the
eyes, and irritative disorders of the eye, such as iritis, glaucoma, and
diseases of the retina. The most frequent discoloration of the retina
is white or milky, but it may be black or amber in color. A gentle tap-
ping of the eyeball, is sometimes effective in restoring the sight by caus-
ing change of position of or absorption of the milk-like deposit.

If the conjunctiva is jaundiced it is suggestive of liver disorder. On
account of the clearness of the normal conjunctiva, any bile pigment
would easily be detected if deposited on it. A yellowish eyeball is in-
dicative of ill health whether from liver or other disorder. A pearly

554 APPLIED ANATOMY.

or bluish eyeball is suggestive of anemia or chlorosis. A retracted eye-
ball is present in wasting diseases but especially in acute disorders of the
intestinal tract accompanied by diarrhea. It is particularly noticeable
in cholera and in the summer diarrheas of children. In some cases the
eyeball becomes shrunken while in others the retraction is due to the
emaciation. A prominent eyeball is found in exophthalmic goitre.
There is supposed to be formed a cushion of fat behind the eye which
pushes it forward. This should not be confused with cases in which the
eye is normally prominent. Landois says: "Protrusion of the eyeball
takes place: (1) As a result of marked distension of blood-vessels, es-
pecially of the orbital veins, when there is an obstruction to the outflow
of venous blood (for example in the head after execution by hanging).
(2) As a result of contraction of the unstriated muscle fibers in Tenon's
capsule, in the sphenomaxillary fissure, and in the eyelids, which are
innervated by the cervical sympathetic. " An irritative lesion in the
neck would then produce exophthalmus. In the dog, section of the
cervical sympathetic nerves will produce retraction of the eyeball or an
inhibitor lesion will produce the same effect. The lesions in exoph-
thalmic goitre are often found in the cervical region, thus both the effect
on the eyeball and the thyroid gland can be accounted for. It has been
observed that contraction of Muller's muscle produced protrusion of
the eyeball. This muscle also receives its innervation from the cervical
sympathetic and thus would be involved in neck lesions.

The appearance of the eye is indicative of the degree and character
of the illness. In pneumonia, the eye is unusually bright and the patient
is on the alert and sees everything that takes place in the room. In
typhoid fever, the eye is listless and the patient is not cognizant of the
surroundings. As a rule, the eye has a dull sleepy appearance and the
movements of the eyelids are very slow in patients that are really sick.
The eye of an insane person is roving and restless and the patient does
not look his questioner in the face but attempts to avoid his eye. In
alcoholism, the eye has a dazed expression; a similar one is seen in epilep-
tics and confirmed masturbators.

Strabismus or squint, is indicative of weakness of the eye-muscles,
of central disease and quite frequently of disorders of the cervical spinal
cord as a result of a neck lesion. Nystagmus or rolling of the eyeballs
occurs in hysteria, brain disorders and irritative conditions of the upper
cervical cord. It occurs in convulsions and in the disease called Freid-

APPLIED ANATOMY. 555

erick's ataxia. It is the direct result of a disturbance of the centers in
the brain that control ocular movements.

A blurring of the vision is suggestive of disease of the optic nerve.
If in the field of vision there appear floating objects, or if a part is ob-
structed, blindness will appear within a short while if care is not taken.
If the object or "speck" is stationary that is, stays at such a point that
the eye can not be focussed directly on it, it is probably due to a particle
in the humor of the eye or else a congestion of some of the blood-vessels
of the eye.

Hemianopsia, is the result of disease of the optic tract, that is in the
optic nerve or chiasm, or of disease of the visual centers. In this dis-
order the patient often carries the head to one side in order that the
rays of light may enter the eye to the best advantage. As pointed out
before, disturbances of the cervical sympathetic nerves will affect the
nutrition of the centers for vision and among other effects, hemianopsia
sometimes results. Diplopia is usually binocular, and is the result of de-
rangement of the muscular balance so that the image of the object is
thrown upon two points of the retina instead of being focused on only
one point. It most commonly is the result of strabismus but may occur
in cases of impairment of vision and in constitutional diseases. Pressure
on the eyeball will produce diplopia. The writer has seen some cases
in which lesions of the upper thoracic and cervical vertebra?, were re-
sponsible for the disorder. It is not unusual for an injury to these re-
gions to produce strabismus and double vision within a very short per-
iod of time. The explanation of the relation that exists between the
eye and the cervical and dorsal regions lies in the fact that the motor,
vaso-motor and secretory nerve supply to the eye comes almost entirely
from the upper part of the spinal cord and muscular contractures and
bony lesions in relation, will interfere with these nerves.

Pain in the eye is usually due to congestion of the eyeball. This
congestion may be the result of eye-strain, brain disease, congestion of
the centers for vision, reflexly from disturbances of the pelvic organs
or from disturbances of the cervical sympathetic nerves through which
vaso-motor and other impulses reach the eye. Pain in the eyeball often
comes from increased intra-ocular tension as in glaucoma. Congestion
of the brain will produce a similar effect. Intense pain in one eye may
and often does come from pelvic congestion or inflammation; in the
female a displaced uterus being frequently the cause. Abuse of the eye
will produce a pathological congestion, hence the pain.

556 APPLIED ANATOMY.

Weakness of the eyes has become a serious problem in the young.
One has only to note the great number of people, especially young girls,
that wear glasses. Weakness of the eyes may be a part of a general
weakness of the body and should be associated, in the young, with
weakness of the generative organs, and sexual abuses are responsible
for many cases. The frequency of neck lesions is an important cause
and often, in fact, in nearly all cases can the eyes be at least strength-
ened by the correction of the cervical lesions. By doing this, better
circulation and nutrition of the eyes are assured and consequently they
become stronger. In all eye affections whether the trouble is in the
eyelids, lachrymal apparatus or the eyeball, examine for lesions of the
articulations of the axis and the second thoracic vertebra. If the
trouble is an inflammatory one, first of all carefully examine the eye
for the presence of a foreign body that causes an irritation hence the
congestion and inflammation.

THE EAR.

The ear is divided into the external, middle and internal ear. The
external, includes the pinna and the external auditory canal. The
pinna varies in shape and size in different individuals but these varia-
tions as a rule are of no practical importance except in the degenerate
and the insane. The color of the pinna is indicative of the patient's
state of health. If it is pale and anemic, the blood is impoverished and
the patient is weak and anemic. If they are red or pink in color, it is
indicative of good blood, hence a healthy condition.

The external auditory canal extends from the concha inward to the
tympanum. From without in, it is directed upward, forward, inward
and slightly downward. On account of these changes in direction, the
pinna should be grasped and drawn upward and forward in attempts to
inspect the canal. The canal is composed partly of bone and partly of
cartilage, the cartilage lining the outer portion. The skin that covers
the pinna is continued into the meatus and lines the entire cavity and
covers the outer surface of the tympanum. That part lining the ex-
ternal portion has in it a number of tubular glands called the ceruminous
glands. The cerumen serves as a lubricant and protects against the in-
vasion of the part by foreign bodies. In the very rugged, there are
several large, stiff hairs that guard the entrance to the canal. The
canal serves as a conductor of the sound-waves to the tympanum. It

APPLIED ANAYOMY. 557

receives its blood from the posterior auricular, the superficial temporal
and the deep auricular branch of the internal maxillary. Its nerve
supply is principally sensory and is derived from the auriculo-temporal
branch of the fifth and the auricular branch of thepneumogastric. These
nerves are affected by neck lesions, subluxation of the lower jaw and by
caries of the teeth. Contracture of the neck muscles as in the catching
of cold, often brings on earache especially in the young. Such a lesion
either affects the vaso-motor supply to the canal or else the sensory
nerves direct. In the average case the disorder is due to a vascular
change in which the blood pressure is increased, such being character-
ized by the throbbing pain. Earache from other causes consists of a
continual, constant pain.

Although the canal is curved in several ways in order to prevent
foreign bodies from getting into the canal, yet in children it is not un-
usual for cherry-stones, beads and other objects to find their way into
the meatus. Insects sometimes pass into the canal and give rise to a
great deal of discomfort in addition to the impairment of the sense of
hearing. Soon after the entrance of the insect into the ear, that is, be-
fore it dies,- it can usually be removed by pouring into the ear some
luke-warm water.

Polypi occasionally form in the canal. They cause disturbances of
the tympanum from pressure and in some cases seen by the writer, pro-
duced Bell's paralysis. A discharge of pus from the meatus, is indi-
cative of suppuration of the mastoid process or of the middle ear, and
perforation of the ear-drum. The ear should be thoroughly cleansed to
prevent desiccation of the discharge on the tympanum.

The escape of cerumen occurs in anemic and constitutionally dis-
eased children. Hardening of the ear-wax produces an impairment of
hearing in that it interferes with the vibrations of the ear-drum. In all
cases of unilateral deafness it is advisable to examine quite thoroughly
the external auditory meatus; in tinnitus aurium, a desiccation of the
wax -may be the cause.

The tympanum is of importance from a pathological standpoint
in that it is quite frequently the seat of disease. It is an irregularly
shaped cavity in the temporal bone and connects the external and middle
parts of the ear. It communicates with the mastoid cells and the
pharynx. On account of these communications, disease may travel
from the mastoid cells and the throat to the middle ear. The ear-drum

558 APPLIED ANATOMY.

which separates the tympanum from the external ear, is a membranous
structure that is placed obliquely in the canal. It is disc-shaped with
its convexity directly outward. Its function is to transmit the sound
waves to the middle ear and the ossicles. It does this by vibrating.
If it is very tense, the vibrations are increased in intensity and roaring
of the ear is the result. If it is relaxed, the sound-waves are not trans-
mitted in a normal way and deafness, partial or complete is the result.
If the air-pressure is not alike on the two sides of the membrane, it will
be forced to the side of lesser pressure and its function is affected thereby.
The membrane can be seen by the aid of an ear sjneculum. If it is healthy,
it is of a "pearly-gray" color and presents a glistening surface. The
short process of the malleus, appears as a whitish point while the handle
of this bone forms a ridge leading from this point downward and back-
ward.

The tensor tympani muscle produces by its contraction, increased
tension in the tympanum by drawing the handle of the malleus inward.
It is supplied by a branch from the motor division of the fifth, by way of
the otic ganglion. Since lesions of^the upper cervical vertebrae will
affect the fifth nerve, such a lesion will affect the tone of the ear drum
and thus an impairment of its function will result.

The tympanum receives its blood from the deep auricular branch of
the internal maxillary, the tympanic branch of the same artery and from
the stylo-mastoid branch of the posterior auricular. These arteries are
supplied with vaso-motor impulses from the superior cervical sympa-
thetics by way of the carotid plexus. Therefore a lesion that affects the
source of these impulses or the nerves over which they are transmitted,
will produce trophic and vascular disorders in the tympanum. It has
been demonstrated clinically that such is the case.

The veins that drain the tympanum empty into the external jugular,
the venous plexus that surrounds the Eustachian tube, the veins of the
dura mater and partly into the lateral sinus. From this it is seen that
muscular contractures of the cervical region, occlusion of the Eustachian
tube, and congestion of the brain and meninges, will obstruct the drainage
of the tympanum and thus produce vascular disturbances of it. Neck
lesions are directly or indirectly responsible for vascular disorders of the
ear-drum.

The nerve supply of the tympanum, comes principally from the auri-
culo-temporal branch of the fifth cranial, the auricular branch of the

APPLIED ANATOMY. 559

pneumogastric, the tympanic branch of the glossopharyngeal (Jacob-
son's nerve) and the carotid plexus. Disturbances of these nerves af-
fect the function of the ear-drum, therefore impairing the sense of hearing.

The mastoid antrum and cells are of interest in that abscesses oc-
casionally form at these points. The}' may be affected from disease of
the ear, trauma or by lesions of the neck in that the nerve supply to
them is from the first cervical nerve.

The Eustachian tube connects the middle ear and the naso-pharynx.
Its function is to conduct air to the tympanum in order that the pressure
on the two sides of the ear-drum be equalized. The tube is composed
parti}' of bone, internal part, and partly of cartilage. It is about one
and one-half inches in length, is lined with mucous membrane that is
continuous with that lining the naso-pharynx. In inflammation of the
throat as in measles, the disease is prone to travel along the tube to the
ear and there set up an otitis media. Catarrhal conditions of it are very
common and lead to partial deafness and tinnitus aurium. The ex-
planation is that in an occluded condition of the tube, the external air
pressure forces in the tympanum, the internal pressure being lessened
by the absence of air. In tonsillitis, sore throat, or in any disease of the
throat characterized by congestion and swelling, the tube becomes
partly or completely closed and partial deafness is the result. The
fifth cranial nerve furnishes sensory impulses to the tube while the sym-
pathetic or vaso-motor fibers, are derived from the cervical region by
way of the superior cervical ganglion and the branches that accompany
the internal maxillary and ascending pharyngeal arteries. The tube
can often be opened by relaxing the contractured tissues of the throat
and by relieving the congestion partly by deep, and forward and down-
ward manipulation under the angle of the jaw, and by the correction of
the cervical lesions that are so frequently present.

The ossicles of the ear are the malleus, stapes and incus. They
form an irregular chain or line of levers through which the sound-waves
are supposed to pass. They also furnish attachment for the muscles of
the middle ear. Inflammatory diseases of the middle ear, such as otitis
media, involve these bones and as a result, they poorly transmit the
sound-waves and give insecure support to the muscles of the tympanum,
the tensor tympani and the stapedius.

The inner ear consists of the vestibule, semicircular canals, cochlea,
and the membranous labyrinth. This part of the ear is located in the

560 APPLIED ANATOMY.

petrous portion of the temporal bone and is quite well protected against
injury. Most of the disorders of this part of the ear, come from causes
external to it, that is from extension of disease from the middle ear or
from lesions of the upper cervical vertebrae that affect the nerve and
blood supply of it. The internal auditory branch of the basilar with
some minute branches from the stylo-mastoid, supply this part of the
ear with blood. The vasomotor nerves that accompany the internal
auditor)', are derived from the vertebral plexus which surrounds the
basilar artery and gives off filaments with each branch. From this it
can be seen that a lesion in the cervical or upper dorsal region will affect
the ear in some way. Clinically, such lesions are found in cases of deaf-
ness due to derangement of the mechanism that receives the sound waves,
and by correcting them, the symptoms are relieved. The explanation
is that neck lesions affect, in this way, the nutrition of the inner ear or
else the nutrition of the cells that form the auditory centers in the brain.
This form of deafness is not so common as the form due to an impair-
ment of the mechanism that conveys the sound waves, but is a great deal
harder to cure than the latter form.

THE NOSE.

The nose which is the peripheral organ of smell, is divided into an
external and an internal portion. The outer part is subject to trauma;
fracture and depression of the cartilages being the most common of its
affections. The condition of the nostrils is sometimes suggestive of
a diseased condition of the respiratory tract. If markedly dilated
during respiration, it is suggestive of obstructed respiration as in asthma.
Deflections of the nasal septum are common and occasionally give rise
to disturbances of respiration, the important one in children being,
mouth breathing. Foreign bodies such as beans, buttons, etc., are often
placed in the nostrils by children and should be thought of in cases of
swelling of the nose accompanied by obstructed breathing. The nostrils
are protected by stiff hairs in the adult, which lessen the amount of dust
and other particles that would otherwise be drawn into the respiratory
tract.

The turbinated bones are soft and usually affected in chronic catarrh
of the nose. They may become thickened or absorbed and thus obstruct
the passageway or give rise to a foul discharge as in cezena. They are
also affected in chronic cases of hay-fever. The change in the character

APPLIED ANATOMY. 561

in, and the accumulation of the secretions of the nose are principally
responsible for the softening and decay of these turbinated bones. The
disturbance of secretion comes primarily from cervical lesions that in-
terfere with the blood supply and nutrition of the mucous membrane of
the nasal cavity.

The Schneiderian or nasal mucous membrane lines the nasal fossa,
contains many secreting glands, the olfactory cells and the terminations
of the olfactory nerves. It is highl}r vascular, quite thick and firmly
bound down to the adjacent bone and cartilage. It is continuous with
the mucous membrane that lines the pharynx, conjunctiva and the
various sinuses that communicate with the nasal fossa, and extends to
the Eustachian tube, tympanum, the mastoid cells and anteriorly is
continuous with the skin.

The function of tins mucous membrane is that of protection to the
delicate nerves that terminate in it, and the secreting of a mucus that
moistens the terminals of the olfactory nerves and collects particles of
dust that are drawn into the nose in respiration, thus preventing them
from reaching the lungs. Since the principal diseases of this membrane
and of the nose, are characterized by disturbances of secretion and since
secretion depends so much on the amount and character of the blood
circulating through the glands, it is important to understand the causes
of vascular changes in them.

The principal artery that supplies the nasal mucous membrane is the
spheno-palatine which is a branch of the internal maxillary. The
branches of this artery supply the septum, antrum, frontal sinus, the
turbinated bones and the meatuses. The ethmoidal branches of the
ophthalmic supply the upper portion and outer wall of the nasal fossa.
The facial also sends some branches to the nose. These arteries re-
ceive their nerve supply from the upper thoracic spinal cord by way of
the superior cervical ganglion and its ascending branches that follow the
carotid arteries. Lesions at the exit or along the course of these vaso-
motor nerves, will affect the transmission of the impulses and thus pro-
duce some effect in the parts supplied by them. These lesions consist
of contractured muscles and bon}r subluxations. Usually the impulses
are inhibited and as a result the blood-vessels dilate, in other words a
congestion will result. In this there is the explanation of nasal catarrh
and hay-fever.

The veins form into plexuses and empty into the ophthalmic, ptery-

562 APPLIED ANATOMY.

goid plexus and the facial. In all likelihood they also have vaso-motor
nerves that are derived from the same source as the arteries and would
be affected in a way similar to the arteries. Communications are es-
tablished between these veins and those of the cranial cavity by way of
the cribiform foramina and the foramen cecum. On this account, nose
bleed, will often relieve a congestion of the brain that is producing a
headache. These veins also communicate with the facial, through the
small foramina in the lower part of the nasal bones. Cunningham
says: "The ethmoidal veins communicate with the ophthalmic veins
and the veins of the dura mater; further, an ethmoidal vein passes up
through the cribiform plate of the ethmoid, and either opens into the
venous plexus of the olfactory bulb or directly into one of the veins
of the orbital part of the frontal lobe of the brain."

The sensory nerve supply of the nasal mucous membrane is derived
from the fifth cranial. The nasal branch of the ophthalmic, supplies the
anterior and upper part. Branches from the Vidian and from Meckels
ganglion, supply the outer wall, the roof, posterior part of the septum
and the superior turbinated bone. The anterior or large palatine, sup-
plies the lower part and the two lower turbinated bones. In addition to
these, there are the naso-palatine, and anterior dental nerves. These
branches of the fifth pair of cranial nerves are affected by neck lesions
and by peripheral changes from the presence of foreign bodies or irri-
tating particles in the nasal passageway.

The olfactory nerves pass through the foramina in the cribiform
plate of the ethmoid bone and are distributed principally to the upper
and posterior part of the nasal fossa.

The sympathetic nerve supply comes from the cervical region, the
filaments following the arteries. Langley states that strong and mod-
erately strong stimulation of the cervical sympathetic, produced intense
flushing in the mucous membrane of the lips, gums, cheeks, hard palate,
nose and in the neighboring parts of the skin. He further states that
the vaso-motor fibers to the nose pass by way of the superior and in-
ferior branch of the fifth. " Broadly speaking we may say that all parts
of the skin and mucous membrane which receive their sole sensory sup-
ply from the fifth nerve, receive their sympathetic supply also by way
of the fifth nerve."

Nasal catarrh is a vaso-motor disturbance of the mucous membrane
of the nose caused primarily by lesions that affect the vaso-motor nerve

APPLIED ANATOMY. 563

supply to it. Hay-fever is an exaggerated vascular disturbance of the
membrane. This leaves the membrane in such an irritable condition
that any exciting lesion will cause a marked stimulation that results in
intense congestion followed by sneezing and increased secretion.

Nasal polypi are occasionally found in the nasal fossa. They, like
growths on other mucous membranes, are the result of perverted nutri-
tion. This interference with nutrition or circulation through the part
may come from injury, as a blow on the nose, extension of disease from
parts in relation, but especially from lesions of the cervical region that
affect the vaso-motor nerve supply to the mucous membrane of the nasal
tract. The indications of polypi in the nose are, mouth breathing, an
anxious expression on the face, general malnutrition and deformities of
the thorax if they occur in the young before the ribs have become as thor-
oughly formed as they are in the adult. A "stopping-up" of the nose
is quite constant and the voice is muffled, that is, the patient is said to
talk through the nose, but in reality the passing of the air through the
nose in hindered or entirely obstructed, and the patient does not talk
through the nose, hence the peculiarity of speech.

In recent colds and in chronic nasal catarrh, the nose is "stopped
up" and the patient with difficulty can breath through the nose. Mouth
breathing leads to throat disorders and enlargement of the tonsils.
Adenoid growths in the nose produce similar effects on respiration, nutri-
tion and the general condition of the individual. Any disorder of the
nose may come from a cervical lesion whether it be a coryza or a polypus.
The explanation, as given above, is that such a lesion will interfere with
the vaso-motor innervation of the nose since the impulses on their wray
to the nose, pass in relation with the upper thoracic and cervical verte-
brae. A tightening of the neck muscles will immediately produce a
stopping up of the nose; sitting in a draught being the most common
illustration.

THE MOUTH.

The mouth is affected directly by lesions of the neck that involve
the fifth and seventh cranial nerves. In Bell's paralysis, the cheek is
so affected that food accumulates between the teeth and the cheek on
account of paralysis of the buccinator muscle. Lesions of the middle
thoracic region affect the mouth by causing indigestion. An acid gas
is produced which leads to accumulations in the mouth and on the teeth,

564 APPLIED ANATOMY.

of particles of food and saliva that have undergone some change. In
some cases the saliva is so changed that it produces canker sores in the
mouth, the stomach in such cases' being intensely acid.

' The gums often show signs that are characteristic of certain dis-
eases. In syphlitic children, the gums are usually red, thick and soft
and the teeth soon become yellow, soften, crumble and drop out. The
condition of the gums determines the condition of the teeth. They are
richly supplied with blood-vessels from the internal maxillary artery.
This artery receives its nerve supply from the spinal cord by way of
the superior cervical ganglion and the carotid plexus. Since the con-
dition of the teeth depends on that of the gums, and the condition of the
gums on the internal maxillary artery, and the artery on the nerve sup-
ply to it, lesions of the neck that affect the nerve supply to the artery
will affect the condition of the teeth. Caries of the teeth is on the in-
crease, and it' is partly due to the frequency of these cervical lesions. I
believe that the teeth can be jDreserved by keeping the cervical region
in an adjusted condition, in other words, the nutrition of the teeth is
affected by these lesions. The teeth may be affected as a result of
errors in diet, general nutritional disturbance, as in scrofula or tuber-
culosis in children in which the incisor teeth have a saw edge, and in
syphilis, in which the teeth are notched, or the so-called Hutchinson
teeth.

The appearance of the tongue is often indicative of the general con-
dition of the patient, and its changes are of diagnostic importance in
many disorders. It is composed chiefly of muscles and in addition to
being the principal organ of taste, assists in speech, mastication and
deglutition. The mucous membrane covering the tongue is continuous
with that of the neighboring structures and contains the papillae of the
tongue. These papillae give it the peculiar roughness that is so charac-
teristic of the upper surface. The muscles of the tongue are divided
into an extrinsic and an intrinsic group. The extrinsic, are the stylo-
glossus, hyo-glossus, genio-hyo-glossus, palato-glossus and a part of the
superior constrictor. These muscles control the movements of the tongue
and are supplied almost entirely by the twelfth nerve. The pharyngeal
plexus supplies the palato-glossus. Clinically, lesions of the neck affect
this nerve, at least such lesions produce motor disorders of the tongue.
The intrinsic muscles of the tongue form only a small part of it, being
thin bands that are in close relation with the mucous membrane.

APPLIED ANATOMY. 565

The sensory nerve supply of the tongue is derived from the lingual
branch of the inferior maxillary division of the fifth; the lingual branch
of the glosso-pharyngeal ; some branches from the superior laryngeal;
the lingual and chorda tympani, branches of the facial. The motor
supply, is from the hypoglossus.

The chief artery of the tongue is the lingual from the external
carotid. A few twigs from the facial and ascending cervical also reach
the tongue. The principal vein is the ranine. On account of its close
relation to the frenum, in operations for tongue-tie, it is sometimes cut.
The nerve supply of the vessels of the tongue is derived from the upper
part of the thoracic spinal cord and pass to the tongue by way of the
branches of the superior cervical ganglion that supply the external
carotid artery and its branches. Vascular and trophie disorders result
from lesions that interfere with this nerve tract, they being found in
the upper dorsal and cervical regions.

Enlargement of the tongue is indicative of inflammation or glossitis.
A livid, red tongue is found in cirrhosis of the liver, and if round and
pointed, is suggestive of acute intestinal disease such as dysentery. It
is usually pale in anemia, especially so in chlorosis. A coating of the
tongue occurs in nearly all disorders of the gastro-intestinal tract. Some
believe that it is due to micro-organisms, others think it is due to pre-
cipitation of saliva. In typhoid fever, there is at first a yellowish ac-
cumulation on the back of the tongue, which is followed by redness of
the tip and edges, and the formation of a deep median fissure. As the
tongue becomes dried from the fever, other fissures develop and the
color changes to a brownish one. In the ordinary gastro-intestinal dis-
eases, there is a coating of a whitish or yellowish nature on the dorsal
aspect. In children that drink milk, often the tongue has a white coat-
ing. In the "strawberry tongue," the fungiform papillae which have
been deprived of their epithelium, show prominently through the white
coating. It is supposed to be quite indicative of scarlet fever, but occurs
in many other diseases. A dry condition of the tongue is found in mouth
breathers, in fevers and in cases in which the movements are lessened,
this leading to a prolonged coating. Hare says "Dryness of the tongue
in the presence of grave disease is always an evil omen, and returning
moisture of the tongue a favorable one." He further says "Coating of
the tongue aside from digestive derangements depends chiefly on three
factors: first, immobility of the tongue so that it is not kept clean by

566 APPLIED ANATOMY.

rubbing; second, mouth-breathing, whereby the surfaces become dry
and less easily cleansed; and, third, fever, which not only dries the sur-
face of the tongue by mouth-breathing, but interferes with salivary
secretion.

The movements of the tongue depend on the integrity of the hypo-
glossal nerve. Lesions along the neck are sometimes responsible for
impaired action of the tongue. In one case treated by the writer, a
lesion of the axis produced intermittent spasms of the tongue. Dis-
eases of the brain affect this nerve and hence impair the movements.
In progressive bulbar paralysis or what is known as glosso-labio-pharyn-
geal paralysis, the tongue is progressively paralyzed so that speech,
mastication and swallowing are difficult. In apoplexy and Bell's
paralysis, the tongue can not be protruded in a straight line. The slow
scanning speech which is characteristic of Freidreick's ataxia, is the
result of the -effect of the disease on the twefth nerve. Hare says "In
still other cases pressure upon the nerve (the hypoglossal) in its foramen
may cause unilateral paralysis, or wounds of the neck, caries of the first
cervical vertebra, or cervical tumors may so result." This harmonizes
with our observations along the line of disorders of the neck producing
disturbances of the twelfth nerve. The sensory part of the fifth is also
supposed to contain trophic filaments for the tongue and thus lesions
of the cervical vertebra? that affect the fifth, may affect this part of it
and produce atrophy and paralysis of the tongue. In painful affections
of the tongue, the fifth cranial is the one involved. The pain may be
a reflex one from disease of any other part of the nerve as in caries of the
teeth, or it may be caused by lesions that affect the nutrition of the
nerve or by structural disease of the substance of the tongue as in
malignant growths.

If in the new-born, the tongue can not be protruded, a short frenum
is usually present, it constituting the condition called, "tongue-tie.''
If the membrane is quite thin, it can be broken by means of the finger
nail, but if thick, it will be necessary to sever the edge of the band with
a pair of scissors after which, the frenum can be torn with the finger.

The tonsils are two oval shaped bodies located between the anterior
and posterior pillars of the fauces. They are about an inch in length
and one-half an inch in thickness and width. The mucous membrane
covering them is continuous with that of the oral cavity. The internal
surface presents from ten to fifteen orifices that lead into ■ recesses in

APPLIED ANATOMY. 567

the surface of the tonsils, called crypts. The mucous secretion often
fills these crypts. It forms a cheesy plug which undergoes decomposi-
tion and thus gives the breath a foul odor. Portions of these plugs drop
into the throat especially in the morning, and are then expectorated
It is associated with chronic nasal catarrh. Deaver says: "It is quite
probable that germs in the stagnant secretion in the crypts of the ton-
sils, enter the lymphatic vessels, and cause many of the cases of inflam-
mation and tuberculosis of the deep cervical chain of lymphatic glands."
It is the rule for scrofulous children to have enlarged tonsils. The
lymphatic glands of the neck and throat are in a state of chronic en-
largement and the patient has a delicate and puny appearance.

The blood supply of the tonsil is derived from the ascending branch
of the external carotid, the descending branch of the internal maxillary,
the dorsalis lingua? branch from the lingual, the ascending palatine and
tonsillar from the facial.

The nerve supply of these arteries is derived from the cervical sym-
pathetic and the impulses pass to them by way of the carotid plexus.

In vascular disturbances of the tonsil, it is the rule for a lesion to
be found in the upper cervical region. The explanation of this is that
the vaso-motor impulses intended for the tonsil, are in some way ob-
structed by such lesions, since they pass in close relation with the upper
thoracic and cervical vertebrae, and consequently the size of the blood-
vessel is changed, it usually being increased. The veins of the tonsil
empty into the tonsillar plexus which is drained by the pharyngeal
veins. Contracture of the muscles and tissues in relation with these
veins, obstruct the passing of the blood through them and a passive con-
gestion of the tonsil follows. These contractures are the result of re-
peated colds but especially of cervical lesions. The lymphatics of the
tonsil, which are quite numerous, empty into the lymphatic glands at
the angle of the jaw and into the deep cervical glands. They are en-
larged in disorders of the tonsils. They* communicate with those drain-
ing the back of the tongue. The nerves supplying the tonsil are derived
from the fifth cranial by way of Meckel's ganglion, and from the glosso-
pharyngeal. The vaso-motor nerves accompany the arteries and in
this way reach the tonsil and control its nutrition, and to a great extent
its activity.

The function of the tonsil is not well understood but it is supposed
to have an internal secretion that has to do with the elaboration of the

568 APPLIED ANATOMY.

blood. Some recent investigators have stated that it was a useless
organ like the appendix, and should be removed, as a prophylactic meas-
ure against tubercular infection of the lymphatic system. The writer
is of the opinion that there is no superfluous part in the human body
but that every structure has its special function and the tonsil is of this
number.

Hypertrophy of the tonsil is often associated with pelvic disorders, that
is, some forms of pelvic disease are complicated by its enlargement and in-
flammation. In mouth breathing, in talking through the nose, that is,
if the voice is muffled, and in cases in which there is obstructed respira-
tion accompanied by deformities of the thorax and a strained expression,
it is well to examine carefully for enlargement of the tonsil. If the ton-
sil is enlarged to any great extent, it can be palpated externally, and
the contour of the neck will be so changed that the diagnosis can be
made from this external enlargement. The greater part of this enlarge-
ment below the angle of the jaw is, however, due more to the enlarged
lymphatic glands than to the tonsil itself.

The principal disorders of the tonsils are, hypertrophy, inflammation
and quinsy, which is a purulent form of tonsillitis. All of these dis-
eases are the result of a disturbance of the circulation through the ton-
sils which acts as a predisposing cause and thus the exciting cause, the
more easily and readily acts. By correcting the bony and muscular dis-
turbances of the cervical region, the circulation through the tonsil can
be so improved that it will assume its normal function and size provided
the degenerative changes are not too marked. In some cases there is
an obstruction below as in subluxations of the first rib and of the clavicle.

The uvula is a conical process that is suspended from the middle of
the soft palate. It is of interest in that it often becomes elongated and
irritates the sensory nerves in relation, thereby setting up a constant,
hacking cough. This is especially true of out-of-door speakers. It
derives its sensory innervation from the fifth, and its blood supply from
palatine branches of the facial and the internal maxillary arteries.
Lesions of the neck affect the blood supply to the palate, hence the uvula,
and in this way produce congestion of it.

The pillars of the fauces extend downward from the uvula and em-
brace the tonsils. In sore throat, croup and diphtheria, these parts are
the. ones in which the disease starts. The vitality of these parts, like
that of any part of the body, depends on the amount and character of

APPLIED ANATOMY. 569

the blood circulating through them. If the blood-stream is slowed in
the least, the quality of the blood is affected so that the parts are pre-
disposed to the actions of the micro-organisms that might be in relation.
If the vaso-motor nerves innervating the blood-vessels of the part are
in a normal condition, the vis a tergo, that is the heart's action, will
carry the blood on through, but if these nerves are inhibited, the cir-
culation through the parts will be impaired. The impulses that supply
the blood-vessels of the fauces, are derived from the upper thoracic
spinal cord and pass by way of the sympathetic gangliated chain to the
superior cervical ganglion, thence out over the carotid plexus and its
branches that supply the branches of the carotid arteries. The point
is this, lesions of the neck especially muscular contractures, interfere
with the vaso-motor innervation of the soft palate and fauces and thus
produce a congestion of the blood-vessels of the throat. Sitting in a
draught of air will, in most people, produce soreness of the throat within
a short time. Lesions of the cervical vertebra will predispose to these
muscular contractures and this explains the difference in patients as to
susceptibility to throat disorders. In diphtheria, the blood becomes
stagnated in the fauces and other parts of the throat, and the vitality
is so lowered that the ever ready microbe finds a nidus favorable for
propagation and this particular type of disease results. Contracture
of the muscles of the front of the neck obstructs the venous drainage and
thus makes the congestion the greater. Manipulation of these tissues
coupled with correcting any disorder of the clavicles and first ribs, will
relieve a case of sore throat within a very short time. The mucous
membrane of the fauces is often the seat of an ulcer in secondary syphil-
is, called a mucous patch.

THE PHARYNX.

The pharynx is a musculo-membranous tube about four inches
in length that is located behind the nasal cavities, larynx and mouth.
It has opening into it the posterior nares, Eustachian tubes, mouth,
esophagus and larynx. It carries the food from the mouth to the
esophagus, "bridges the gap in the respiratory tract between the larynx
and the nasal cavities, " and gives resonance to the voice.

The walls of the pharynx are composed principally of the fibrous
ajDoneurosis of the pharyngeal muscles, is lined with mucous membrane
and surrounded by the constrictor muscles of the pharynx. Foreign

570 APPLIED ANATOMY.

bodies that lodge in the pharynx are found in the lower end which is the
smallest, at which place they obstruct respiration on account of rela-
tion to the larynx. In tetanus, the pharyngeal muscles are affected
next in order to the muscles of mastication. The mucous membrane
is continuous with that lining the cavities in relation. It varies in thick-
ness and structure in the different parts. In the upper portion or what
is called the nasopharynx, it is provided with ciliated epithelium for
the passing of air, while in the lower part or oro-pharynx, there is squa-
mous epithelium. There are many mucous secreting glands through-
out the pharynx which keep the throat moist and lubricated. Near the
Eustachian tube there is an aggregation of these mucous glands and
lymphatic follicles which constitute the so-called pharyngeal tonsils.
Hypertrophy of these tonsils constitutes adenoid growths of the throat.
They are found most frequently in the upper part, hence the disturb-
ance of function would be, obstructed respiration and impaired resonance
of the voice.

The mucous coat of the pharynx is very vascular and probably on
this account, is pharyngitis or sore throat so common. The arterial
supply is from the ascending pharyngeal; the facial by way of its ascend-
ing palantine and tonsillar branches; the superior thyroid through the
superior laryngeal branch; and from the inferior laryngeal branch of the
inferior thyroid. The size of these blood-vessels is determined by the
condition of the vaso-motor nerves innervating them. The}r are de-
rived from the upper thoracic spinal cord and, like the vaso-motor sup-
ply to other parts of the head and face, pass by way of the superior
cervical ganglion and out over the plexus surrounding the carotid arteries,
to their destination. The veins of the pharynx are arranged in a plexus
that empties into the facial or the internal jugular. These veins are
subject to impingement from contracture of the muscles of the front of
the neck. The lymphatics empty into the cervical glands. The nerve
supply of the pharynx in from the pharyngeal plexus. This plexus is
formed by branches from the pneumogastric, glossopharyngeal nerves
and by branches from the superior cervical ganglion. Sensory fibers
are furnished it by the pneumogastric and to a certain extent by the
glosso-pharyngeal nerves. Motor impulses are furnished it by the vagus,
while the sympathetic branches from the superior cervical ganglion carry
to' it vaso-motor and secretory impulses. Since lesions of the cervical
vertebrae, especially of the atlas and axis, affect any or all of the above

APPLIED ANATOMY. 571

named nerves, almost any form of disease of the pharynx may result from
an upper cervical lesion, because nearly all diseases have their origin in
disorders of the innervation of the part diseased. The vaso-motor im-
pulses that are supposed to be furnished the pharynx by the pneumo-
gastric and glosso-pharyngeal nerves, come originally from the pharyn-
geal branches of the superior cervical ganglion. On this account, con-
gestion and inflammation of the pharyngeal mucous membrane, hyper-
trophy of it as in adenoids, dysphagia from disorders of the constrictor
muscles and sensory disturbances as in tickling in the throat which
produces a chronic cough, may be the direct result of muscular and bony
lesions of the upper cervical region. These lesions predispose to dis-
eases of this part by weakening the natural resistance so that the exciting
cause readily acts.

THE LARYNX.

The larynx is the organ of voice. It is composed principally of
cartilages so arranged and united that they form a more or less rigid
framework yet possessing a certain amount of movement which is neces-
sary to the proper performance of the laryngeal functions. There are
nine of these cartilages of which the thyroid and cricoid are the most
important.

The thyroid, is the largest and consists of two alse that unite anter-
iorly at an angle, thus forming the pomum Adami. This point is an im-
portant landmark of the neck. This cartilage gives attachment inter-
nally to the true and false vocal cords. It is attached to the hyoid bone
by means of the thyro-hyoid membrane and the thyro-hyoid ligament.
On account of these attachments, any displacement of the hyoid bone
will usually affect the position of the thyroid cartilage and some disturb-
ance of the voice will result. This cartilage is sometimes broken or dis-
placed in injuries to the neck as in choking. It moves upward and down-
ward in deglutition, it reaching the hyoid bone.

The cricoid cartilage is the strongest. It is situated below the
thyroid and rests on the upper ring of the trachea. It can be palpated
externally and forms one of the landmarks of the front of the neck.
The remainder of the laryngeal cartilages are of such little importance from
a practical point of view that they will not be considered here, except the
epiglottis. This cartilage is a leaf-like door that guards the entrance to
the larynx. During respiration, it lies in a vertical position but in swallow-

572 APPLIED ANATOMY.

ing, it drops back and closes the superior aperture of the larynx. If
one attempts to swallow and talk at the same time, the epiglottis is
imperfectly closed and food is apt to enter the larynx. Nature tries to
overcome the disturbance by setting up a violent fit of coughing in order
to expel the foreign body. In the introduction of a stomach tube, the
action of this cartilage must be considered.

The muscles of the larynx have been divided into the extrinsic and
the intrinsic. These muscles have to do with the position of the various
cartilages to which they are attached, hence determine the size of the
lumen and the tone of the vocal cords. Disturbances of respiration,
phonation and deglutition result from contracture or relaxation of some
or all of them. They are innervated by the pneumogastric, through
its superior and inferior laryngeal branches, and by branches of the
cervical nerves that pass to the infra-hyoid muscles. The cervical nerves
do not directly innervate the larynx but indirectly have to do with its
position through the muscles that are attached to the hyoid bone. As
a result of this, lesions of the neck produce disturbances of respiration
and deglutition but especially of phonation, on account of effect on the
nerves innervating both the intrinsic and extrinsic muscles of the
larynx.

The mucous membrane of the larynx is quite vascular and is con-
tinuous with that covering the pharynx and trachea. Inflammation of
it will spread by continuity of tissue, from one part to another and es-
pecially from above downward, as is often the case in diphtheria and
bronchitis. Mucous glands are found in all parts of it except over the
vocal cords. In congested and inflamed conditions of the laryngeal
mucous membrane, the secretion of these glands is affected, sometimes in-
creased, while in other cases it is lessened. In public speakers after
long continued speaking especially in the open air, the throat becomes
dry and the voice husky from lack of lubrication of the vocal cords.
The superior laryngeal nerve supplies the part with sensory impulses and
is quite often reflexly affected, as is indicated by the frequency of cough
from disease of structure not in relation.

The true vocal cords consist of bands of nbro-elastic material,
stretched between the anterior angles (vocal processes) of the arytenoid
cartilages and the retiring angle of the thyroid cartilage on each side of
the median line. In phonation they become tense and the passing of
air through the chink between the true vocal cords sets lip vibration of

APPLIED ANATOMY 573

them. The false vocal cords are folds of mucous membrane and have
nothing to do with phonation. The tone of the vocal cords is controlled
by the intrinsic muscles of the larynx. These are under the control of
the pneumogastric nerve by way of its laryngeal branches. Contrac-
ture of these muscles or congestion of the true vocal cords, will' affect
the tone of the voice. Lesions of the upper cervical vertebra?, will not
only affect the motor supply of the part, but the vaso-motor nerves sup-
plying the larynx and the vocal cords.

The blood supply of the larynx is from the superior and inferior
thyroid arteries. The superior, is a branch of the external carotid and
through its superior laryngeal branch, supplies the greater part of the
larynx. McClellan says: "Its radicles anastomose freely with those of
its fellow and those from the inferior thyroid arteries, so that the mucous
membrane is very vascular, as is demonstrated by the rapid engorgement
and change from the ordinary pink color to a bright red in consequence
of the slightest irritation. " The inferior thyroid artery is a branch of
the thyroid axis of the subclavian. The innervation of the superior
thyroid is from the superior cervical ganglion, while the inferior, receives
its nerve supply from the subclavian plexus. This plexus is derived
from the inferior cervical and stellate ganglia. On this account, lesions
of the lower cervical vertebrae but especially lesions of the upper two
ribs, will affect the innervation of the arteries of the larynx, hence will
produce disease of the part or at least a weakening with predisposition
to disease. A tightening of the lower cervical muscles and of those at-
tached to the first rib, is usually found is patients suffering with disorders
of the larynx.

The veins accompany the arteries and empty into the superior,
middle and inferior thyroid veins. Inward and backward subluxations
of the clavicle, upward displacement of the first rib and contracture of
the tissues of the lower part of the front of the neck, will obstruct these
veins and tend to produce congestion of the larynx.

The lymphatic vessels accompany the veins and empty into the
deep cervical glands.

The sensory nerve to the larynx is the superior laryngeal, a branch
of the pneumogastric. The recurrent or inferior laryngeal is the motor
nerve. The explanation of the course of this nerve has been the sub-
ject of much speculation for many years. Perhaps the best explanation
is based on its function and action, it acting from below upward, or

574 APPLIED ANATOMY.

rather in respiration and in coughing the muscles supplied by it act from
below upward. The sympathetic nerve supply to the larynx, that is, the
vaso-motor and secretory nerves to it, is derived from the cervical ganglia
and pass to the larynx with the blood-vessels and the vagus. They are
of importance in that they control the amount of blood and secretion
of the part. In congestion, inflammation and in catarrhal conditions
of the larynx, these nerves are affected.

Disturbance of function of the larynx results from conditions pro-
ducing an irritability or narrowing of the cavity or openings of it. In-
flammation of it which is called laryngitis, disturbs its function by lessen-
ing the size of the lumen, by thickening the vocal cords, weakening the
muscles and by irritating the sensory nerves of the part. It is excited
by many things, such as abuse of the part, but primarily produced by
anatomical derangements by which the blood supply to, and the inner-
vation of, it are affected, which so weaken the larynx that any exciting
cause the more readily and easily acts. Edema of the larynx lessens the lu-
men and consequently respiration is embarrassed. Laryngismus stridulus
consists of a spasm of the laryngeal muscles which makes respiration dif-
ficult because of the narrowing of the larynx. This is often a reflex effect
from gastro-intestinal irritation. In adults, it most frequently is the
result of direct irritation of the motor nerve of the larynx from pressure
as in goitre, aneurysms and in lesions that affect the nerve along its course
or at its exit. The disturbances of phonation are the most important of
effects of impairment of function of the larynx, because of their frequency
and diagnostic importance. Hoarseness is the result of a thickening of
the vocal cords from congestion. The congestion is the effect of muscular
contracture from thermic influences and from subluxations of the cer-
vical vertebrae. In some cases hoarseness is due to pressure on the
vocal cords as a result of a tumor on, or in relation with, the larynx.
If the voice has a nasal twang, it is indicative of obstruction of the air
passages as in adenoids. In stuttering, the trouble is not necessarily
in the larynx but is commonly the result of the individual attempting
to speak with the lungs empty, hence the air is not directed in the proper
way against the vocal cords and a sort of spasm of the laryngeal muscles
is the result. If the patient were to take a deep inspiration before at-
tempting to speak, this difficulty would be overcome and the muscles
would not be thrown into a spasm. Since the party is able to sing or at
least is able to produce a prolonged sound, it goes to prove 'that the fault

APPLIED ANATOMY. 575

does not lie with the vocal apparatus but is in the mechanism that has
to do with controlling the laryngeal muscles and the amount of air pass-
ing through the chink between the true vocal cords, called the glottis
vocalis. In some cases the writer has found lesions of the neck and of the
hyoid bone that had something to do in the production of stammering.
A slow, hesitating, weak speech is indicative of marked weakness of the
body as in the exhaustive fevers. A jerky, short speech is found in pa-
tients suffering with pneumonia and pleurisy, The explanation is that
the air can not be expelled except spasmodically, on account of the
pain from the pleurisy. In cardiac disorders, especially in marked pal-
pitation, the speech is jerky and weak. A slow, scanning speech occurs
in Friedreich's ataxia. In glosso-labio-pharyngeal paralysis, the speech
is of a mumbling character and if the larynx is involved, there is great
feebleness of the voice.

Aphonia is an effect of laryngeal disorder. Since phonation is de-
pendent on muscular contraction by which the true vocal cords are made
tense, anything that interferes with this will produce aphonia or at least
impairment of the voice. In cases treated by the writer in which the
trouble was not due to irritating gases, hysteria or trauma, a displace-
ment of the hyoid bone was found in nearly all. The displacement is
the result of contracture of some of the muscles attached to it, the
omo-hyoid being most frequently affected. This contracture pulls the
bone out of place and since the larynx is attached to the hyoid bone, it
is affected. The displacment of the thyroid cartilage alters the tension
of the vocal cords and consequently hoarseness or aphonia results. The
cause of the contracture of the hyoid muscles is either a thermic one,
or else there is a lesion of the upper cervical vertebra? that affects the in-
nervation. In syphilis in which the mucous patches have formed in the
throat, huskiness of the voice or even aphonia, is common. In other
cases the vocal cords become thickened from inflammatory deposits
and thus the vibratory qualities are impaired.

THYROID GLAND.

The thyroid body or gland is situated on the front and sides of the
upper part of the trachea. It is a very vascular and belongs to the
class of ductless glands. It consists of two lobes and an isthmus. Each
lateral lobe is about two inches in length and about one inch thick and
wide. The anterior surfaces are covered by the omo-hvoid, infra-hyoid,

576 APPLIED ANATOMY.

sterno-hyoid, sterno-thyroid and partly by the sterno -mastoid muscles.
Its posterior surface is adherent to the esophagus, and is in close relation
to the larynx, pharynx, trachea, inferior thyroid artery and the inferior
laryngeal nerve. The isthmus or middle lobe, connects the two lateral, and
lies in anterior relation with the third ring of the trachea. It is firmly
attached to the trachea and the thyroid and cricoid cartilages and on
this account, it rises and falls with deglutition and can thus be differ-
entiated when it is enlarged, from other enlargements of the neck. In
the performing of tracheotomy, the incision should be made in the space
immediately above the middle lobe and below the cricoid cartilage since
this space is not covered by the gland. If the operation is performed
below the gland there is danger of cutting the thyroid plexus of veins
which is in relation. The gland varies in size in different individuals
and in the same person at different periods. It is larger in women and
children than in men. During menstruation it often enlarges quite
considerably. In old age it decreases in size and becomes quite firm.
In enlargements of the gland, the pressure symptoms are in evidence on
account of the relation of the gland to the trachea and since the sterno-
thyroid and omo-hyoid muscles prevent anterior displacement and thus
it is forced backward against the structures in posterior relation.

The arteries of the thyroid gland are the superior and inferior thy-
roid, branches of the external carotid and the thyroid axis, respectively.
The nerve supply of the superior, is from the carotid plexus which is a
branch of the superior cervical ganglion. Lesions of the upper cervical
vertebrae will affect the nerve supply to this artery and thus affect the
thyroid gland. The inferior thyroid artery gets its innervation from
the middle and inferior ganglia. The arteries are very large, anastomose
freely and form a complete network around the acini of the gland. In
some dissections made by the writer, these and the facial arteries were
several times larger in cases of exophthalmic goitre than in the normal
subject.

As a rule in this disorder, the arteries are considerably enlarged.

The thyroid veins are the superior, middle and inferior thyroid.
The upper two empty into the internal jugular, while the inferior, anasto-
moses freely with the veins that drain the trachea, and empty into the
innominate veins. Upward displacement of the first rib will indirect ly
exert pressure on these veins thus producing congestion of the gland.
A downward and inward subluxation of the clavicle will have a similar

APPLIED ANATOMY. 577

effect. In soft goitres, a treatment directed toward lowering the first
rib and lifting the clavicle upward and forward, will temporarily reduce
to a marked degree, the enlargement of the gland.

The nerve supply to the thyroid is derived from the superior,middle
and lower cervical sympathetic ganglia, the branches reaching the gland
along with the thyroid arteries. Gray states that the inferior laryngeal
and possibly superior laryngeal nerves, send branches to the gland.
Lesions along the lower part of the neck, upper thoracic region and of
the upper ribs, will directly affect the innervation and tend to produce

Fig. 152. — Showing a very bad case of simple goitre. The patient has now be-
gun to show indications of Cretinism. (From photo).

disease of the gland. The impulses that pass over the thyroid nerves
are derived from the upper part of the thoracic spinal cord. They pass
into the gangliated cord thence through the above named ganglia and
out over the thyroid branches. Lesions of the upper ribs will especially
affect the exit and origin of these nerve fibers and consequently are im-
portant ones in the production of thyroid diseases, such as goitre.

The function of the thyroid gland is not well understood at the pres-
ent time. Experimentally it was ascertained by Horsley that extirpa-

578 APPLIED ANATOMY.

tion of the thyroid gland in the monkey, was followed by loss of appetite,
fibrillary contractions of muscles, tremors and spasms, mucinoid degen-
eration of the skin, giving rise to puffiness of the eyelids and face and to
a swollen condition of the abdomen, hebetude of mind frequently termi-
nating in idiocy, fall of blood-pressure, dyspnea, albuminuria, atrophy
of the tissues followed by death of the animal in the course of from five
to eight weeks. There seems to be an internal secretion that has to do
with the elaboration of the blood. Brubaker says: "The view that
the gland removes from the blood certain toxic bodies, rendering them
innocuous and thus preserving the body from a species of auto-intox-
ication, is gradually yielding to the more probable view that the epithe-
lium is engaged in the secretion of a specific material, which finds its
way into the blood or lymph and in some unknown way influences
favorably, tissue metabolism. " Landois says that the morbid phenomena
following extirpation of the gland, may be counteracted at least tem-
porarily by the internal administration of thyroid gland substance.
"These facts prove that the thyroid gland produces a substance that is
indispensable for normal metabolism. Stated more accurately, the
function of the thyroid gland is to neutralize a substance produced in
the body, the accumulation of which, has a toxic influence on the nervous
system. "

The principal disturbances of function of this gland are goitre in
which the gland is enlarged; cretinism; and myxedema, in which it is
congenitally absent or else degenerated. There are many causes of these
disorders but only the anatomical lesions that affect the gland will be
discussed here. Clinically, in nearly all cases of exophthalmic goitre,
there are found muscular contractures of the lower art of the cervical
region and of the muscles attached to the first rib; subluxations of the
cervical and upper thoracic vertebra?; upward luxations of the upper two
ribs and a tightening of the tissues in relation with the first rib and
clavicle. On account of the frequency of these abnormal conditions in
goitre cases, and the fact that often by correcting the abnormalities the
goitre disappears, we are warranted in stating that these disturbances
affect the function of the thyroid gland. There are several reasons why
the gland is affected by these lesions. (1) The tightening of the tissues
interferes with the circulation to and from the gland by obstructing the
blood-vessels, since they are in relation. (2) The displacement of the
cervical and upper thoracic vertebrae cause's contracture of the muscles

APPLIED ANATOMY. 579

that are attached to the first rib, and it is drawn upward against the
clavicle and thus obstructs not only the blood-vessels but the nerves
that supply the gland. (3) These lesions directly affect the thyroid
nerves and thus disturb their function, and as a result there are vascular
and secretory disorders of the gland.

The first rib is usually displaced upward at its vertebral end and its
sternal end is displaced backward and inward. This affects the inferior
and stellate ganglia that are in relation with the head of this rib. The
inward displacement of the sternal end produces pressure on the tissues
and blood-vessels below the gland and thus interferes with the drainage.
When these lesions are present, the exciting causes can the more easily
act, such as pelvic disease, nervousness and the other exciting causes.

The heart is usually affected in exophthalmic goitre. The explana-
tion given is that it is due to nervousness or to the toxemia that is pres-
ent in the system, stimulating the heart. I believe the best explanation
is that the same lesion that produces the goitre, produces the heart dis-
order by affecting the accelerator nerves to it. Lesions of the lower
part of the neck, or of the upper thoracic region or upper ribs, affect
the segments of the cord that give rise to the cardiac accelerators or
else affect the pathway of these impulses, and since the nerves to the
thyroid gland come from the same source and pass over practically
the same route, that those that supply the heart do, that is by way of the
lower ganglia of the sympathetic, both sets of nerves would be affected
by the above named lesions.

THE TRACHEA.

The trachea in continuous with the lower portion of the larynx. It
is about four and one-half inches in length, is about an inch wide and
composed of cartilaginous rings that prevent collapse of it. These rings
are absent posteriori}', thus giving the esophagus more room in deglu-
tition. The trachea is of interest in that it is the seat of inflammatory
diseases; foreign bodies occasionally lodge in it ; and in that it is the struc-
ture incised in the operation of tracheotomy, for obstructed respiration.
In croup and the laryngeal types of diphtheria, the membranes often
get as low in the respiratory tract as the trachea and soon the child dies
from asphyxia. Intubation is now generally substituted for tracheo-
tomy whenever it is possible. The trachea is impinged on in aneurysms
of the arch of the aorta, and in enlargements of the thyroid gland.

580 APPLIED ANATOMY.

THE BRONCHI.

At the level of the body of the fourth cervical vertebra posteriorly
and opposite the second intercostal space anteriorly, the trachea divides
into a left and right bronchus. The bronchi vary in size, length and
direction.

The bronchi subdivide at the roots of the lungs into the bronchial
tubes. The tubes continue to divide until they become quite small, in
which case they are called bronchioles. The bronchioles have no com-
munication with each other, thus when one gets stopped, the corres-
ponding vesicle is deprived of air and the resonance of the part is lost
or lessened. The amount of cartilage decreases while the elastic and
muscular fibers increase in proportion, as the tubes become smaller from
division. Mucous glands are not found in the smallest branches but the
larger tubes are abundantly supplied with them. The smallest bronchi
have in their walls unstriated muscle fibers which have to do with con-
trolling the size of the tube.

The bronchial tubes are lined with a mucous membrane which is
of interest in that it is so frequently affected by extension of inflammation
from above downward, and sometimes from below upward. Labored
respiration, as in prolonged and vigorous exercise, will cause an increase
of mucus secreted bv these glands, lining the bronchial tubes and their
ramifications. It has been noted by the writer that it is not only in-
creased in amount but becomes quite tenaceous in character. In
asthma, there is labored respiration and there is an increase in amount,
and change of quality of the mucous from the tubes. This partly ex-
plains the formation of the spirals peculiar to asthma. Lesions affect-
ing the mucous membrane, will produce a similar effect on the secretion
of mucus as has been demonstrated in many clinical cases of bronchitis.

The blood-supply of the bronchial tubes is derived from the bron-
chial arteries, branches of the thoracic aorta. They are generally three
in number, one on the right and two on the left side. These arteries
supply the substance of the lungs, pleura, the bronchial glands, mucous
membrane and walls, and the walls of the blood-vessels, and a few branches
pass to the esophagus. The nerve supply of these arteries is, so far as
can be determined clinically, derived from the thoracic aortic plexus.
This plexus is formed by branches from the upper thoracic sympathetic
ganglia, the impulses coming originally from the upper thoracic seg-

APPLIED ANATOMY. 5S1

merits of the spinal cord. Muscular contractures in the upper dorsal
region will, in most cases, produce some form of bronchitis, that is, con-
gestion of the blood-vessels that supply the bronchial mucous mem-
brane. Lesions of the first, second and third thoracic vertebrae and
corresponding ribs, predispose to colds on the lungs or bronchial tubes,
by affecting the vaso-motor supply to the parts, which reaches the tubes
by way of the bronchial arteries. The blood returns to the heart by
way of the bronchial veins, the right one emptying into the vena azygos
major and the left, into the left superior intercostal vein. Since the
superior intercostal veins drain the muscles of the upper thoracic region,
contracture of the muscles of this part interferes with the drainage of
the lungs, thus predisposing to congestion. In all probability, these
veins have vaso-motor nerves which are derived from the same source
as those that supply the arteries.

The nerve supply of the bronchial tubes is derived from the pneu-
mogastric and the pulmonary plexuses. The vagus seems to be the
motor nerve, while the sympathetic nerves supply the tubes with vaso-
motor and secretory impulses. Landois says: "It appears that the
function of the unstriated muscle-fibers in the trachea and in the entire
bronchial tree, is to offer resistance within the air passages to the in-
creased pressure that occurs in all forced expirations, as in speaking,
singing, blowing, straining. " Stimulation of the vagus is followed by
contraction of these unstriated muscle fibers, thus interfering with ex-
piration, by lessening the size of the lumen of the tube.

The lymphatic glands of the bronchi are situated at the bifurcation
of the bronchi. They drain in part the visceral layer of the pleura, per-
icardium, back part of the heart, trachea and lungs. In early life they
are pink in color, but as the patient advances in age they become pig-
mented from the deposit in them of particles of dirt.

The function of the bronchial tubes is affected by congestion and
inflammation of the mucous membrane, and by constriction from con-
traction of the unstriated muscle fibers that are in the walls of the tubes.
There are several causes of disease of the mucous membrane and con-
striction of the tubes other than lesions of the spine and muscular con-
tractures, but only the connection that these lesions bear to the function
of the tubes will be considered here.

Lesions of the upper ribs and thoracic vertebrae will affect the vaso-
motor innervation of the tubes, because the impulses pass out of the

5S2 APPLIED ANATOMY.

upper thoracic intervertebral foramina and in relation with the heads
of the upper ribs and thus would be subject to pressure from a sublux-
ation of either vertebra or rib. Muscular contracture in this region, in-
terferes with the circulation through the upper thoracic spinal segments
and thus affects the cells from which the vaso-motor impulses arise that
supply the tubes. Asthma seems to be the result of stimulation of the
motor nerves innervating the unstriated muscles surrounding the tubes,
that is, branches of the pneumogastric. It may also be the result of
congestion of the mucous membrane lining the tubes which produces a
narrowing of the lumen and thus obstructs the passing of air through
it. In some cadavers dissected by the writer, it was found that the
vagus received branches from the upper thoracic sympathetic gang-
liated cord, the nerve filaments passing directly across from the ganglia
into the sheath and substance of the pneumogastric. If this were true
in all cases'the explanation of why lesions of the upper thoracic verte-
bra? and ribs produced asthma, would be comparatively easy. It has
been demonstrated beyond a doubt that in most cases of asthma, a le-
sion in the above region was the cause of the trouble since by correcting
the subluxation, the disease was cured unless emphysema had developed.
It is recognized that there are exciting causes that have something to
do in the production of the disorder but back of all these, the bony le-
sion is present in most cases. There are several reasons why such lesions
produce asthma. They may directly irritate the motor nerves supplying
the bronchial muscles; congest the mucous membrane lining the tubes;
irritate the sensory nerves that supply the mucous membrane and thus
excite reflex contraction of the tubes: or the lesions may increase the se-
cretion of mucus, thus obstructing the lumen. It is the opinion of the
writer that the lesion most frequently affects the vaso-motor nerves
supplying the mucous membrane lining the bronchial tubes in such a
way that it is congested and thickened, which not only causes a narrow-
ing of the lumen of the tube from increase in thickness of the mucous
membrane, but causes a reflex contraction of the muscle fibers forming a
part of the wall of the tube.

THE LUNGS.

The lungs are the special organs of respiration and occupy, in the
normal state, a greater part of the thoracic cavity. Each lung is com-
posed of bronchial tubes, alveoli or air vesicles, blood-vessels, lymphatics

APPLIED ANATOMY. 583

and nerves imbedded in elastic and fibrous tissues. The elastic tissue
performs an important part in respiration, the distensibility and size
of the alveoli being under the control of it so that when the lung tissue
becomes diseased as in pulmonary tuberculosis, the elasticity is lessened
or lost and the lung collapses. The two lungs differ slightly as to their
lobes and form. The right is the larger, shorter, and possesses three
lobes instead of two, as does the left. Each presents an outer and inner
surface, anterior and posterior border, a base and apex. The outer
surface is convex and corresponds to the concavity formed by the chest
wall. This surface is in close relation with the upper ribs so that it
bears the impressions of the ribs. The inner surface is concave and is
in relation with the heart and the mediastinum. The contour and size
of the heart determines to a great extent, the shape of this surface. The
anterior border is quite thin and the two almost touch in the median
line in deep inspiration. The left is deeply notched, thus leaving the
pericardium uncovered. The posterior border is in relation with the
bodies of the upper thoracic vertebrae, and is quite thick. On account of
this relation to the vertebrae, the size and condition of the lungs have a
great deal to do with the contour of the thoracic part of the spinal column.
The base of the lung is concave to conform to the convex surface of the
diaphragm with which it is in relation. The apex is rather blunt and
rounded, and rises above the level of the first costal arch. In deep in-
spiration, the apex therefore passes upward through the inlet of the
thorax and thus the contour of the parts in relation with the clavicle
and first rib, depends on the height and degree of development of the
apices of the lungs. This is of interest in that a deep infraclavicular or
supraclavicular fossa, is suggestive of weakness, if not disease of this
part of the lung. This part of the lung is the least used in ordinary res-
piration, and probably on this account, is most subject to diseases that
attack the substance of the lung as in pulmonary tuberculosis.

The left lung is divided into two lobes by a long, deep fissure, while
the right has two fissures that divide it into three lobes. These fissures
and lobes are subject to great variations and are of little practical im-
portance. The lungs are surrounded by a double fold of serous mem-
brane called the pleurae. Each pleura forms a closed sac in which is a
fluid that serves to lubricate the two surfaces. It is the rule to find on
post-mortem examination, adhesions uniting the two pleural surfaces;
the result of pleuritis.

584 APPLIED ANATOMY.

The relations of the lungs are important, in that disease of them is
often due to impairment of some contiguous structure. The bodies of
the upper thoracic vertebra? are in relation posteriori}'. Lesions of them,
such as an anterior subluxation, or disease as in caries or Pott's dis-
ease, will directly affect the lungs on account of the contiguity. In
respiration these vertebrae are moved; posteriorly in inspiration and
anteriorly in expiration. In lesions of the vertebras whether it be a distinct
subluxation or simply a stiffened or anchylosed condition, this movement
is impaired.

The ribs are in posterior and lateral relation with the lungs. The
contour of the chest is dependent on the size of the lungs. A displace-
ment inward of any of the ribs in relation will cause direct pressure on
the lung substance and thus lead to disease of the lung. The expansion
of the lungs is restricted by certain rib lesions and soon the contour of
the chest changes.

The heart lies between the two lungs and bears an intimate relation
to them. Diseases of the one will necessarily affect the other, this being
especially demonstrated in pneumonia in which the heart symptoms
have to be combated more than any other in order to prevent a serious
termination. This, however, is not the result of contiguity. In en-
largement of the heart, the lungs are compressed and respiration is con-
siderably embarrassed. In a dissection made recently, there was a marked
pericardial effusion that displaced the lungs backward and laterally to
such an extent, that the contour of the chest was changed. In such
cases, the lungs are so compressed that the circulation through them is
affected and consequently pneumonia and other lung diseases develop
from the least exposure or other exciting cause. On the other hand,
enlargement of the lungs, affects the heart by compression and thus pro-
duces irregularities or other disturbances of the heart-beat.

The diaphragm is in inferior relation with the lungs, the concave
surface of the lung fitting accurately on the convex upper surface of the
diaphragm. In descent of the diaphragm the lung follows, while a dis-
eased lung pressing directly on the diaphragm, will often produce cough-
ing and respiratory disorders. The stomach is in inferior relation with
the left lung, the diaphragm separating the two. Distension of the
stomach causes shortness of breath, as is demonstrated by exercise after
a full meal. In accumulation of gas in the stomach, respiration is af-
fected as well as the action of the heart. The liver is in inferior relation

APPLIED ANATOMY. 585

with the right lung and, as in the case of the stomach, the diaphragm
intervenes. In abscess of the liver, the lungs may be involved, pleural
adhesions being the most common effect. Liver disturbances may
cause a cough from irritation of the phrenic or perhaps from effect of the
pressure on the lungs. On account of this relation, diseases of the lung,
especially the pleura, are mistaken for liver affections and vice versa.
The venae azygi veins are in close posterior relation and are subject to
pressure in all cases of enlargement of the lungs and in patients that are
forced to lie, for any length of time, on the back. The veins of the left
side cross to the vena azygos major and are especially subject to pressure
from the above named causes since they rest on the bodies of the ver-
tebrae, and thus are the more easily compressed. Lying on the back for
several weeks, as in typhoid fever, is an important factor in producing
congestion of the structures and parts dz-ained by the azygi veins. These
veins drain the spinal cord in particular and also the muscles of the back.
Many a case of paralysis results from permitting the patient to lie on
the back too long at a time, especially if the patient is old and feeble or
if very much exhausted from a long, debilitating illness. The explana-
tion is that the lungs press on the azygi veins and consequently there is
a passive congestion of the spinal cord sufficiently great to interfere
with its functions.

The nerves in posterior relation with the lungs, principally the
sympathetic gangliated cord and its branches, are likewise subject to
pressure from congestion or other enlargement of the lungs. This is
also true of the thoracic aorta and the inferior vena cava, but ordinarily
these structures are free from pressure unless the enlargement is quite
marked.

The pleurae closely invest the lungs. There is really no pleural
cavity since the parietal and visceral layers are in contact in all normal
cases. In pneumothorax and hydrothorax, these layers are separated
so that there is a cavity formed between them. The parietal layer
lines the thoracic cavity and is affected in fractures and dislocations of
the ribs. On account of the proximity of the two layers, inflammation
of the one will directly affect the part of the other layer in relation.
Therefore lesions or fractures of ribs, will affect the visceral as well as
the parietal layer and thus may produce disease of the lungs. The in-
nervation of the parietal layer is derived from the intercostal nerves
in relation and the pain in lung disorders is usually referred to the chest
wall on this account.

586 APPLIED ANATOMY.

The pleurae permit of free and easy movement of the lungs and to a
certain extent, protect them against injury. Distension of the lungs
as in inspiration causes the two surfaces of the pleura? to glide on each
other, they being lubricated by a slight amount of fluid. The pleura
protects the lungs against further injury by limiting the amount of mo-
tion in respiration, if the lung is diseased as in pneumonia. It does this
by producing pain whenever the parts are moved which acts as a warning
to the organism that the parts need rest. Most, if not all, of the sen-
sory nerves that have to do with the lungs, are in the pleura and when-
ever the lungs move, these nerves are irritated and pain is the result.
If this were not the case, it would take quite a long time to secure healing
of an injury or diseased condition of the lungs.

The condition as well as the position of the lungs, is determined by
percussion and auscultation. The normal lung gives a resonant, elastic
note on percussion. In order to get best results in percussion, the pa-
tient should be in the sitting or erect posture and the fingers placed
parallel with the ribs. The precordial dullness, the tympanitic
note of the stomach and the marked hepatic dullness, serve as a con-
trast to the resonant note of the lung.

The surface markings have been considered. (See Thorax as a
Region). The apex of the lung extends slightly above the first rib,
while the lower border extends as low as the sixth rib in the mammary
line, the eighth, in the axillary and the tenth rib posteriorly. In deep
inspiration the lung descends about the width of a rib lower in the tho-
racic cavity.

The blood passing to the lungs comes from two distinct sources,
the bronchial arteries and the pulmonary veins. The bronchial, are
derived from the thoracic aorta and serve to carry nutrition to the sub-
stance of the lung. These arteries follow the bronchi and give branches
to them, the "lymphatic glands at the hilus of the lungs, the large trunks
of the pulmonary vessels (vasa vasorum), and the pulmonary pleura."
There is some anastomosis between the two sets of blood-vessels. The
bronchial arteries receive their vaso-motor impulses from the upper
thoracic segments, they passing by way of the pulmonary and aortic
plexuses to the arteries. The pulmonary vessels send out many branches
that "follow those of the air-passages, and are so closely applied to the
latter that their pulsations may be communicated to the contained air. "
These vessels also receive their nerve supply from the upper thoracic

APPLIED ANATOMY. 587

segments of the spinal cord, they passing by way of the pulmonary plexus.
The bronchial veins drain the substance of the lungs. They empty into
the vena azygos major on the right, and into the left superior intercostal
on the left. On this account they are subject to pressure or other dis-
turbances from contracture of the muscles of the back and from en-
largement of the lung. Landdis says: " Part of the vessels arising from
the capillaries communicate with the beginnings of the pulmonary veins;
and for this reason any considerable stagnation of blood in the lesser
circulation causes a like stagnation in the circulation in the bronchial
mucous membrane, with resulting bronchial catarrh. " This is of value
in explaining the various effects of pulmonary congestion, as well as the
results of upper thoracic lesions. Experimentally, it is hard to estimate
the blood-pressure and speed of the current of the flow, since the chest
has to be opened and this destroys the mechanism of respiration. The
walls of the pulmonary vessels are considerably thinner than those of
other vessels of the same caliber. This is indicative of a lessened blood-
pressure. Howell's Text-Book of Physiology says: "As the pulmonary
artery and veins lie wholly within the chest, but outside the lungs, their
trunks and larger branches all tend to be dilated continuously by the
elastic pull of the lungs — a pull which increases at each inspiration. On
the other hand, the pulmonary capillaries lie so close to the surface of
each lung that they are exposed to the same pressure, practically, as that
surface, and the full weight of the atmosphere may act on them. These
conditions all tend to unload the capillaries and the pulmonary veins,
but to weaken the unloading of the pulmonary artery. "

In congestion of the lungs as in lobar pneumonia, the danger lies
in the weakening of the right heart which has to do with the lesser cir-
culation. The vaso-motor nerves to the pulmonary blood-vessels are
derived from the upper thoracic spinal segments, principally the second
and third, and pass to the lungs by way of the pulmonary plexuses.
Lesions of the upper five thoracic vertebra? either affect the origin of
these vaso-motor nerves to the lungs or else they interfere with the
connection, or line of communication, existing between these nerve cells
and the lungs. Contracture of the upper thoracic muscles has a similar
effect and these lesions are present in all cases of lung disorder. The
usual effect on the vaso-motor nerve is that of inhibition, judging from
the effect on the size of the vessels innervated. Diseases are predis-
posed to, since the vessels are engorged, the speed lessened and the vital-

588 APPLIED ANATOMY.

ity of the part lowered, which conditions make it possible for the micro-
organisms to become active. These nerves from the upper thoracic
segments, also contain trophic and secretory fibers. The pneumogastric
contains trophic, sensory, secretory and afferent pressor fibers. Un-
doubtedly the vagus is controlled or at least influenced by the upper
thoracic nerves, for clinically, lesions in this region disturb the function
of the pulmonary branches of this nerve. Perhaps all of the nerves that
have to do with supplying the lungs, are connected with the respiratory
centers in the medulla, and in this way the pneumogastric would be in-
directly affected by the upper thoracic lesions through the effect on the
medulla.

There are many lymphatic vessels of the lungs and they empty into
the bronchial glands. The color of the lung varies with the age of the
individual. During infancy it is a distinctly pink color and gradually
becomes darker as particles of coal dust and other matter, are deposited
in them until the lung becomes slate color.

The function of the lung is to furnish oxygen to the blood which is
indispensable to the organism. The quality of the blood depends more
on the amount of oxygen in it, than upon all ather things combined.
The patient becomes fatigued in proportion to the amount of toxic
matter in the blood. Since oxygen destroys the toxic materials in the
blood, after all, fatigue can be measured by the amount of oxygen that
is available for the use of the organism. In order that this function of
purifying the blood be exercised to the best advantage, the pulmonary
circulation must be normal, the nutrition of the lung be in good condi-
tion, that is, the bronchial vessels be normal, and the air passages be
open. Lung diseases depend on impairment of one or more of these
conditions. An impairment of the pulmonary circulation results from
cardiac weakness, structural disease of the lung, and lesions of the upper
thoracic vertebra and ribs that affect the vaso-motor innervation of
these vessels. Pneumonia is a good representative of this type of dis-
ease. Shallow breathing from laziness or other cause, is responsible
for inany cases of impaired pulmonary circulation. The nutrition of the
lung is under the control of bronchial vessels and they in turn, under
the nerve centers in the upper thoracic spinal cord. Therefore, lesions
in this region impair the nutrition of the lung. Another important
point concerned in the nutrition of the lung is use. Any part of the
body tends to undergo atrophy and degeneration if not Used, and the

APPLIED ANATOMY. 589

lung is no exception. The using of the part is indispensable to normal
circulation of blood through it. Pulmonary tuberculosis is the best
type of structural disease of the lung. It attacks the parts least used,
that is, the parts of lowest vitality, viz., the apex. In broncho-pneu-
monia, the function of the lung is affected in several ways : from obstruc-
tion to the air-passages from thickening of the mucous membrane, and
from congestion of the bronchial vessels. In asthma, the air-passages
are obstructed and thus the function is affected. On account of the
fact that the arteries of the lung belong to the class called end arteries,
emboli lodging in the lung, cause much disturbance of function since the
circulation of the part beyond the point of obstruction is practically cut
off, from lack of anastomosis.

The effects of disturbances of function of the lung are characterized
by quickened, shallow respiration, getting out of breath readily, and
impoverished blood that may give rise to almost any symptom. The
contour of the chest is altered in accordance with the change in size of
the lung. The lesions that are primarily responsible for these disturb-
ances of function are: subluxation of one or more of the upper four ribs
and vertebrse, prolonged or repeated contracture of the upper thoracic
muscles and lesions of other parts of the body that interfere with elim-
ination of toxic material so that the blood is impoverished and conse-
quently the lung is over-worked. The upper thoracic lesions affect the
lungs by direct pressure on them, pressure on the veins draining them
and by affecting the origin and course of the nerves that supply, they
coming from the upper thoracic spinal cord. If the spine in this region
is flat or straight and the ribs oblique, the patient either already has lung
disease or will have whenever the exciting cause, the micro-organism,
becomes active.

THE HEART.

The heart is a hollow muscular organ that has to do with propelling
the blood through the vessels of the body. It is pyramidal in shape with
its apex directed downward and to the left in relation with the left nipple.
The normal heart is about the size of the closed fist and has little or no
fat in its makeup. The size varies with the amount of work required of it,
it being large in those who exercise a great deal and in those suffering
with some form of cardiac regurgitation, since it attempts to overcome
the leakage by compensatory hypertrophy. The heart has four cham-

590 APPLIED ANATOMY.

bers, the two auricles and the two ventricles. They are of interest in
that they increase in size in certain forms of heart disease. The walls of
the auricles are weaker than those of the ventricles and on this account
they respond to external pressure, as in pericarditis with effusion, more
readily than do the ventricles. The left ventricle is stronger than the
right, since it has to do with the greater circulation, the right with the
lesser or pulmonic circulation. The muscle fibers of the auricles are
arranged in two layers, an outer and an inner. They surround the open-
ings of the veins, being especially marked around the inferior vena cava.
On account of the arrangement of the muscle fibers in this way, the
auricle is able to contract independently of the ventricle. The superior
caval opening, on account of the direction it faces, is not guarded by a
valve while the other openings usually have valves to prevent regurgita-
tion. The Eustachian valve is quite large in the fetus and serves to
direct the bfood across to the foramen ovale which leads to the left
auricle. Sometimes this foramen does. not completely close at birth and
consequently the blood is not properly oxygenated and a condition
called cyanosis neonatorum or "blue baby" results. The opening lead-
ing into the right ventricle, is guarded by the tricuspid valve, which like
the other valves of the heart, is composed or formed from the endocar-
dium. In disease of the endocardium or in obstruction of the pul-
monary circulation as in pneumonia, this valve imperfectly guards the
opening from weakness as in endocarditis or on account of increased
pressure against it from the pulmonic obstruction. Incomplete closure
in indicated by a murmur that is detected most readily by auscultation
over the sternal end of the second rib on the right side. The right ven-
tricle by its contraction, forces the blood around the lesser circulation.
If this function is impaired in the least, the quality of the blood is im-
paired, since it is not properly purified. In obstructions to the- course
of the blood, the ventricle undergoes hypertrophy and thus compensa-
tion is established. The valves that guard the entrance into the pul-
monary artery are called the semilunar valves. Occasionally these
valves become thickened so that they close imperfectly or else the lumen
is so much lessened in size that the normal amount of blood cannot
pass through, both producing a murmur. The left auricle receives the
blood after it is oxygenated and forces it on through the bicuspid valves
into the left ventricle. The left ventricle has by far the thickest walls
because the blood by the contraction of these walls has to be forced

APPLIED ANATOMY. 591

around the greater circuit. Whenever there is any impairment of the
systemic circulation, greater work is thrown on the left ventricle. Violent
exercise increases the force of the ventricular contraction and in athletes,
the left heart is usually enlarged. If the exercise is not kept up, fatty
degeneration may set in and death result from any sudden over-exertion.
In disease of the arteries as in artero-sclerosis, the left ventricle is af-
fected on account of the increased work thrown on it in order to force
the blood into a set of vessels that are less yielding than the normal,
As the work required of the left ventricle is increased, the pressure within
the ventricle increases and often the valves guarding the auriculo-ven-
tricular opening give way and the blood is forced back into the right
auricle. This is called mitral regurgitation. In addition to the increased
work of the heart, the condition of the bicuspid valves should be con-
sidered, since if they are weakened from disease as in endocarditis, they
give way on the slightest increase of the pressure in the ventricle. Com-
pensatory hypertrophy is to be sought in such cases so that the increased
force of the cardiac contraction, will make up for the blood regurgitated.
In all cases of regurgitation, the heart with difficulty responds to emer-
gency calls as in vigorous exercise and the patient gets "out of breath"
and is readily fatigued. There is nothing that will so rapidly weaken
an individual as some derangement of the heart, as in palpitation, since
the purity of the blood depends on proper oxygenation, and this is im-
possible in such cases, and the strength of the patient depends on the
purity of the blood.

The pericardium is a fibro-serous sac that encloses the heart and
the roots of the great vessels. It is quite strong and tough and loosely
surrounds the heart. It is attached above to the great vessels, each
receiving a separate investment. Below it is firmly attached to the
central tendon of the diaphragm, and anteriorly it is attached to the
sternum by means of bands or ligaments. It has two layers, a serous
and a fibrous. The serous, is smooth and glistening and is divided into
a visceral and a parietal layer. These layers permit of free movement
of the heart. A few drachms of a straw-colored fluid is found in the
pericardium in the normal subject. In pericarditis with effusion, there
may be a pint or more of the fluid. In a dissection made by the writer,
the lungs were markedly displaced by an effusion that doubled the size
of the space occupied by the pericardium.

The arteries supplying the pericardium, are derived from the internal

592 APPLIED ANATOMY.

mammary, bronchial and the esophageal. The branches of these arteries
are surrounded by nerves that control their size which are derived from
the plexuses that surround the subclavian and the thoracic aorta.

The nerves are the phrenic, pneumogastric. and sympathetic fila-
ments from the plexuses in relation, the pulmonary and the aortic, they
reaching the pericardium by way of the blood-vessels. In effusions,
there seems to be a congestion and irritation of the pericardium that
are responsible for the increased secretion. Lesions of the upper ribs
were found in all cases seen by the writer. These lesions affect the per-
icardium through the nerves and blood-vessels supplying it; a conges-
tion of the blood-vessels being the effect. The action of the heart is
hampered, respiration disturbed, and the contour and percussion note
of the chest in relation changed, if there is much effusion. "A rich
net-work of lymph vessels lies within the pericardium itself, as well as
more deeply" toward the muscle-mass of the heart. "

The endocardium lines the cavities of the heart and forms the valves.
It is of special interest in that it is frequently diseased and consequently
the action of the valves affected. Endocarditis is the usual form of dis-
ease and is supposed to be most frequently the result of articular rheu-
matism. Perhaps the toxemia that accompanies the rheumatic fever
is partly responsible for the endocarditis but I am of the opinion that
it alone is not a sufficient cause for the inflammation. In cases of rheu-
matic fever treated by the writer, cardiac complications were prevented
by correcting all lesions that ordinarily affect the heart, such as sublux-
ations of the upper ribs and vertebra? and contracture of the muscles of
the back. By such a treatment, the circulation and nutrition of the heart
was kept in good condition and the changed condition of the blood had
apparently no effect on the endocardium. It is advisable to keep the
patient quiet for a considerable length of time after the disease is sup-
posed to be overcome, since in all cases the strength of the endocardium
is lessened and any exertion may throw too much strain on the already
weakened valves, and cause them to rupture or become thickened from
congestion.

The relations of the heart are of importance in understanding the
effects on the heart of other disorders, and the effects on adjacent organs
from cardiac disease. The apex, is in relation with the central tendon
and left leaflet of the diaphragm, to which the pericardium is attached.
In descent of the diaphragm the heart, and through it the cervical fascia

APPLIED ANATOMY. 593

to which the pericardium is attached above, are drawn down. McCellan
states that he is not of the opinion that the central tendon descends
with contraction of the diaphragm, but that only the leaflets descend.
The stomach is in inferior relation with the heart. This is of importance
in that distension of the stomach with food or gas, will embarrass the
heart's action. The writer has treated many cases in which the patient
declared that the trouble was one of cardiac disease, but stomach dis-
order, such as enlargement and distension, was found. On account of
the intimate relation of the stomach and heart, acid eructations from the
stomach are popularly called "heart burn." In some cases the liver
when enlarged, reaches to, and is in relation with, the lower part of the
heart. Anteriorly, a portion of it is not covered by the lung and it is
in relation with the chest wall and sternum. Displacement inward of
the ribs in relation with the heart, especially the fourth rib on the left
side, causes pressure on the heart and embarrasses its action. In many
cases of cardiac disturbance, the symptoms can be immediately relieved
by adjusting these ribs, that is, by restoring them to their normal posi-
tion. The lungs are in lateral relation with the heart, the heart and the
great vessels separating the two lungs. Posteriorly, are found the de-
scending aorta, esophagus, the lower right pulmonary vein, and the
bodies of the fifth, sixth, seventh and eighth thoracic vertebrae.

In the process of development of the heart, it descends somewhat
and thus the nerves to it are stretched and elongated as are the nerves
of the ovary and testicle. As in the case of all viscera, the nerves and
blood-vessels come from a point considerably higher in the spine than
the level of the viscus. On this account, look for the lesion to be above
the affected viscus rather than below it.

The blood-supply of the heart is derived from the coronary arteries,
branches of the ascending aorta, which come off from a point called the
sinus of Valsalva. These arteries, the right and left coronary, supply
every part of the muscular substance, and the valves, if there are muscle
fibers in them. *" Blood-vessels occur in the auriculo-ventricular valves
in considerable numbers only where there are muscle-fibers. " (Landois).
The semilunar valves are supposed to .contain blood-vessels only under
pathological conditions. The endocardium, so far as it can be ascer-
tained, has no blood-vessels in it. The arteries of the heart are essential-

*Text-book of Human Physiology, p. 92.
1l

594 APPLIED ANATOMY.

ly end-arteries since "the resistance in the
branches is too great for an efficient circulation to be maintained through
them. Thus, closure of any one of them is followed by sudden anemia
and infarction of the capillary areas which they supply." (Langley).

The nerve supply of these arteries is derived from the vagus and the
cardiac plexus, the vaso-dilator impulses passing over the pneumo-
gastric and the vaso-constrictor impulses are carried by the sympathetic
filaments that branch from the cardiac plexus. These vaso-constrictor
impulses seem to come principally from the fourth thoracic spinal seg-
ment of the cord, since lesions in this region affect the blood-supply and
nutrition of the heart. Calcification of the coronary arteries often
occurs in the aged. The frequency of this condition is believed to be
due at least in part to the great thickness of the elastic and connective
tissue intima. Angina pectoris is attributed to faulty nutrition of the
heart substance, possibly the result of an atheromatous condition of
the blood-vessels of the heart.

The veins accompany the arteries and return the blood from the
walls of the heart. They are divided into the great anterior and pos-
terior cardiac veins, and the coronary sinus. The coronary sinus re-
ceives a greater part of the blood, the opening of which is guarded by a
valve called the valve of Thebesius.

The nerve supply of the heart is derived from the pneumogastric,
the cervical sympathetic ganglia and the upper thoracic ganglia. The
immediate supply is from the coronary plexuses and the intrinsic ganglia,
the ganglia of Remak and of "Bidder.

The vagus supplies the heart through the external branch of the
superior laryngeal nerve, inferior laryngeal nerve and sometimes through
the pulmonary branches of the vagus. The vagus contains both af-
ferent and efferent fibers. Some have stated that the efferent fibers
leave the medulla by way of the spinal accessory, while more recent in-
vestigators claim that "they leave the medulla along the path by which
the afferent fibers enter and never become associated with the spinal
accessory nerve at its origin." The vagus is regarded by most inves-
tigators as the viscero-inhibitor nerve of the heart, that is stimulation
of it, produces cardio-inhibition. Some claim that it also contains
motor fibers and that stimulation of this nerve produces an acceleration

*Schafer's text-book of Physiology, Vol. II, p, 164.

A V PLIED ANATOMY. 595

of the heart-beat. The writer has seen a few cases in which marked
effects could be obtained on the heart by manipulation of the pneumo-
gastric nerve in the neck. Stimulation along the course of the nerve
decreases the rate, while inhibition increases the heart beat. Practic-
ally, such treatments, are of little value since the only effect obtainable
if any is gotten at all, is a temporary one and is not curative, since the
cause of the disorder is not removed by such treatments. The entire
theory of controlling the heart's action by treatment of the pneumo-
gastric nerve is wrong unless it is primarily at fault, since only an effect
is counteracted and that in an improper way. To properly regulate
the action of the heart, control the amount of motor impulses that sup-
ply it, they passing to the heart by way of the sympathetic branches of
the lower cervical and upper thoracic ganglia.

Physiologically and clinically, the superior and middle cervical
ganglia have little or nothing to do with the nerve supply of the heart.
Langley is of the opinion that the sympathetic impulses to the heart
pass through the stellate ganglion and that none of them pass by
way of the superior and possibly the middle cervical ganglia. Clinically,
this seems to be the case, for it is the exception for lesions in the neck
to have any direct effect on the action of the heart.

The cardiac accelerator nerves arise in the upper thoracic segments
of the spinal cord and the impulses pass out over the white rami into
the gangliated cord, thence upward by way of the stellate ganglion, or
directly across to the heart, or possibly they reach the heart over both
sets of fibers. *Brubaker in speaking of the sympathetic nerve supply
of the heart says : ' ' The fibers are peripherally coursing axons of nerve-
cells situated in the ganglion stellatum. The nerve cells in the gang-
lion stellatum are in relation with small medullated nerve fibers which
emerge from the cord in the anterior roots of the second and third thor-
acic nerves, pass through the white rami communicantes, and thence
to the ganglion stellatum, where their end branches arborize around the
nerve-cells."

These nerves with the pneumogastric, form the cardiac plexuses.
The deep cardiac plexus lies between the trachea and the arch of the
aorta and is formed by branches of all the cardiac nerves with the ex-
ception of the left superior cardiac branch of the superior cervical ganglion
and the left inferior branch of the pneumogastric. Some of the branches

*Brubaker, p. 291.

596 APPLIED ANATOMY.

of this plexus go to the anterior pulmonary plexus but a majority of
them follow the coronary arteries and form the coronary plexuses, while
some of them go to the right auricle. The distribution of the branches
of the superficial plexus corresponds to that of the branches of the
deep. A small ganglion called the cardiac ganglion of Wrisberg is found
in this plexus, near the ductus arteriosus. *Landois gives the following
structures as belonging to the cardiac plexus: (a) "The right and left
coronary plexuses, which convey the vaso-motor nerves of the coronary
vessels through the vagus portion and the dilators through the sympa-
thetic; and in addition contain sensory fibers derived from the vagus
and passing principally to the pericardium, (b) The nerves embedded
in the heart muscle and in the furrows, which are richly supplied with
ganglia and which have been designated the automatic motor centers
of the heart. The heart contains a circle of nerves richly supplied with
ganglia at the edge of the interauricular septum and another at the
junction of the auricles and the ventricles. Wherever the two meet
they exchange fibers. The ganglia are for the most part found near
the pericardium." Clinically, the lesions that affect the innervation
of the heart are subluxations of the upper ribs, especially the fourth
and fifth; the third, fourth and fifth thoracic vertebra?; the clavicle and
lesions that affect it through effect on viscera and other structures, such
as the diaphragm.

The point at which the heart can be most easily reached corre-
sponds to the spine of the fourth thoracic vertebra. Manipulation di-
rected to this point, that is passive movement of the vertebrae or the
corresponding ribs will in the average case increase the heart rate.
Pressure directed here will have the opposite effect. Lesions may in-
hibit or stimulate, hence a lesion that inhibits the nerves at this place
will decrease the heart beat while an irritative one will increase the pulse
rate. This is substantiated by an experiment performed by Dr. Fassett.
As described by himself it was as follows: "The subject was a man
thirty years of age, whose heart had at one time, shown some functional
disorders but which for sometime had been practically regular although
slightly faster than normal. The experiment was performed about
4:30 p. m. when the acceleration sometimes observed after a meal could
be assumed to have passed away. The room was quiet and the subject
had been in the room for over an hour so that the element of excitement

*Text-book of Human Physiology, p. 114.

APPLIED ANATOMY. 597

could probably be neglected and, moreover, excitement is apt to cause
an increase rather than a decrease in the number of heart beats. The
subject had been lying on the table for half an hour so that the slowing
with change of posture had probably reached its limit. With the sub-
ject still in the reclining posture an operator took his position with his
hands so placed that, at the desired time, he could exert pressure on the
region between the angle of the left fifth rib and the corresponding spinous
process. The cardiograph was placed over the apex beat of the heart
and the levers of the registering apparatus and the time marker were
placed in contact with the smoked paper. In this case the latter was at
a higher level. The drum was then set in motion and, after about a
minute, pressure was begun in the region described and continued for
about two minutes and then carefully removed. After about four
minutes of observation, the levers were removed from the paper and the
strokes of the time marker counted and divided into groups of 30 each.
As these strokes were two seconds apart it is obvious that the space
covered by each of these groups represents one minute of time. The
number of strokes of the heart lever in the space covered by each of these
groups were then counted with the following result :

First minute (during which pressure was begun) 74 beats; second
minute, 71 beats; third minute (during which pressure was stopped)
66 beats; fourth minute, 64 beats.

If it were safe to draw conclusions from one experiment, this would
show that pressure in the region of the fifth rib on the left side, exerted
a marked inhibitory influence on the heart and that this effect is con-
tinued for sometime after the pressure is removed."* Observations
of the writer have confirmed the above experiment and it is proven be-
yond a doubt that the heart can thus be affected by external manipu-
lation. It seems that the more nearly normal the heart, the less marked
the effect obtained; while in cases in which there is a functional affec-
tion, the effect is very well marked.

The diseases of the heart may be classified into those that result
from causes that are external to the heart and into those that are due
to changes in the heart itself. To the first belong the various functional
disorders such as palpitation, in which the trouble seems to lie in the
nervous mechanism that runs the heart.

Valvular disease and angina pectoris are due to changes in the

*Journal of Osteopathy, July, 1901.

598 APPLIED ANATOMY.

heart itself. In both, the circulation and nutrition of the heart-muscle
are affected so that it imperfectly performs its function. Such diseases
result from the above named lesions because they affect the vaso-motor
and nutrient nerves to the heart, since they come from the upper thor-
acic spinal cord. In practically all cases of heart disorder whether
functional or organic, tenderness will be found on pressure over the
spines of the fourth and fifth thoracic vertebrae and usually along the
course of the corresponding ribs on the left side. The patient often com-
plains of pains in the left side of the chest, pains of a shooting or stab-
bing character. Especially in angina pectoris, the left arm is involved
and numbness is frequent in the little and ring fingers of the left hand.
In functional disorders of the heart the most common lesion is a sublux-
ation of the fourth or fifth ribs on the left side.

THE STOMACH.

The stomach, the most dilated part of the alimentary tract, lies
when empty, in the left hypochondriac and epigastric regions. It is
retained in position by its attachment to the diaphragm by means of
the esophagus, to the liver by means of the lesser omentum and the
hepatico-duodenal ligament and to the spinal column by means of the
duodenum. When empty, it is in an almost vertical position but as
soon as food is introduced into it, it rotates and descends so that it is
more nearly horizontal. The larger and more capacious part is called
the cardiac end and is directed toward the left side of the body. On
account of the greater part of the stomach lying on the left, lesions af-
lecting it are most frequently found on the left side. The constricted
portion of the stomach lies when empty in the median line but when dis-
tended, crosses an inch or more to the right side. It is called the pylorus,
because it guards the entrance into the duodenum. It is more anterior
than the cardiac end and is thus exposed to a greater degree to trauma,
such as a blow on the upper part of the abdomen.

The pylorus is produced by a thickening of the circular muscle
fibers into quite a strong ring and the opening in the normal case, will
scarcely admit the little finger, it being the most constricted portion of
the alimentary canal. The lesser curvature of the stomach is directed
towards the liver and marks the line of attachment of the lesser omentum.
The gastric and pyloric vessels run along this curvature. The greater
curvature is about three times as long as the lesser, and corresponds in

APPLIED ANATOMY.

599

the greater part of its course, to the attachment of the great omentum.
The right and left gastro-epiploic vessels lie in relation, between the
layers of the omentum.

Fig. 153. — Showing the relation of the abdominal viscera to the back. Note
the relation of the stomach to the spleen and kidneys.

600 APPLIED ANATOMY.

The relations of the stomach are of importance on account of fre-
quency of disease of parts in relation producing disturbances of function
of it. Anteriorly, are the diaphragm, liver and anterior abdominal wall.
Contraction of the diaphragm assists in the expulsion of the contents
of the stomach. A prolapsed diaphragm affects the movements of the
stomach and forces it to a lower level. The entire stomach can not be
accurately percussed on account of the left lobe of the liver covering
a part of it. In some dissections made by the writer, the left lobe was
so markedly enlarged that it displaced the stomach backward and down-
ward and produced a dull percussion note over the stomach. Behind,
are the pancreas, spleen, left kidney, left suprarenal capsule, diaphragm,
aorta, inferior vena cava, vena azygos minor, transverse meso-colon and
the great solar plexus. Distension of the stomach whether from accumu-
lation of gas or from over filling with food, will cause pressure on the
structures in "posterior relation, especially if the individual assumes the
dorsal posture. Pressure on the veins interferes with the circulation
and especially affects the drainage of the spinal cord. Pressure on the
solar plexus is also a cause of much disorder, since it affects the entire
circulation of the body. Insomnia and nightmare are due partly to the
effects of pressure on the solar plexus from an overloaded stomach, the
patient retiring before digestion was completed. Superiorly, are the
diaphragm, lesser omentum and the liver. Liver disease such as an
abscess, will directly affect the stomach from contiguity of tissue. In-
teriorly, are the transverse colon, spleen and the great omentum. On
account of contiguity of the structures surrounding the stomach, there
may be dyspnea from pressure on the lung; and palpitation of the heart
from pressure on it.

In pleural effusions it is often difficult to determine whether the
trouble is in the stomach, kidney or in the pleural cavity. The effects
on the heart are the most common and often a case of supposed heart
disorder is in reality one of gastric disease. *Deaver says: "Because
of the proximity of the stomach and heart, painful affections of the one
may be mistaken for disease of the other, so justifying the advice that
'if the patient complain of his stomach, suspect heart disease; if he
complain of his heart, suspect indigestion.' "

In distension of the stomach there is often found marked pain on
the left side of the spine in the region of the vertebral ends of the fifth,

*Surgical Anatomy, Vol. Ill, p. 165.

APPLIED ANATOMY. 601

sixth and seventh ribs and in the left shoulder. This is due to the
pressure of the stomach on the nerves in posterior relation, principally
the intercostals. When the stomach is distended with gas, the pressure
is greatest on structures in relation with the cardiac end since the gas
is only contained in that end.

The stomach is subjected so frequently to alterations of position
that the external landmarks are of little value. Normally, the stomach
may occupy any position from the primary vertical one when empty,
to a position almost horizontal, immediately above the umbilicus. There
are many factors responsible for this variation in position. Tight lacing
is an important one. In such cases all the abdominal viscera are gradu-
ally but forcibly displaced downward producing a condition called en-
teroptosis. Overloading of the stomach causes it to be displaced down-
ward from the increased weight. If this is frequently repeated, the
stomach will remain in descent. Obstruction at the pylorus will cause
distension and later on, displacement downward. In nearly all cases
of chronic dyspepsia, general weakness and emaciation, the stomach is
both dilated and displaced downward. It is well in every case of indi-
gestion to ascertain the size of the stomach. This is best accomplished
by percussion, which should be performed in different positions and
especially in the upright , since the stomach will then settle to its maximum
degree of descent. By causing the patient to drink a cup of water be-
fore the examination, theoutlineof thestomachcan be ascertained by the
succussion note. Succussion is present in most cases of catarrh of the
stomach and furnishes a valuable diagnostic sign. If the tympanitic
note of the stomach is found as low as the umbilicus or an inch or more
to the right of the median line of the body or as far to the left as the mid-
axillary line, the stomach is either very much enlarged or displaced.

In structure, the walls of the stomach are formed of the usual
four coats, the serous, muscular, submucous and the mucous. The
shiny appearance of the walls is due to the peritoneum that covers all
parts with the exception of the curvature's and a small portion back of
the cardiac orifice. The muscular coat consists of three layers arranged
longitudinally, obliquely and in a circular manner. The circular are
best developed at the pylorus. This arrangement of the muscle fibers
permits of the grinding movements of the stomach. The blood-vessels
and nerves break up in the submucous coat to be distributed to the walls
of the stomach. The mucous lining of the stomach is of moderate con-

602 APPLIED ANATOMY.

sistency, pink in color and thickest at the pylorus at which place it is
most frequently diseased. When the stomach is empty, it is thrown
into longitudinal folds or rugae. The surface is covered with minute
openings which are the mouths of the many glands embedded in the
mucous membrane. The muscle fibers, composing the walls of the
stomach depend, like all muscle fibers, for their tone and nutrition on
the condition of and connection with the trophic cells, located in the an-
terior horns of the grey matter of the spinal cord. If the circulation to
these cells in the cord is impaired, or if the nerve connection is broken
by a lesion, the walls of the stomach undergo relaxation and the stomach
enlarges and becomes displaced downward. The condition of the back
muscles in relation with the spines of the fifth, sixth and seventh thor-
acic vertebra?, furnishes a good clue as to the condition of the walls of
the stomach as to their tone.

The stomach receives a rich supply of blood. All the arteries are
ultimately derived from the celiac axis. The special branches comprise
the coronary, the pyloric from the hepatic, right gastro-epiploica from
the gastro-duodenal and the left gastro-epiploica from the splenic and
the vasa brevia branches of the splenic. These arteries run along in
the omenta that is, along the curvatures of the stomach, lying at first
beneath the peritoneum but they very soon pierce the muscukr coat and
break up into innumerable branches. On account of the^act that
the blood supply comes from several arteries instead of one as in the
case of the small intestines and colon, gangrene is not so likely to result
from injury of the part. The size of these arteries of the stomach, is
controlled by the branches of the celiac plexus of nerves, which sends
out filaments along with all the branches of the celiac axis, that is over
the splenic, gastric and hepatic arteries. The impulses come orig-
inally from the fifth, sixth and seventh segments of the thoracic spinal
cord. They pass out over the white rami into the gangliated cord and
on through it by way of the great splanchnic nerve, to the solar plexus
and particularly to the lower part or celiac plexus. It is an established
fact that lesions at the fifth, sixth and seventh thoracic vertebrae pro-
duce vascular disturbances of the stomach. The explanation is that
vaso-motor, as well as other impulses intended for the stomach, pass by
way of the nerve filaments that go to form the great splanchnic nerve.
These nerve filaments pass through the intervertebral foramina and are
subject to pressure even in the slightest lesion, thickening of the liga-

APPLIED ANATOMY. 603

ments or deviation. Consequently the vaso-motor impulses for the
blood-vessels dilate. The pressure exerted by the subluxation of the
vertebra, will affect the passing in and out of the blood that nourishes
and drains the nerve-cells in the cord from which the impulses arise that
supply the stomach, therefore disturbance of function of the stomach
must follow. These lesions only predispose to disease by causing a
weakening of the viscus thus making it possible for trivial exciting causes
to become effective.

The veins in a way correspond in arrangement to the arteries. The
important feature of them is the fact that they empty directly or in-
directly into the portal vein. As a result of this, practically all the blood
from the stomach passes through the liver before it gets to the heart,
consequently any obstruction in the liver such as a congestion, whether
from overeating or from lesions or disease, will produce a passive con-
gestion in the stomach. From this it follows that in all cases of liver
disease there is stomach disorder. These veins are probably supplied
with vaso-motor nerves that are continuations of those that supply the
portal vein, but this has not as yet been proven experimentally. The
lymphatic vessels accompany the veins and empty into glands lying along
the curvatures and at the cardiac and pyloric ends.

The nerve supply of the stomach is derived from the pneumogastric
and sympathetic branches of the solar plexus. These branches form a
plexus between the layers of muscle fibers and immediately under the
submucous coat. Large ganglionic nerve cells are found in connection
with these fibers, the whole constituting Auerbach's and Meissner's
plexuses. The filaments that form that part of the solar plexus taking-
part in the innervation of the stomach, are derived ultimately from the
thoracic spinal cord, the fifth, sixth, seventh and eighth segments, but
especially the sixth. The impulses pass out of the spinal cord by way
of the anterior root, pass into the common trunk, white ramus, gangiiated
cord and on through it by way of the splanchnic nerve to the solar plexus.
In short, there is a direct line of communication existing between the
spinal cord and the stomach and any interruption in the form of a
lesion will affect the function of the stomach.

The motor impulses to the stomach come principally from the
pneumogastric but some are furnished by the splanchnic nerves. *Star-
ling says: "According to Schiff, motor fibers also reach the stomach

*Schafer's text-book of Physiology, Vol. II, p. 324.

604

APPLIED ANATOMY.

Fig. 154. — Showing the relations of the stomach and colon to the regions of the
abdomen; S. stomach; D. duodenum; H. F. hepatic flexure; S. F. splenic flexure; T.
transverse colon; M. McBurney's point; C. cecum; D. C. descending colon; S. F. sig-
moid flexure; R. rectum. The dotted lines indicate the relations of the liver and
pleura.

APPLIED ANATOMY. 605

from the sympathetic chain, by way of the splanchnics. Morat also
observed one case in which the rhythmical contractions of the stomach
(and intestine) were augmented on stimulation of the splanchnics."
The splanchnic nerves to the stomach are regarded by most observers
as inhibitor in action that is, stimulation of them lessens the move-
ments of the stomach. Judging from the effects of lesions, the splanch-
nic nerves are motor to the stomach, for irritative lesions along the
mid-dorsal region, increase the movements of the stomach and certain
forms of manipulation in this region, also affect the peristalsis of the
stomach. Either this is true, or else the splanchnic is closely associated
with the vagus so that stimulation of it will increase the activity of the
vagus. In either case, it is a well known fact that lesions that are irri-
tative in character, along the mid-dorsal region, increase the activity of
the stomach while lesions that are inhibitory that is, paralytic in charac-
ter, decrease the peristalsis of the stomach; these effects presumably
being through the splanchnic nerves. The sensory nerves to the stomach
according to Head, are derived from and "run in the sixth, seventh,
eighth and ninth dorsal nerve-roots, the cardiac end being especially
associated with the sixth and seventh, and the pyloric end with the ninth
roots." The pneumogastric nerve also furnishes sensory fibers to the
stomach. Sherrington says: "*As to the sensory nerve channel for
the local sensation of hunger, likely enough it is the vagus but very
possible the stomach receives nerve fibers also from the thoracic spinal
ganglia, via the rami communicantes." The vagus supplies secretory
fibers to the glands of the stomach. The splanchnic nerves also have
to do with gastric secretion possibly more through the blood supply
than through the so-called secretory nerves. Secretion depends to a great
extent on the kind and amount of blood supplying the gland and since
the splanchnics control the blood-supply to the glands of the stomach,
they also control to a large extent, the amount of secretion. Conges-
tion of the mucous membrane of the stomach causes an increase in secre-
tion regardless of the cause of the increased amount of blood, f" Grutzner
observed in a. dog that the mucous membrane secreted continu-
ously under the influence of a chronic gastric catarrh, but the gastric
juice was deficient in pepsin, cloudy, viscous, less acid, even alkaline.
The introduction of food did not modify the secretion; the stomach,
therefore, never actually comes to rest." This offers an explanation

♦Schafer's text-book of Physiology, Vol. I , p. 991.
fText-Book of Human Physiology, Landois, p. 340.

606 APPLIED ANATOMY.

of indigestion from congestion of the mucous membrane of the stomach.
The lesions along the spine are the important causes of this secretory
disorder since they primarily cause the congestion.

The trophic nerves of the stomach walls are the splanchnics. They
also are intimately associated with the vaso-motor nerves. It seems
that each muscle fiber of the stomach is connected with a cell in the
anterior horn of the grey matter of the spinal cord, especially the sixth
thoracic segments. These cells control the tone and nutrition of the
muscle fibers. The connection is by way of the splanchnic nerves.
This connection is broken or impaired by a lesion that lessens the size
of the foramen through which the fibers, hence the impulses, pass. Any
subluxation of vertebrae in the middle dorsal region, will lessen the size
of the foramina, hence is responsible for weakness of the walls of the
stomach, which is the most common of all disorders of the stomach.

The vaso-motor nerves are the splanchnics. Lesions that inhibit
them produce dilatation of the vessels supplied by them and conges-
tion is the result. After reaching the solar plexus by way of the splanch-
nics, the vaso-motor impulses reach the blood-vessels of the stomach
by way of the hepatic, splenic and gastric plexuses, branches of the celiac.
The walls of the stomach contain automatic ganglia that control their
tone. These are connected with the pneumogastric and splanchnic
nerves.

The higher centers that control the degree of contraction of the
cardiac end, the body of the stomach and the pyloric end, are located
respectively in the posterior quadrigeminal bodies, corpora quadri-
gemina, and in the cortex, the path being along the pneumogastric.
Dilatation centers are located respectively in the corpus striatum and
upper part of the spinal cord for the cardiac orifice; the upper cord for
dilatation of the body of the stomach; while the center for dilatation of
the pylorus corresponds to the centers that control constriction of the
cardiac orifice, viz., the corpora quadrigemina. A majority of the im-
pulses connecting these centers with the stomach, pass through the spinal
cord and out over the splanchnics, hence are affected by spinal lesions
and can be reached by spinal treatment. This is of value in the treat-
ment of gastric disorders, such as obstruction of the pylorus and the
accumulation of secretions and food in the cavity of the stomach, from
deficient peristalsis. The best results can be obtained by the correction
of lesions that interfere with the action of these centers .but in some

APPLIED ANATOMY. 607

cases inhibition applied to the left side of the spinal column at about
the fifth or sixth thoracic spine, will cause the pyloric end to dilate.
Pressure applied directly over the pyloric end of the stomach and kept
up for a few minutes, has a quicker effect although it is only temporary
but often long enough to relieve.

The stomach acts as a reservoir for the ingested food, assists in di-
gestion by its movements and secretions, and aids in absorption. These
functions are affected by lesions that weaken or cause spasmodic con-
traction of the walls of the stomach, thereby increasing or decreasing
the size of the cavity," by lesions that interfere with the motor nerves to
the stomach which result in perverted peristalsis; by lesions that affect
the secretory and vaso-motor nerves thereby interfering with secretion
and nutrition; and by disturbances of absorption. The first is repre-
sented by the distended stomach, the second by imperfect mixing of the
food, the third by disturbances of secretion, hence indigestion as in
gastritis and catarrhal conditions in which there is succussion.
Lesions of the fifth, sixth, seventh and possibly the eighth thoracic
vertebrae and the corresponding ribs of the left side, disturb these func-
tions by changing the size of the intervertebral foramina so that the
impulses to the stomach are affected, usually inhibited ; by disturbing
the nutrition of the nerve cells in the spinal cord that give rise to the
impulses that pass over the nerves that supply the stomach; or these
lesions stimulate or inhibit the nerves after they have emerged from
the spinal foramina. Indirectly these lesions and others, may affect the
functions of the stomach by disturbing the position or circulation of
other viscera that are in relation as for example, the liver. These le-
sions affect the stomach in various ways. They may disturb the tone
and nutrition of the muscle fibers, the size of the blood-vessels, the
secretory nerves and consequently there are gastroptosis, gastritis, and
catarrh.

*McConnell states in experiments on dogs in which lesions of the spine
were produced (fourth, fifth articulations). "Careful chemical analysis
of the stomach contents of the dog before and after production of the
lesions showed a marked difference in the chemical reaction. The fol-
lowing deductions as to the stomach may be drawn from the analysis
and experiments:

1. The muscular action of the stomach is lessened.

*Journal A. O. A., Vol. 5, p. 17.

60S APPLIED ANATOMY.

2. The secretions of the stomach are decreased.

3. The physiological and mechanical functions of the stomach are
retarded.

The microscope reveals intra-cellular congestion and ecchymoses
of the stomach tissues and beginning degeneration of the glandular
cells."

THE LIVER.

The liver is the largest gland in the body, weighing, on an average,
four pounds. It is situated in the right hypochondriac and epigastric
regions and may extend across to the left hypochondriac region. In
the normal case it seldom extends more than two inches across the
median line of the body but it is the exception for it to be normal in size.
The writer has been surprised at the frequency of enlargement of the
liver in the cadavers dissected at the school with which he is connected.
It is the exception for a normal liver to be found and sometimes it is
twice the size of the average or normal.

In the infant, the liver is proportionately much larger than in the
adult and this should be considered before giving a diagnosis of enlarge-
ment of the liver. It is divided by the falciform ligament into two
lobes, the right and left. In addition there are the Spigelian, caudate
and quadrate lobes.

The anterior border is thin and sharp and extends slightly below
the costal arch, when the patient is in the erect posture. If it extends
further than this, it is indicative of enlargement unless it has been
forced downward from the wearing of tight clothes. This border is
notched to the right for the gall-bladder and to the left, for the separa-
tion of the right and left lobes.

The two posterior borders are grooved for the inferior vena cava
and are in relation with the spinal column. The right extremity is
thick and blunt, it contrasting with the thin, flat extremity on the left.

The superior surface is very smooth and convex, conforming to the
arch of the diaphragm. It is covered by peritoneum and has a shallow
depression on the left lobe for the heart.

The inferior surface is irregularly concave, consists of three parts,
the quadrate and left lobes and the under surface of the right, and is
covered with peritoneum except in relation with the gall-bladder and at
"e point where the lesser omentum leaves the liver. On this surface are

APPLIED ANATOMY.

609

to be found the remains of the umbilical vein, now the round ligament,
an impression for the stomach, a fossa for the gall-bladder and impres-
sions for the hepatic flexure of the colon, right kidney and descending
part of the duodenum.

The posterior surface is in relation with the spinal column. The

Fig. 155. — Showing a hj'pertrophied liver. Drawn from a dissection made at
the A. S. 0.

Spigelian lobe is opposite the bodies of the tenth and eleventh thoracic
vertebra?, and the right crus of the diaphragm. It is connected with
the right lobe by means of the caudate lobe. The fissures are arranged
according to Morris, like the capital letter. H. The umbilical, a part

610 APPLIED ANATOMY.

of the longitudinal fissure, and the fissure of the ductus venosus form-
ing one side; the transverse bar of the H, being formed by the transverse
or portal fissure, while the remaining part of the letter is formed by the fossa
of the gall-bladder in front and the fissure of the vena cava behind.
These are of little importance except from a surgical viewpoint as in
operations on the gall-bladder and in abscesses. The ligaments are
formed from peritoneum, except the round. The}r are all attached to
the diaphragm with the exception of the round, which being the remains
of the umbilical vein, is attached to the umbilicus. The peritoneal
ligaments are the coronary, two lateral and the broad or falciform.
These ligaments in conjunction with the blood-vessels support, or rather
suspend, the liver.

On account of the frequency of enlargement of the liver, its rela-
tions are of marked importance on account of the effects on structures
and viscera'that are in relation.

Anteriorly, the abdominal wall and the diaphragm are in relation.
Blows on the abdomen in this region may injure the delicate, friable
tissue of^the liver. A great many cases of abscess of the liver are due to
direct injury. Although only a part of it extends below the costal arch,
all of this portion is subject to injury from a blow on the part or from
a hard treatment. Superiorly, is the diaphragm and back of it, the
lungs. In abscess of the liver, the pus may burrow through the dia-
phragm into the lungs and be expectorated. This often gives rise to
errors in diagnosis unless the relations of the lung and liver are considered.
Liver disorders sometimes give rise to a chronic cough, popularl}' called
a liver cough. It is the result of pressure exerted on or irritation of,
the diaphragm and the lung, from an enlarged or diseased liver. In
marked enlargements of the liver, the contour of the abdomen is changed
and the action of the diaphragm interfered with.

Posteriorly, are found the lower end of the esophagus, tenth and
eleventh thoracic vertebrae, crura of the diaphragm, right supra-renal
capsule, right kidney, aorta, inferior vena cava, the great nerve plexuses
of the abdomen and the vena azygos major vein. From this it follows
that enlargement of the liver, or lying in the dorsal position for any
length of time, will affect by pressure, the above named structures. Per-
haps the most important effect is that on the gangliated cord and its
branches and the veins in posterior relation.

Below the liver are the stomach, hepatic flexure of .the colon, the

APPLIED ANATOMY. 611

right kidney, and the first and second portions of the duodenum. En-
largement of the liver causes an encroachment on these organs. Tight
lacing has a similar effect by crowding the liver downward. The normal
liver extends as high as the fourth costal space in the mammary line on
the right side. Posteriorly it reaches to the tenth rib. "*Its lower
margin corresponds superficially to the eighth rib in the axillary line,
tenth dorsal vertebra behind, and in front to a line from the tip of the
ninth right costal cartilage to the eighth left costal cartilage. At a deep
level it extends to the eighth rib behind.''

The outline of the liver is best obtained by percussion while the
patient is in the erect posture, since, in this position, the organs are more
nearly in their proper relations. On palpation, the condition of the
liver to a certain extent, can be determined, and especially so if it is en-
larged, in a position of descent and tender.

The blood-supply of the liver is derived from two sources, the hepa-
tic arteries from the celiac axis that carry nutrition to the substance of
the liver, and the portal veins that carry blood to the liver for elabora-
tion by the action of the liver-cells. The hepatic arteries pass up be-
tween the two layers of the lesser omentum and divide into two branches,
one for each lobe. It enters the left end of the transverse fissure, gives
off branches to the capsule of Glisson, the fibrous coat and the gall-
bladder. It then divides and subdivides within the substance of the
organ. This artery receives its innervation from the hepatic plexus
of nerves and ultimately from the spinal cord by the way of the great
splanchnic nerve. In disorders characterized by disturbances of nutri-
tion of the substance of the liver, the hepatic arteries are at fault but if
the symptoms are those of jaundice, the portal system is affected.

The portal vein is formed by the splenic, mesenteric, pancreatic and
gastric veins. The portal system is peculiar and bears a close relation
to the arterial. Practically all the blood from the digestive tract passes
through the liver to be purified or otherwise acted on by the liver. Any
obstruction in the liver will cause the blood to back up and accumulate
in the viscera drained by the portal vein, hence any disease of the liver
characterized by congestion, predisposes to or actually produces, dis-
order of the stomach, pancreas, spleen and small and a part of the large
intestine.

The nerve supply of the portal vein has been pretty well investi-

*Eisendrath, Clinical Anatomy, p. 200.

612 APPLIED ANATOMY.

gated, in fact, more fully than that of any other vein. *"Bayless and
Starling localize the outflow of vaso-constrictor nerves to the portal
system in from the third to the eleventh anterior thoracic roots. By
excitation of the eighth to the eleventh roots, they obtained, first, a
rise of pressure in the portal vein due to constriction of the mesenteric
arteries, forcing blood on into the portal vein; secondly, a fall due to the
diminished flow of blood through the mesenteric arteries; and lastly, a
rise due to constriction in the hepatic branches of the portal vein."
In another place the same investigator says: "By stimulation of the
thoracic sympathetic cord, blood was actively expelled from the liver.
If the hepatic nerves were divided, this stimulation of the sympathetic,
by causing contraction of the spleen, produced dilatation of the liver.
The liver is exceedingly vascular, and forms an enormous reservoir for
the venous blood at periods when the diastolic filling of the right heart is
impeded; foi». instance, during an intense muscular effort, or a prolonged
dive under water. The portal circulation is aided considerably by the
action of the respiratory pump. The abdominal wall compresses the
blood, while the thorax sucks the blood from the liver. The circula-
tion through the liver is thus greatly accelerated by muscular exercise."
The above statements go to prove that there is a connection existing be-
tween the spinal cord and liver and that stimulation applied to the middle
thoracic nerves, affects the blood-vessels of the liver. The application is
that a lesion either stimulates or inhibits, and that a lesion in the middle
dorsal region will affect the circulation through the liver. The explana-
tion is that it either stimulates or inhibits the passing of nerve impulses
from the spinal corcl to the liver, they passing by way of the splanchnic
nerves. These lesions act as predisposing causes to liver disease in that
they impair the hepatic circulation . Undoubtedly the frequency of disease
of the liver is to% great extent due to dietetic errors and abuse and in many
cases, to these lesions that so weaken the vessels of the liver that the
abuse readily affects the organ. The most important. of these lesions
are those that affect the seventh and eighth thoracic vertebrae.

The blood is gathered up by the radicles of the hepatic veins and
emptied into the inferior vena cava. Lying on the back has a tendency
to produce pressure on these veins and thus interfere with the drainage.

The lymph vessels empty into glands that are around the pancreas,
in the omentum, while the superficial, empty into the anterior mediastinal

*Hill, Schafer's text-book of Physiology, p. 140.

APPLIED ANATOMY. 613

glands and into glands in the small omentum. The practical part of
this is the fact, that it is the exception for the omenta to be in a normal
position and in displacements of it, the lymph drainage of the liver is ob-
structed. Some of the lymph vessels empty into the lumbar glands on
the right side.

The nerve supply of the liver is from the celiac plexus, the pneumo-
gastric, especially the left, and from the phrenic. The impulses pass
from the spinal cord by way of the sixth, seventh and eighth thoracic
nerves into the great splanchnic, thence through the celiac plexus and
over the hepatic, to the liver. They unite with the filaments from the
pneumogastric. They are vaso-motor, trophic and possibly secretory
in function. *Landois says: "The celiac plexus sends trophic and vaso-
motor nerves to the liver. Destruction of this plexus therefore causes
degeneration of the liver-cells, and dilatation of the hepatic artery. The
pneumogastric nerve supplies dilator-fibers to the vessels, and the greater
splanchnic motor branches to the muscles of the bile ducts. " As stated
above, lesions of the spine affect the innervation of the liver because as
Brubaker states, the liver is supplied with nerves derived from the cen-
tral nervous system and the fibers pass through the thoracic interver-
tebral foramina. Filaments of the right phrenic pass through the cor-
onary ligament to the right lobe of the liver after it passes through the
diaphragmatic plexus. fMcClellan says: "The pain which is felt at
the top of the right shoulder in disease of the liver is conjectured to be
due to the reflex influence through the phrenic nerve to the third and
fourth cervical nerves, whence the supra-acromial nerves are also de-
rived. " A better explanation is that the same segments of the spinal
cord that give rise to the fibers of the splanchnic that supply the liver
and stomach, also give rise to the nerves that supply the muscles and in-
tegument of the parts involved in this liver pain, that is the fifth and
sixth thoracic nerves. The pain seems to be under the scapula rather
than in the region of the acromial process.

The splanchnics, contain afferent fibers that convey sensory impulses
from the liver to the spinal cord and are involved in all painful affec-
tions of the liver. On account of the close connection existing between
these and the cerebro-spinal nerves on the right side, the pain is referred
to the integument over the liver in many diseases of the liver.

*Text-book of Physiology, p. 311.

f Regional Anatomy, p. 56.

614 APPLIED ANATOMY.

In structure, the liver is composed of an enormous number of min-
ute polyhedral cells which are imperfectly separated from each other.
The blood-vessels, hepatic ducts, and lymphatics are in the connective
tissue that surrounds each cell. The liver is very friable thus easily
torn and bruised. Hemorrhage from a tearing of the substance of the
liver, is profuse as in trauma, the result of a bullet wound or a fractured
rib. It is sometimes bruised by injudicious treatment in which it is
too severly massaged.

The important functions of the liver are the secretion of bile, the
storing up of glycogen and the formation of urea. It also has something
to do with the formation and destruction of the red blood corpuscles.
These functions are dependent on the amount and character of the
blood carried to the liver and the condition of the nerves supplying it.
Digestive disorders affect the quality of the portal blood and thus affect
the function of the liver. Overeating produces an excessive amount of
portal blood consequently the liver is congested.

The above mentioned lesions affect the nerve and blood supply and
are thus the important predisposing causes of liver disease. The lesions
that are most frequently associated with disturbances of the liver are
subluxations of the sixth, seventh and eighth, thoracic vertebrae; dis-
placement of the corresponding ribs, particularly on the .right side;
contracture of the muscles in the mid-dorsal region and displacement
or disease of the viscera drained by the portal vein, thus affecting the
character of the blood that is carried to the liver. The lesions of the
ribs on the right side result in many cases, in pressure directly on the
liver as in tight lacing. As in most effects of lesions, the above produce
circulatory disturbances in the liver and consequently any sort of dis-
turbance of function will follow, it depending on the degree of the dis-
turbance and the exciting causes; normal circulation being absolutely
necessary to perfect function.

The gall-bladder is a membranous sac that acts as a reservoir for
the bile. It is lodged in a shallow fossa on the under surface of the
liver. The wide end or fundus is lowest and reaches to the lower
edge of the liver. It is the part that, in favorable cases, can be palpated
and being the lowest part, contains the residue of the bile and the cal-
culi that have not already passed into the duct. The constricted por-
tion or neck is somewhat curved which is continued into the. duct. This

APPLIED ANATOMY.

615

is of importance in the working of gall-stones out of the duct. The
cystic and hepatic ducts join at an acute angle to form the common duct.
The gall-bladder and these ducts have muscle fibers and nerves. The
action of them seems to be a reflex one. Pressure exerted on the bladder
will not cause emptying of its contents by the mechanical force exerted,
but will reflexly cause relaxation of the neck, and contraction of the
fundus, thus permitting of evacuation of the contents.

Pig. 156. — Showing hypertrophy of the liver with ascites. The swelling extended
to all parts of the abdomen and was so distressing that it was necessary to resort to
repeated "tapping." (From photo).

The innervation is from the cystic plexus, the eighth and ninth
thoracic segments being the particular source of the impulses. The
great splanchnic nerve is the inhibitor nerve to the gall-bladder and the
ducts, while the pneumogastric seems to be the motor nerve. "Stim-
ulation of the central end of the splanchnic, causes relaxation of the
ducts and bladder, while stimulation, of -the central end of the pneumo-
gastric nerve causes their contraction, together with relaxation of the

616 APPLIED ANATOMY.

sphincter of the duodenal orifice." (Landois). The ducts often become
partly occluded by the accumulation of mucus in them and can best be
removed by pressure directed along their course, they reaching almost
to the umbilicus. In hepatic colic, pressure over the common gall-duct
will cause dilatation and at the same time produce a numbing of the
sensory nerves supplying the part. Lesions of the spinal column that
affect the substance of the liver, affect the gall-bladder and the charac-
ter of the bile. These lesions affect the gall-bladder and its ducts through
disturbance of the splanchnic nerves, hepatic and cystic plexuses, the
pneumogastric through the hepatic plexus, and through the cystic artery,
a branch of the hepatic. In short the various impulses that pass to and
from the gall-bladder and its ducts pass through the seventh, eighth
and ninth thoracic intervertebral foramina, and since these foramina
are usually lessened in size by a lesion of the corresponding vertebrae
and ribs, therefore such lesions would directly affect these impulses and,
disturbance of function result. Inhibition applied at the exit of the
nerve from the intervertebral foramen, will often relieve the pain in gall-
stone colic.

THE PANCREAS.

The pancreas, is a long gland of a grayish color that is situated in
the epigastric and left hypochondriac regions, deeply placed in relation
with the bodies of the first and second lumbar vertebrae. It varies
much as to size, the average length being about six inches, and is about
three quarters of an inch thick. During digestion it becomes engorged
with blood and is considerably larger than at other times. The head
"of the pancreas fills up the concavity between the descending and in-
ferior parts of the duodenum and is attached to the walls of the duo-
denum. The body lies on the aorta, the left cms of the diaphragm and
the left suprarenal capsule, and is covered by the meso-colon. The
tail of the pancreas is in relation with the left kidney and rests on the
spleen. It lies entirely back of the peritoneal cavity, but has a capsule
that sends processes between and around the lobules that compose it.
The surfaces are moulded to conform to the adjacent structures.

From right to left, it is in relation with the duodenum, superior
mesenteric vessels, transverse colon, meso-colon, superior and inferior
pancreatico-duodenal vessels, inferior vena cava, left renal vein, aorta,
common bile duct, pyloric end of the stomach when it is distended, bodies

APPLIED ANATOMY.

617

of the first, and a part of the body of the second lumbar vertebra, left
crus of the diaphragm, left kidney and its vessels, left suprarenal cap-
sule, and the spleen. From these relations it can be seen that any en-
largement or disease of it will affect important structures. The pos-
terior surface is closely adherent to the structures in relation while the
anterior, is covered by the peritoneum.

The principal duct traverses the entire length of the organ and

Fig. 157. — Showing the surface markings for the abdominal viscera. ■.• Note the
umbilicus and the ensiform cartilage; the center of the line connecting these points,
marks the place of tenderness in practically all cases of organic disease of the stomach
and pancreas.

618 APPLIED ANATOMY.

empties into the common bile-duct which opens into the duodenum at a
point near the junction of the first and second portions.

The writer has noted that in practically all cases of indigestion, that
there was an enlargement, about midway between the ensiform car-
tilage and the umbilicus. This enlargement is greatest in organic dis-
eases of the stomach as in gastric ulcers. It is also present in cases of
gastritis, the more severe the case the greater the enlargement. I have
seen many cases of gastric and pancreatic disorder that were diagnosed
as cancer of the stomach. The enlargement at the above described
place, is principally in the pancreas, some of it being in the pyloric end
of the stomach. This enlargement is always tender on pressure. It
lessens in size under treatment in proportion to the relieving of the
primary disease.

Since gall-stones are found in the common, as well as the hepatic
duct, they obstruct the outflow of pancreatic juice and thus affect the
function of the pancreas as well as that of the intestines. On account
of the relation of the head of the pancreas to the common bile ducts,
disease of it as in carcinoma will cause jaundice. "Calculi form in
these ducts, giving rise to colic resembling that of gall-stones, with fat
diarrhea and diabetes." (Eisendrath).

The blood-supply of the pancreas in very abundant and the arteries
tortuous. It is derived from the pancreatic branches of the splenic,
and from the superior and inferior pancreatico-duodenal arteries which
are derived respectively, from the hepatic and the superior mesenteric.

The innervation of these arteries supplying the pancreas, is from
the splanchnic, according to the experiments of Francois-Franck and
Hallion. *"They obtained evidence of vaso-constriction on excitement
of the splanchnic nerves on either side, and traced the origin of the
constrictor fibers to the anterior roots from the fifth thoracic to the
first lumbar nerves. Expansion of the pancreas seemed to follow ex-
citation of the peripheral end of the vagus. Reflex constriction of the
organ was produced by stimulation of any sensory nerve, or of the cere-
bral cortex; reflex dilatation, by excitation of the central end of the
vagus." From clinical observations it seems that the vaso-motor
nerves come mostly from the sixth to the eighth thoracic segments
judging from the effects of lesions on the circulation of the pancreas.

The venous blood is gathered up by the pancreatic , veins which

*Schafer's Text-book of Physiology, p. 164.

APPLIED ANATOMY. 619

empty into the portal, that is, all the blood that passes through the
pancreas must pass on through the liver before it reaches the heart-.
As a result of this as in the case of the stomach, any liver disorder will
cause more or less disturbance in the pancreas.

The nerves to the pancreas are arranged in plexuses that follow the
arteries, that is the hepatic, splenic and the superior mesenteric. These
plexuses are derived from the solar and ultimately from fibers of the
pneumogastric and splanchnic nerves. They are principally vaso-motor
and secretory in function, however the amount of secretion seems to
depend most on the amount of blood in the pancreas. Pain impairs the
character of the pancreatic secretion and thus tends to, and in many
cases actually does, produce indigestion.

The functions of the pancreas are evidently very important but
little understood. It has to do with the digestion of starches, proteids
and fats in the intestine. These functions are due to the ferments of
the pancreatic juice, amylopsin, trypsin and steapsin. "Casein is almost
wholly digested by trypsin. " A patient that can not digest cheese
probably has some disorder of the pancreas. Some believe that the
pancreas secretes a ferment that is for the purpose of destroying the
sugar in the blood, others that the secretion holds in solution the sugar.
That the pancreas has something to do with the sugar of the blood is
beyond question, since in disease of the pancreas, glycosuria is usually
present. Lesions of the spine affect the functions of the pancreas by
interfering with the innervation and blood-supply to it. The nerves are
affected since the impulses come from the spinal cord by way of the
great splanchnic, they passing through the intervertebral foramina in
relation with the sixth, seventh and eighth thoracic vertebra, and these
are always lessened in size by the average lesion. Thus the impulses
designed for the pancreas, are obstructed or in some way impaired. The
blood-vessels are under the control of the sympathetic nerves supplying
the pancreas and would thus be affected by the lesions named above.
If the circulation of the pancreas is affected at all, the secretions of it
are disturbed since normal secretion is dependent on a normal circula-
tion. As a result of this secretory disturbance, intestinal digestion is
interfered with.

Dr. Still has stated that the pancreas secreted a kind of fat or oil
that had to do with holding the cholesterin and the other ingredients
that go to form gall-stones, in solution. Whenever this secretion is

620 APPLIED ANATOMY.

decreased or stopped, the "chalky deposits" form, and that by starting
up again this secretion, these deposits can be dissolved. It seems that
the secretion of the pancreas when normal, prevents the formation of
gall-stones and from cases that I have seen Dr. Still treat, I am of the
opinion that not only further formation of gall-stones can be prevented
by restoring the normal functions of the pancreas, but that stones already
formed can be dissolved, if the pancreatic secretions become normal.

The important lesions to be considered in addition to those men-
tioned above are lesions of the sixth, seventh and eighth ribs on both
sides but especially on the left. The explanation of why such lesions
affect the secretions of the pancreas must be that they in some way af-
fect the function of the fibers of the great splanchnic nerve that sup-
ply the pancreas with vaso-motor and secretory impulses, which is
certainly possible considering the proximity of this nerve to the ribs as
well as the blood-vessels that supply not only the nerve, but the spinal
and the gangliated cords that give rise to it.

THE SPLEEN,

The spleen — one of the ductless glands — is a somewhat elliptical
shaped organ, situated in the left hypochondric region. It is about five
inches in length, three or four inches in breadth and a little over an inch
in thickness. It weighs on an average about seven ounces. It is placed
obliquely in the side of the abdominal cavity, its long axis corresponding
to the long axis of the tenth rib. Its upper end is attached to the diaph-
ragm by means of the phrenico-splenic ligament and consequently the
organ takes part in the respiratory movements of that muscle. This
assists in the circulation of the blood through the organ and furnishes a
valuable point in the differential diagnosis of splenic, from other tumors
of the region, tumors of the spleen moving during the respiratory acts
while tumors of parts not attached to the diaphragm are not changed as
to position on contraction of the muscle.

The outer surface is in relation with the ninth, tenth and eleventh
ribs being partly separated from them by the diaphragm and to a cer-
tain extent, by the lung. The pleura and peritoneum are also between
the spleen and the ribs and thus are affected in lesions of the spleen and
displacement of the ribs. On account of these relations excision, from
the external aspect is impractical. The inner surface of the spleen is
quite markedly concave and is in relation with the great cul-de-sac of

APPLIED ANATOMY. 621

the stomach and the spleen. It is connected with the stomach by the
gastro-splenic omentum and the splenic and vasa brevia arteries. Be-
hind the gastro-splenic, is the lieno-renal ligament which connects the
spleen with the kidney and through which pass the splenic vessels.
Thus in displacement of the spleen or kidney these vessels will be affected.
The anterior border of the spleen has a notch which is of value in diag-
nosing enlargements of the spleen from other tumors. In enlargement
of the spleen, it is displaced forward and downward, often beyond the
median line of the body. The outline of the spleen can best be obtained
by percussion with the patient in the erect posture' with the left arm
extended over the head. It is almost completely enveloped by peri-
toneum, the folds of it serving to hold it in position. Accessory spleens
are not uncommon, being characterized by globular masses of splenic
tissue.

The arteries of the spleen are branches of the splenic that reach it
by passing through the folds of the lieno-renal ligament, and breaking
up into several twigs, pass into the spleen at the hilus. The splenic
vein empties into the superior mesenteric which in turn empties into the
portal.

The nerves of the spleen are derived from the splenic plexus which
is formed from the celiac, the filaments following the splenic artery into
the spleen. The nerve cells from which they arise are in physiologic
relation with nerve-fibers (pre-ganglionic fibers), which emerge from
the spinal cord in the anterior roots of the third thoracic to the first
lumbar nerves inclusive, though they are found most abundantly in the
sixth, seventh and eighth thoracic nerves. (Brubaker). The predomi-
nating center is in the medulla oblongata. Asphyxia causes a lessening
in size of the spleen from the effects on the centers in the medulla. Stim-
ulation of the nerves to the spleen at any part of their course, gives rise
to a diminution in the volume of the spleen. Inhibition of them prob-
ably has the opposite effect although this has not been experimentally
demonstrated. Lesions of the seventh, eighth and ninth thoracic ver-
tebrae and the corresponding ribs on the left side, will affect these nerves
thus producing a stimulation or inhibition of them which produces
vaso-motor and other effects in the spleen. In most of the cases of
splenic disorder seen by the writer, lesions in this region were important
as etiological factors in the production of the disease and in proportion
to the degree to which the lesion was reduced, the symptoms were re-

622 APPLIED ANATOMY.

lieved. The size of the spleen varies considerably on account of the
variation in the amount of blood that it contains. Enlargements are
the most frequent of its affections. These are distinguished by move-
ment with respiration, descent and gravitation to the right when the patient
is turned on the right side, increased area of dullness, palpation of the
notch on the under surface and by the fact that they are as a rule, pain-
less. The causes are associated in some way with diseases that produce
a marked toxemia such as syphilis, malaria, and Hodgkin's disease,
while the above named bony lesions act as predisposing causes.

Experimentally, it has been shown that (in the dog) lesions of the
fifth to the ninth ribs inclusive, cause enlargement of the spleen. Mc-
Connell has noted that it enlarged to "over twice the normal size" within
two weeks after the ribs were subluxated. This was also found to be
the case in subluxation of the corresponding vertebra;. These experi-
ments are in accordance with the clinical observations of practitioners
that have noted such cases.

The functions of the spleen are not well understood. The spleen
can be removed from an animal with few, if any, immediate pathologi-
cal effects. In such experiments it has been noted that the activity of
the bone-marrow is increased and that the lymphatic glands enlarge.
It is supposed to have to do with the formation of leukocytes and the
destruction of functionally useless red-blood corpuscles. It is evident
from the effects of disorder of it that it has something to do with the
elaboration of the blood. In nearly all fevers, it becomes enlarged and
tender to the touch. In some cases the splenic disturbances are effects
of disease of other parts while in many they are the direct effects of le-
sions of the thoracic vertebrae from the seventh to the tenth, but more
frequently, the result of lesions of the corresponding ribs, on the left side.

THE SMALL INTESTINE.

The small intestine commences at the pyloric end of the stomach
and extends to the cecum in the right iliac fossa. It is on an average
about twenty feet in length and is divided into three parts, the duo-
denum, jejunum and the ileum.

The duodenum, so named from its length, it equaling the breadth
of twelve fingers, extends from the pylorus to the left side of the body
of the second lumbar vertebra, at a point in relation with the crossing of
the intestine by the superior mesenteric artery. The duodenum has

APPLIED ANATOMY. 623

the thickest walls, is largest and is more fixed than the other parts of
the small intestine. It in turn is divided into three parts, the first or
superior portion, the second or descending portion and the third or in-
ferior portion. The first portion is entirely covered by peritoneum,
passes to the right and backward beneath the liver and at the neck of
the gall-bladder passes into the second part. It is in relation with the
quadrate lobe of the liver, head and neck of the pancreas, pyloric end
of the stomach, portal vein, the vena cava, bile duct and the gastro-
duodenal artery. These relations are of interest and importance, in the
differential diagnosis of disease of this part of the small intestines.

The second portion of the duodenum passes from the neck of the
gall-bladder, downward behind the transverse colon and ends at the
right side of the upper part of the fourth lumbar vertebra. It is held
quite firmly in its position by cellular tissue, this being necessary on ac-
count of the emptying of the bile and the pancreatic secretions into this
part. It has in relation with it the hepatic flexure of the colon, the as-
cending colon, the right kidney, with its ureter and vessels, the liver
and a part of the right psoas muscle. The common bile and pancreatic
ducts lie in posterior relation to the first and second portions of the
duodenum and affections of the one produce some effect on the other.
These ducts empty into this portion of the duodenum about four inches
below the pyloric end of the stomach. This point is of value in the
treatment of hepatic colic whether from a mucous plug or from a gall-
stone. Superficially, the point of entrance of these ducts is almost as
low as the umbilicus in the normal subject and in the average patient,
is even lower than the umbilicus.

The third part of the duodenum extends from the termination of the
descending portion that is from the body of the third or fourth lumbar
vertebra, to the left side of the body in relation with the pancreas at
which place it passes into the jejunum. As it crosses the body of the
second lumbar vertebra, it is firmly fixed to it by a sort of muscular band
called the musculus suspensorius duodeni — a band of non-striated mus-
cle fibers that has its origin from the left crus of the diaphragm and the
tissues around the celiac axis. It is in relation with the vena cava, left
renal vein, aorta, left psoas muscle and the crura of the diaphragm. At
the point where the duodenum and jejunum meet, is a triangular fold
or pouch and in some cases is the seat of internal hernia. These hernia?
are more common than was formerly supposed and are responsible for

624 APPLIED ANATOMY.

many painful derangements of the small intestines. They usually result
from strong muscular efforts that markedly increase the intra-abdominal
pressure and thus force a loop of the intestine through a fold or de-
pression in the mesentery. By placing the patient in the Trendelenburg
position and exerting gentle traction on the displaced part, relief can be
given and in a short time the bowel replaced.

The jejunum is that part of the small intestine immediately beyond
the duodenum. It is about eight feet in length and is attached to the
posterior abdominal wall by the mesentery.

The ileum is about twelve feet in length and opens into the large
intestine at the junction of the cecum and ascending colon. The arrange-
ment of the coils of the small intestine varies, but generally the jeju-
num is to the upper left part and the ileum to the right lower part
of the abdominal cavity. It is often the case that the small intestines
get displaced downward and are thus packed into the true pelvic cavity.

In structure, the walls of the small intestines are composed of the
usual coats, the serous, muscular, submucous and the mucous. The
serous coat is incomplete in the duodenum but complete in all parts of
the remainder of the small intestine. The muscular coat is thickest
and strongest in the upper part and gradually becomes thinner as it is
traced down the intestine. The submucous coat in the upper part, con-
tains the glands of Brunner and in the jejunum and ileum, the solitary
glands. The mucous coat is thickest above and is covered with villi.
In this coat are found the Peyer's patches which seem to be primarily at-
tacked in t3rphoid fever. They are especially large and prominent in
the ileum. The valvulse conniventes are formed from the mucous coat
and are most developed in the jejunum.

The small intestines are protected against trauma by the sensitive
and strong muscular abdominal wall. On the shortest notice the wall
involuntarily contracts to resist the blow and in this way lessens and
commutes the force. They are supported by the mesentery and the
abdominal wall. The mesentery attaches them to the spinal column and
affords a passage-way for the blood and lymph vessels. The abdominal
wall is a very important factor in the support of them and in cases in
which it is relaxed, the intestines are invariably in a state of prolapsus
or descent.

The mesentery is a broad, triangular fold composed of two layers
of peritoneum that connect the intestine to the posterior abdominal

APPLIED ANATOMY. 625

wall, in an oblique line running from the left side of the body of the sec-
ond lumbar vertebra to the right iliac fossa. The folds of the mesentery
contain the blood-vessels that carry blood to and from the small intes-
tine, the lymphatic vessels and glands, a considerable amount of adipose
tissue and the intestine itself. These things are of importance in that
displacement or torsion of the bowel, will result in obstruction of the
blood-and lymph- vessels, hence congestion of the blood-vessels of the
intestine.

Enteroptosis is very common and is an important predisposing cause
of typhoid fever and other disturbances of the small intestine. In such
a condition, not only are the vessels and nerves in the mesentery stretched
but they are also partly or completely ligated and consequently, the cir-
culation in and through the bowel becomes slower and the vitality thus
lowered.

The function of the small intestine is that of digestion and absorp-
tion. Digestion is accomplished by the action of the secretions and the
peristalsis. Most of the absorption takes place in the small intestine,
especially that of the fats, proteids and the carbohydrates. Absorp-
tion depends more on the vascular condition of the walls of the intestine
than on all other conditions. After all, proper circulation is the most
important of all things so far as the functions of the human body are
concerned.

The blood-vessels of the small intestine which are very numerous,
are derived mainly from the superior mesenteric artery. The duo-
denum is supplied by the superior and inferior pancreatico-duodenal
arteries, branches of the gastro-duodenal and superior mesenteric.
These arteries pass between the two layers of the mesentery and give off
branches — the vasa intestini tenuis — which form arches and finally
reach the intestine as terminal arteries. While in the layers of the
mesentery there is free anastomosis, they forming an intricate network
or interlacement that to the naked eye appears to be marvelous. For
the perfect functioning of the part, these blood-vessels must be free from
obstructions since on account of the great number and size of the vessels,
a marked stagnation will result from a twist of the mesentery, this
causing congestion of the walls followed by perverted movements and
secretions. This acts as a predisposing cause of microbic diseases of the
small intestine, such as typhoid fever.

The veins are arranged similarly to the arteries, that is, they lie

626 APPLIED ANATOMY.

between the layers of the mesentery and are thus subjected to a greater
pressure from a twist of it than are the arteries because the walls are
less resisting. The vaso-motor nerves for these vessels, the veins as
well as the arteries, are derived from the plexus that surrounds the super-
ior mesenteric artery. Landois says: f'The splanchnic nerve is also
the vaso-motor nerve of all the arteries and veins of the small intestine,
including the portal vein, thus controlling the largest vascular area of
the body."

The lymphatics empty into the mesenteric glands. They are known
as lacteals and begin in the villi and form into plexuses between the
various coats of the wall. These vessels, like the blood-vessels, are con-
tained between the layers of the mesentery and are thus subject to dis-
turbances in displacement of the bowels. The mesenteric glands num-
bering from forty to one hundred and fifty, become tender and enlarged
in inflammatory and other diseases of the small intestine. The lymph
eventually reaches the receptaculum chili.

.: The nerve supply of the small intestine is derived from the solar
plexus by way of the superior mesenteric plexus, the right vagus and
from the plexuses of Auerbach and Meissner that are formed from the
above. The pneumogastric seems to be the motor nerve to the intes-
tine since experiment all y stimulation of it is followed by increased per-
istalsis. It also contains some inhibitor fibers according to some inves-
tigators. According to Landois the splanchnic nerves are the inhibitor,
motor, vaso-motor and sensory nerve to the intestine. He says: "The
splanchnic nerve is the inhibitor nerve for the intestinal movements, but
only so long as the blood in the capillaries has not become venous while
the circulation in the intestine remains undisturbed. If the latter con-
dition has arisen, irritation of the splanchnic causes increased peristalsis.
If arterial blood be introduced, the inhibitory action is prolonged. 0.
Nasse believes that it may be concluded from the experiments that, in
addition to these readily exhausted inhibitory fibers, paralyzed by venos-
ity of the blood, there are present motor fibers that are excitable for a
longer time, inasmuch as stimulation of the splanchnic nerve after death
always causes peristalsis of the stomach and intestines, as does stimu-
lation of the pneumogastric nerve. "* This conforms to the clinical ex-
periences of the osteopathic practitioner and working on this plan the

*Landois' Physiology, p. 288.

APPLIED ANATOMY. 627

movements of the small intestine can to a great extent, be controlled by
manipulation of the spine by which the splanchnic nerves are stimulated
or inhibited. Lesions of the spine that affect the circulation of the
blood through the small intestine affect the function of the nerves in-
nervating it, since according to the above experiment, the function of the
splanchnic nerve is governed by the condition of the blood. The nerve
impulses that are destined for the small intestine originate in the middle
spinal cord, the eighth, ninth and tenth thoracic segments being the
principal ones from which the}' arise. Lesions of the vertebrae corre-
sponding to these segments intercept, or otherwise affect, the passing of
the impulses to and from the small intestine and the spinal cord, and thus
predispose the intestine to disease by lowering its vitality. As has been
mentioned before, these lesions of the spine affect the spinal nerve, hence
its various functions, by lessening the size of the intervertebral foramina
thus producing pressure directly on (1) the nerve fibers that go to make
up the splanchnic nerve and (2) by producing pressure on the blood- and
lymph-vessels that supply and drain the nerve cells in the spinal cord
that give rise to the impulses that pass out over the roots that form the
splanchnics. The first effect of a lesion on the small intestine seems to
be one of vaso-motor inhibition this producing congestion. This is fol-
lowed by relaxation, from the mal-nutrition, secretory and sensory dis-
orders.

The diseases of the small intestine are characterized by a widening
of the median furrow of the back, especially if the disorder is of several
months duration. This widening is due to the atrophy of the spinal
muscles innervated by the same segment of the cord that supplies the
affected viscus, in this case the seventh to the tenth thoracic. Lesions
of the lower ribs are responsible in many ways for disturbances of the
functions of the small intestines. The explanation is that they affect
the gangliated cord, the splanchnic nerves, the peritoneum and the
muscles that form the abdominal wall. In downward displacements
of them, enteroptosis is the inevitable result. The anatomical derange-
ment in typhoid fever that is prominent, is enteroptosis, which causes a
slowing of the blood stream in the intestines, this causing stagnation and
lessening of the intestinal movements, all of which may be the direct
result of spinal lesions affecting the innervation as explained above.
In intestinal indigestion, the principal anatomical change is that of posi-
tion and poor circulation through the intestinal walls. Nearly if not

628 APPLIED ANATOMY.

all, the intestinal disorders are primarily due to disturbances of circula-
tion that at first are characterized by congestion.

THE LARGE INTESTINE.

The large intestine begins at the ileo-cecal junction on the right
side, is about five feet in length and comprises the following parts: the
cecum, ascending colon, transverse colon, descending colon, the sigmoid
flexure and the rectum.

The cecum is the blind commencement of the large intestine and
lies in the right iliac fossa slightly below McBurney's point. It is the
largest part of the intestine and has as an outgrowth from it, a worm-
like process called, the vermiform appendix. The opening to the appendix
is guarded by the ileo-cecal valve which imperfectly closes it. The cecum ■
is generally covered with peritoneum which in part accounts for the
rapidity of development of peritonitis from inflammation of the cecum
and appendix. It rests on the right psoas muscle and the veriform ap-
pendix. The abdominal wall is anterior, this making palpation of it
quite easy. The outer part of Poupart's ligament is in relation exter-
nally while internally, the ileum is in relation.

Impaction of the cecum is its most frequent and perhaps most im-
portant affection. This causes descent from sheer weight, pressure on
the adjacent blood-vessels and the walls of the cecum and appendix
and relaxation and stretching of the ileo-cecal valve. The effects of all
these are weakness of the cecum and appendix and the accumulation of
material in the appendix which, on account of its retention, undergoes
changes that produce inflammation. Constipation, therefore, is re-
sponsible for nearly all cases of appendicitis. Descent of the cecum
causes impaction of the pelvis and consequently disorders of the pelvic
viscera result, leucorrhea being very common.

The vermiform appendix usually springs from the inner and back side
of the cecum. Its direction and length vary considerably. It is sup-
posed to be functionless and the degenerated remains of the herbiverous
cecum which is quite large. By others, the vermiform appendix is re-
garded as the center for peristalsis of the intestines that is, the move-
ments start at the appendix. In a normal condition, it has a peristalsis
of its own and is capable of expelling foreign bodies that may become
lodged in it. In a diseased condition of it, these bodies remain in the
appendix so long that irritation and decomposition result and appendi-
citis follows. It has a mesentery and is completely covered with peri-
toneum. The principal external landmark for locating the appendix

APPLIED ANATOMY. 629

is McBurney's point, which is "a point midway between the anterior
superior spine of the ilium and the umbilicus. " Tenderness and pain at
this place are supposed to be quite diagnostic of appendicitis but may
occur in affections of the small intestine and cecum, the Fallopian tube,
broad ligament and right ovary. Lesions of the lower ribs on the right
side produce pain in the region of the appendix which simulates, and is
mistaken for, true appendicitis. The reason for this is that the nerves
in relation with the eleventh rib, supply sensation to the integument over
the appendix. A lesion of this or the tenth, affects this nerve, hence the
pain in the abdominal wall at this point.

Lesions of the spinal column in this region affect the innervation of
the large bowel, and in this way, produce constipation which in turn is
very likely to terminate in congestion and perhaps inflammation of the
appendix. On account of the proximity of the peritoneum and the in-
testines, suppuration of the appendix produces inflammation of these
structures and peritonitis follows. Clinically, lesions of the lower ribs
and lower thoracic vertebra? are associated with nearly all cases of ap-
pendicitis. The explanation is that such lesions affect the innervation
not only of the appendix, but of the cecum, thereby causing stagnation
of the blood, or at least the circulation through the parts is impaired.

Vasomotor, and trophic impulses seem to pass from the lower part
of the thoracic spinal cord to the appendix by way of the splanchnics
and especially the small splanchinc nerve. These lesions interfere with
this connection and thus the function of the appendix is perverted.

The appendix and the cecum are supplied with blood by the ileo-
cecal artery which is a branch of the superior mesenteric. This artery
divides into three branches, the anterior and posterior cecal and the
artery of the appendix. They pass along the mesentery and are subject
to disturbances in displacement of the bowel as in enteroptosis, a fore-
runner of constipation and appendicitis. The artery to the appendix
passes down behind the cecum so that the accumulation of fecal masses
in the ileum and cecum, produces pressure on this artery sufficient to
give rise to morbid conditions of the part supplied by it. The venous
blood passes into the corresponding veins that empty into the superior
mesenteric and finally into the portal system. These vessels are inner-
vated by the superior mesenteric plexus that surrounds them, the im-
pulses being carried to the plexus by the splanchnics.

The ascending colon begins at the level of the ileo-cecal junction

630 APPLIED ANATOMY.

and runs upward and a little backward to the under surface of the liver
and there bends to the left thus forming the hepatic flexure. It is some-
what larger than the parts of the colon distal to it, the large intestine
becoming smaller as it approaches the rectum. It lies almost wholly
in the right lumbar region and "it often has the appearance of being
pushed into a space which is too short to accommodate it. " (Cunning-
ham). The ascending colon is in relation with the anterior abdominal
wall, coils of the small intestine, right psoas muscle, and is attached by
areolar tissue to the iliacus and quadratus lumborum muscles and to
the right kidney. It passes under the lower ribs on the right and is
further back than it is generally supposed to be. The angle formed at the
junction of the ascending and transverse colon, is in relation with the
liver and this part is called the hepatic flexure. The bend is usually
an acute one and if the transverse colon is sagged in the middle, the angle
is all the more acute. This may give rise to disorders such as impac-
tion or at least constipation in the part of the bowel beyond. In pal-
pating the hepatic colon, the patient should be placed on the left side
and the bowel grasped bimanually, one hand being placed behind and
the other in front.

The transverse colon runs obliquely across the abdomen from right
to left. It begins at the end of the hepatic flexure and terminates with
the splenic flexure. In the first part of its course, it is attached to the
duodenum and head of the pancreas by means of areolar tissue and a
short mesentery. In the middle portion the mesentery is long, permitting
the bowel to sag, while at the splenic end the mesentery is short and
draws the colon up and back. The two ends lie in the right and left
hypochondriac regions and the middle portion in the umbilical or even
in the hypogastric region. The relations of the transverse colon vary be-
cause of the fact that the position of it varies. It lies behind the great
omentum, which seems to protect it; is in relation with the liver and
gall-bladder, stomach, pancreas, spleen, small intestines and the pos-
terior abdominal wall. The omentum often gets rolled up and thus
exposes the colon. When distended with gas, the transverse colon
occupies a large part of the upper abdominal region and occasionally
rises in front of the stomach. This form of displacement is infrequent
as compared with prolapsus of it. When the transverse colon is really
too long for the abdominal cavity or when it is apparently too long, it
sags in the middle. Tight lacing is the common cause of an apparent

APPLIED ANATOMY.

631

lengthening of the colon, since the two ends are approximated. If the

approximation is very marked, the transverse colon is doubled down and
impaction or enteroptosis is the result. As a rule the hepatic and
splenic flexures retain to a degree, their normal position and thus the
angle formed with the transverse colon becomes more acute, this causing
impaction, obstruction or even intussusception of the bowel. In accumula-

Fig. 158. — Showing the relation of the colon to the body-wall. VIII, IX, X,
XI, XII, indicate the lower ribs. The dotted lines show the boundaries of the liver
and pleura.

tion of gas in the transverse colon, the bowel becomes very much distend-
ed and the percussion note tympanitic, thus interfering with the out-
lining of the liver and stomach. The middle portion usually lies im-
mediately below the stomach and crosses the spinal column slightly
above the umbilicus. The splenic flexure runs upward and backward

632 APPLIED ANATOMY.

to the left to the lower part of the spleen. It then makes quite a sharp
bend forward and downward, terminating in the descending colon. It
is considerably farther back than it is generally supposed to be and on
this account, impactions of it may be mistaken for tumors or displace-
ment of the left kidney and spleen. It is attached to the diaphragm
by the phreno-colic ligament which serves to anchor it. Traction exerted
on this ligament as in impaction of this part of the bowel, will affect the
function of the diaphragm.

The descending colon extends from the spleen downward to the
sigmoid flexure. It is smaller and more freely movable than the ascend-
ing colon, and lies in the left hypochondriac and lumbar regions. It is
covered in front and on the sides by peritoneum and usually has a meso-
colon that attaches it to the posterior abdominal wall. It is in rela-
tion with the left kidney, diaphragm, psoas and quadratus lumborum
■muscles, and-the coils of the small intestine. It is subject to distension
from impaction but in many cases it becomes contracted and lessened
in size. In a great many dissections made and seen by the writer, it-
was found that in the aged and in those that had suffered with some form
of disorder of the lower bowel that the descending and sigmoid colon
were uniformly small and in many cases less than an inch in diameter.
The indications of a small lower bowel are constipation, toxemia, indi-
gestion and chronic pain in the region of the lower bowel. On palpa-
tion, the cord-like body can, in favorable cases be distinctly outlined.

The sigmoid flexure extends from the outer border of the left psoas,
to the left sacro-iliac synchondrosis where it becomes continuous with
the rectum. It is of special interest in that it is so frequently displaced,
impacted and abnormally bent on itself. Its displacement is most
commonly due to impaction, the weight carrying the bowel lower in the
abdominal cavity. From this develops prolapsus of the rectum, internal
hemorrhoids and sometimes rectal ulcers. The explanation is that the
displacement obstructs the return of the venous blood from the rectum
and consequently distension of the veins or even ulceration follows if
the stagnation is very marked or of long standing. The function of the
left broad ligament and of the left ovary is disturbed as well as that
of the uterus. The bend in the sigmoid becomes acute, the obstruction
will in many cases result in constipation. In such cases the patient
should be placed on the side or in the knee-chest posture and gentle
traction exerted on the bowel through the abdominal wall, 'thus draw-
ing it from out the true pelvis and straightening the angle formed.

APPLIED ANATOMY.

633

The rectum comprises the remainder of the large intestine, that is,
the part from the third sacral clown. The large bowel enters the true
pelvis at the left sacro-iliac synchondrosis and passes obliquely back-
ward and downward in a zig-zag manner until it reaches the anus. It is
in posterior relation with the uterus in the female and with the prostate
gland and vesicle seminales in the male. It passes between the sacro-
uterine ligaments and on account of its proximity to the pelvic organs,

Fig. 159. — Showing the splenic flexure of the colon and its relation to the body
wall, and the spleen. S. spleen; T. C. transverse colon; D. C. descending colon; the
angle at the splenic flexure often becomes very acute from prolapsus of the transverse
colon. The obstruction thus formed often leads to bowel disorder such as consti-
pation.

disease of it tends to affect the function of the internal genitalia. The
rectum proper is about five or six inches in length. The upper part is
partly covered with peritoneum by the part reflected from the vagina

634 APPLIED ANATOMY.

in the female and the bladder in the male. The lower portion has no
peritoneal investment. This permits of great distension without per-
itoneal restrictions. In the female the Pouch of Douglas forms the
lowest portion of the peritoneum and consists of the reflection of the
peritoneum from the vagina to the bowel. The diameter of the upper
part of the rectum is small but the lower part has a special enlargement
known as the rectal ampulla. The function of the rectum is that of
furnishing a reservoir for the accumulation of the fecal matter just
before the act of defecation. Judging from the results of examination
of several hundred patients, the rectum in the normal patient is empty
except at a time immediately prior to defecation, in other words, if the
rectum is found to be distended, it is indicative of constipation.

The muscular coat of the rectum is thicker than that of the bowel
above, and the fibers are collected into bundles, thus giving rise to sac-
culations. The mucous membrane is redder, thicker and more vascu-
lar than that of the colon and is arranged in folds. These folds
have received the name of Houston's folds or the valves of the rec-
tum. These mucous folds often get prolapsed, this producing consti-
pation and interfering with the introduction of a tube into the bowel.

The anus is the terminal portion of the alimentary canal. It is
about an inch in length and is directed downward and backward. It is
surrounded by the sphincters and is in relation with the perineal body, the
ano-coccygeal body, and the bulb of the corpus spongiosum in the male.

The walls of the large intestine are composed of four coats: the
serous, muscular, submucous and mucous. The serous coat is formed
from the peritoneum and is fairly complete. The appendices epiploicse,
are formed from this covering and consist of small appendages or pouches
of peritoneum that contain fat.

The muscular coat is arranged in layers, the longitudinal and cir-
cular. The longitudinal layer is so arranged that it produces a saccula-
tion of the gut. There are three of these longitudinal bands that begin
at the cecum and terminate in the rectum. The posterior of these
bands is placed along the attached portion of the intestine; the anterior
corresponds to the attachment of the great omentum while the third
called the inner or inferior, is found on the inner border of the ascending
and along the lower part of the transverse colon. When these bands
are severed, the gut assumes a cylindrical shape, the sacculi become ef-
faced and the length increased. These sacculi assist in peristalsis, ab-

APPLIED ANATOMY.

635

Bup. hemor-
rhoidal vein*--.

Con c a 3

A.".

iv I

.„.$:-. - •

' f »

£;>,. *-

' K!^r

.>-

Dnf "hes Art,,:
'J re tar

morrl\.

ftrM

■M1

WW -

Fig. 160. — The blood supply of the lower sigmoid and rectum. (Kelly").

636 APPLIED ANATOMY.

sorption and in giving form to the stool. In cases of constipation due
to lack of peristalsis or secretion, the stool is in the form of lumps that
correspond to these sacculi. The circular muscular fibers form a thin
layer over the surface of the cecum and colon, being most marked be-
tween the sacculi. In the rectum these fibers form a thick and powerful
muscular layer. The submucous layer consists of areolar tissue through
which the nerves and blood-vessels to the bowel pass. The mucous
coat differs from that of the small intestine by the absense of villi and the
valvulse conniventes. The surface is marked by numerous tubular
openings called the crypts of Lieberkuhn, which resemble those of the
small intestine.

The arterial supply of the large intestine is derived from the sup-
erior and inferior mesenteric arteries and from branches of the internal
iliac that supply the rectum. The size of the mesenteric arteries is con-
trolled by the-mesenteric plexuses which ultimately derive their impulses
from the lower thoracic and upper lumbar segments of the spinal cord.
The rectum is supplied with arteries that are derived from three sources,
viz., the superior hemorrhoidal from the inferior mesenteric, the middle
hemorrhoidal from the internal iliac and the inferior hemorrhoidal from
the pudic. These vessels anastomose freely with each other by means
of the branches of the loops formed by them. Experimentally, it has
been ascertained that stimulation of the anterior roots of the lower thor-
acic and upper lumbar nerves produces vaso-motor changes in the colon.
Lesions of the corresponding vertebras either stimulate or inhibit these
vaso-motor nerves and consequently a dilating or a constricting effect
results from the lesion. Ordinarily the lesion produces a dilatation of
the blood-vessels of the bowel by exerting an inhibitory effect on the
vaso-motor nerves in relation.

The blood from the colon passes up through the superior and in-
ferior mesenteric veins and ultimately through the portal system. This
is of importance, since on this account, liver disorders will cause intesti-
nal disturbances. If the liver becomes congested, the blood with diffi-
culty passes through it and since all the blood of the intestinal tract
with the exception of a part of the rectum passes into the portal vein,
consequently congestion of the bowel is the sequel. Congestion of some
part of the body is at the bottom of practically all diseases, and reason-
ing from this, the importance of the hepatic circulation being kept in
good condition can not be emphasized too much. The blood from the

APPLIED ANATOMY. 637

upper part of the rectum passes into the superior hemorrhoidal veins
which empty into the inferior mesenteric. This explains the relation
of liver disorders to hemorrhoids. There is a communication between
the portal and systemic circulation through the hemorrhoidal plexus,
some of the blood returning by way of the portal and some by way of
the internal iliac veins. All the veins of the large bowel undoubtedly
have vaso-motor nerves that control their calibre but they are not so
numerous as the vaso-motor nerves of the arteries for the reason that
there are not so many muscle fibers in their walls. Lesions of the spinal
column affect the veins as well as the arteries and the effects are even
more extensive and important than are those on the arteries.

The nerve supply of the large intestine is derived from the superior
and inferior mesenteric plexuses, the hypogastric by way of the hemor-
rhoidal from the pelvic pelxus, and from the sacral nerves that pass
into the pelvic. The segments of the spinal cord that give rise to most
of the impulses that supply the large bowel are the lower two or three
thoracic and the upper lumbar, while the second and third sacral supply
the rectum and anus. In speaking of the cerebro-spinal innervation of
the rectum and anal canal Quain says: "Experiments on animals have
shown that the longitudinal muscular fibers of the rectum are supplied
with motor fibers from the anterior roots of certain of the sacral nerves,
(2nd and 3rd, and in part the 1st, in the clog), which nerves also supply
inhibitory fibers to the circular coat, whereas the fibers of the hypogas-
tric plexus which supply the circular muscular tissues with motor fibers,
are derived from white rami communicantes of the anterior roots
of certain of the lumbar nerves, which join the sympathetic chain and
lose their medullary sheath before passing to their distribution in the
muscular coat."* According to Langley the rectum has a double nerve
supply, an upper supply in the rabbit from the second, third, fourth
and fifth lumbar nerves and a lower from the third and fourth sacral
nerves. "The upper set of fibers pass into the lumbar sympathetic
chain, and thence in the mesentery to the inferior mesenteric ganglia,
and so by the colonic and hypogastric nerves to the rectum. They are
connected with nerve cells chiefly in the inferior mesenteric ganglia, and
supply the descending colon, rectum, and internal sphincter. A few
fibers pass along the sympathetic chain to the sacral ganglia, and thence
by the grey rami of the ganglia to the sacral nerves, and end chiefly in
the unstriated muscles of the skin round the anus. The lower set of

*Quain's Anatomy, Vol. Ill, p 117, pt. IV.

638 APPLIED ANATOMY.

fibers run in the pelvic nerves, or nervi erigentes. They pass to the
hypogastric plexus and have ganglion cells either as they pass the side
of the rectum or more peripherally."* This form of distribution of
these nerves seems to also be true in the human judging from the effects
of lesions in the lumbar region. These lumbar lesions affect the inner-
vation of the large bowel because the nerve impulses pass through the
lumbar intervertebral foramina which are lessened in size in lesions of
the articulations. This breaks, or otherwise affects the connection that
should exist between the spinal center and the gut and consequently
the function of the part innervated is affected.

The large bowel furnishes a reservoir for the food products in which
there is desiccation, absorption and some digestion. The peristalsis
of this part of the bowel is less than that of the small intestines, it taking
about twelve hours for the matter to pass through the large intestine.
The longer the time consumed in the passage, the drier will be the con-
tents. The drier the contents the less the irritability, and constipation
is the result. If the peristalsis is so increased that the contents of the
small intestine are carried down rapidly into the large, diarrhea is the
effect. The secreting of mucus, called the succus entericus, is also an
important function of the large bowel. This secretion acts as a stim-
ulus to the sensory nerves supplying the part, that is, peristalsis is de-
pendent to a great extent on the amount of this secretion in the bowel.
If there is an excessive amount secreted as is the case in colds that
"settle" on the bowels, diarrhea usually follows. If the secretion is
lessened in amount, constipation is the effect. Lesions of the lumbar
vertebra? affect all the functions of the large intestine by disturbing the
nerves that control peristalsis, secretion, absorption, sensation and nutri-
tion and by affecting the circulation of the lymph and blood through it.
The principal effects of these disturbances are constipation, diarrhea,
indigestion, prolapsus of the. bowel, hemorrhoids and ulcers.

The character of the stool and defecation is the principal guide
as to the amount and character of disturbance of the bowel. In the
diagnostic indications of the feces, the quantity and quality of the food
ingested must be taken into consideration as well as the kind of disturb-
ance of the bowel. Blood in the stool is suggestive of hemorrhoids or
fissure of the rectum. A ribbon-shaped stool is found in stricture of the
*Schafer's Physiology, Vol. II, p. 337.

APPLIED ANATOMY. 639

rectum. If dry and nodular, it indicates lack of secretion and slow
peristalsis. If watery and slimy, congestion or catarrh of the bowel is
usually present. If the stool is tinged with green, it is indicative of
either liver disorder as in colds, or of marked inflammation of the bowel
as in cholera infantum. The above changes in the character of the stool
are mostly dependent on disorders of the large intestine. The charac-
ter and frequency of defecation are also indicative of the kind and degree
of the disturbance of the lower bowel. In some cases there is lack of
force or strength while in others there is tenesmus, an inhibitory lesion
producing the former and an irritative one, the latter. Practically all
of these disturbances of the lower bowel are primarily the result of le-
sions along the spine that affect the motor, sensory, vaso-motor, secre-
tory and trophic nerves supplying the bowel, while the error in diet and
other exciting causes, the more easily and readily act on account of the
predisposition. For a palliative effect, inhibition applied over the
spinous processes of the third or fourth lumbar spines will ordinarily
check diarrhea. Colic, tenesmus and other acute sensory and motor
disturbances can be temporarily relieved in a similar way. In flux and
dysentery, the blood-vessels are engorged to the bursting point, this
being the result of vaso-motor disorders. A subluxation of the fourth
lumbar vertebra is the most common and frequent of all lesions produc-
ing these effects. The explanation as pointed out above, is that the
vaso-motor impulses for the lower bowel rise principally from the fourth
lumbar segment and pass out through the fourth lumbar intervertebral
foramina and the lesion of this vertebra lessens the size of the corres-
ponding foramina and consequently the impulses passing through them
are affected.

THE KIDNEYS,

The kidneys are two bean-shaped bodies situated in the lumbar
regions. They are behind the peritoneum and consist of a duct, the
ureter, leading from the sinus located in the hilum, uriniferous tubules
and a glandular substance. The kidney is about four and three-quarters
inches in length and slightly over an inch in thickness, and weighs on an
average of five ounces. It is surrounded by a mass of adipose tissue
that protects it and assists in holding it in position. The right is the
lower of the two on account of the presence of the liver on that side press-
ing it downward. The left kidney in the male reaches from the eleventh

640 APPLIED ANATOMY.

thoracic vertebra to the upper border of the third lumbar. Both kid-
neys are lower in the female, about the distance of half the body of a
vertebra. They lie obliquely with their lower parts diverging.

The position and consequently the relations of the kidney, are sub-
ject to great variations. Cunningham states that if a line is drawn
round the body at the level of the lowest part of the thoracic wall, the
whole or almost the whole of the left kidney, will be found to lie above
the level of the plane so •determined, and that by far the greatest part
of each kidney lies to the inner side of a line drawn vertically upward
through the middle point of Poupart's ligament. There are no liga-
ments for the purpose of holding the kidney in position, but its fixation
depends on the pressure of the surrounding tissues.

Posteriorly, the kidney is in relation with the psoas, quadratus
lumborum, diaphragm and trans versalis abdominis muscles; pleura;
the last thoracic and the first lumbar nerves and the fascia in that region.
On account of the relation between the kidney and the pleura, a circum-
renal abscess may invade the pleura and the lung. The diagnosis of
pleurisy with effusion may be confused with perinephritic disorders.
In operations on the kidne)', this relation to the pleura should be borne
in mind or else the pleura may be injured. Superiorly, it is in relation
with the suprarenal capsule that crowns the kidney. Anteriorly, the re-
lations of the two kidneys differ slightly. The anterior surface of the
right, is in relation with the liver, ascending colon and the duodenum,
second portion. The part in relation with the liver is covered with
peritoneum. The anterior relations of the left kidney are the stomach,
pancreas, descending colon, spleen and the vessels of the spleen and
colon. It is attached to the suprarenal capsule and the pancreas by
areolar tissue but is separated from the stomach by the lesser sac of the
peritoneum. From in front the external landmarks of the kidney are
the umbilicus and the spines of the iliac bones and the lower ribs. The
lower pole of the kidney extends somewhat below the subcostal plane
with the hilum lying about one and one-half inches from the median
line and opposite the first lumbar vertebra. " In order to place the finger
over the kidney from in front, a point on the abdominal wall should be
chosen about two and one-half inches above and outside of the um-
bilicus." (Moorhead). Posteriorly the outline of the inner border of
the kidney may be represented by a "line drawn parallel to the mesial
plane at a distance of inch from it and lying between the levels of the

APPLIED ANATOMY. 641

superior and inferior poles. The hilum of each kidney lies on, or external
to, this line, at the level of the first lumbar spine. "

As stated before the kidney is supported principally by the pressure
of the surrounding structures. If the pressure from above is increased
and that from below lessened, the kidney will assume a position lower
in the abdominal cavity. The pressure is increased from above in the
female, principally by tight lacing, while that from below is lessened by
the relaxation that usually follows pregnancy. It is the exception for
prolapsus of the kidney to occur in patients that have not given birth
to a child. Most cases occur in patients that have given birth to two or
more children, or at least if there is much relaxation from faulty involu-
tion of the abdominal walls or from other causes. Lesions of the lower
ribs or of the spine that produce relaxation of the abdominal muscles or
enteroptosis, will tend to bring on prolapsus of the kidney or what is
called a floating kidney.

The blood-supply of the kidney is very copious, and is derived from
the renal, a branch of the abdominal aorta. It enters the hilum of the
kidney and immediately breaks up into several large branches which
penetrate the substance of the gland and pass to the cortex. "At the
base of the pyramids branches of the arteries form an anastomosing plexus.
From this plexus vessels are given off, some of which follow the straight
tubules toward the apex of the pyramids, vasa recta, while others enter
the cortex and pass to its surface. In the course of the latter, small
branches are given off, each of which soon divides and subdivides to
form a ball of capillary vessels known as the glomerulus. These cap-
illaries, however, do not anastomose, but soon reunite to form an effer-
ent vessel the caliber of which is less than that of the afferent artery.
In consequence of this, there is a greater resistance to the outflow of
blood than to the inflow, and therefore a higher blood-pressure in the
glomerulus than in capillaries generally."* The innervation of the
renal vessels is derived from the lower thoracic segments of the spinal
cord the impulses passing from them by way of the lower splanchnics
into the aortic and renal plexuses. "The vaso-motor nerves of the
kidney leave the cord from the sixth dorsal to the second lumbar nerve.
In the dog, most of the renal vaso-motor fibers are found in the eleventh,
twelfth and thirteenth dorsal nerves. Stimulation of the nerves enter-
ing the hilus of the kidney between the artery and the vein, causes a

*Brubaker's Physiology, p. 427.
lo

642 APPLIED ANATOMY.

marked and sudden renal contraction but the organ soon regains its
former volume."* In man, the vaso-motor centers of the kidney seem
to correspond to those of the dog as cited above. Lesions of the cor-
responding vertebrae and ribs either stimulate these nerves or else they
inhibit them. In both cases there will be a pathological effect if con-
tinued for any length of time. Experimentally, it has been proven that
stimulation of certain of the roots of the spinal nerves produces circu-
latory changes in the kidney and clinically it has been demonstrated
that a lesion of the vertebral articulations in relation, will have a similar
effect. The explanation is that the vaso-motor impulses pass over these
spinal nerves through the intervertebral foramina and these are lessened
in size by the lesions. The blood supply of the nerves themselves is
also affected by the lesion by impinging on the vessels that supply them.
These lower thoracic lesions so weaken the kidney by affecting the vaso-
motor nerve's to them that they are predisposed to almost any sort of
disorder.

The veins correspond to the arteries, collect the blood from the cap-
illaries and unite to form radicles across the pyramids which finally reach
the sinus and form the tributaries of the renal. The blood in the renal
veins is perhaps more nearly pure than that found in other veins on ac-
count of the action of the kidney on it. These veins seem to have vaso-
motor nerves as do most other veins but this as yet has not been dem-
onstrated satisfactorily.

The nerves supplying the kidney come from the renal plexus. This
plexus is formed by filaments from the lesser and least splanchnics,
the aortico-renal ganglion, the aortic plexus and a branch from the first
lumbar ganglion. The filaments accompany the arteries to the kid-
ney. " Non-medullated fibers penetrate to the surface of the capsule
and between the urinary tubules. It is established physiologically that
motor fibers are present for the unstriated muscular fibers, also vaso-
motor fibers and sensory branches in the capsule and the pelvis of the
kidney. The existence of vasodilator and secretory fibers is also prob-
able, "f Head in his chart of visceral sensation states that the sensory
supply of the kidney and ureter is from the tenth, eleventh, twelfth
thoracic and the first lumbar. This corresponds to the clinical obser-
vations, since in affections of the kidney, lesions are found in this region.

*Am. Text-book of Physiology, p. 49S.
tLandois' Physiology, p. 471.

APPLIED ANATOMY. 643

Since the centers for the kidney are undoubtedly located in the lower
thoracic segments of the spinal cord and the impulses pass out through
the foramina over the splanchnic and upper lumbar nerves, lesions of the
corresponding vertebrae (from the tenth thoracic to the second lumbar,
the twelfth being the most important) will affect the function of the
kidney through the innervation of it.

The function of the kidney is that of excretion of the urinary con-
stituents from the blood. Bowan, who was one of the first to inves-
tigate the process of elimination of the urine from the blood, inferred
that since the kidney presented an apparatus for filtration, the capsule
with its inclosed glomerulus, and an apparatus for secretion, the epithe-
lium of the uriniferous tubules, the elimination of the urinary consti-
tuents from the blood was accomplished by two processes, that of filtra-
tion and of secretion. This is the most generally accepted of the theories
at the present time. There are three things to be taken in considera-
tion in determining the amount of secretion of urine: the blood-pressure,
the quality of the blood and the influence of the nervous system. If the
blood-pressure in the vessels of the kidneys is increased, the amount of
urine secreted is increased. It has been found that ligation of the caro-
tid, femoral and vertebral arteries increased the aortic pressure accom-
panied by an increased urinary flow. On the contrary a decrease of
aortic pressure was accompanied by a lessening of the secretion and if the
pressure were lowered below 40 mm. of mercury, the flow of urine ceased
entirely. Lesions along the lower thoracic areas affect the vaso-motor
supply of the renal vessels and consequently increase or decrease the
blood-pressure in them. From this arises disturbances in the amount
and quality of the urine excreted. The amount of urine secreted is
also affected by changes in the composition of the blood. The presence
of urea in the blood acts as a diuretic. An excess of water ingested has
a similar effect. Saline diuretics when introduced into the blood in-
crease the amount of urine. The accumulations of end-products and
water in the blood, act as stimulants to the kidneys and thereby increase
the amount of urine. Lack of elimination of the skin causes an increased
activity of the kidneys as is illustrated in certain diseases and by the
fact that the amount of urine excreted is a great deal less in patients that
prespire freely than in those that do not. Lesions that affect the liver,
produce urinary disorders by interfering with the secretion of urea
which is nature's diuretic. That the nervous system exerts a marked

644 APPLIED ANATOMY.

influence over the secretion of urine is proven by experiments in which
the nerves are severed or stimulated. If the nerves that accompany
the renal vessels to the kidney are divided, the artery at once dilates, the
kidney enlarges, and the amount of urine secreted is at once increased.
If the peripheral ends of these nerves are stimulated, the blood-vessels
become smaller, the volume of the kidney decreases and the flow of urine
becomes lessened or stops entirely.

There is a direct connection between the spinal cord and the kidney
and if the nerves making this connection are stimulated or inhibited, or
if the cells in the spinal cord that give rise to the impulses passing over
these nerves are stimulated or inhibited, there will be an immediate
effect on the kidney manifest by change in the urine. Lesions of the
spine, especially of the tenth, eleventh and twelfth thoracic vertebrae,
affect the above nerves and their cells, and are the predisposing causes
of disease of the kidney.

There seems to be a vaso-motor center for the kidney situated in the
medulla oblongata, since puncture of the medulla is occasionally followed
by an increase in amount of urine. Cases of diabetes insipidus have been
reported me in which the lesion was in the upper part of the cervical
region, and the cases cured by correcting the lesion.

Disturbances of function of the kidney result from nutritional
changes in the substance of the organ. Spinal lesions are usually the
primary causes, but abuse of the kidney, is a very important cause of
organic disease and should be considered along with the spinal lesions.
The motor, secretory, trophic , vaso-motor and sensory innervation of the
kidney is derived from the spinal cord, the impulses passing to the kid-
ney by way of the anterior nerve roots, common trunk, anterior divi-
sion, white rami, lesser and least splanchnics, aortico-renal ganglion,
aortic plexus and renal plexus. Lesions along the lower part of the spine
affect the generating or transmission of these impulses and consequently,
some or all of these nerves are affected. The most important are the
vaso-motor nerves, since secretion, circulation and nutrition seem to
depend on their integrity.

In all affections of the kidney the urine should be thoroughly ex-
amined. The urinary changes that are suggestive of disease of the kid-
ney are, lessened or increased amount ; change in the color varying from
the limpid urine to hematuria; and changes in the constituents, there
being present albumen, blood, pus, urates, phosphates, 'casts, sugar,
and an absence of urea.

APPLIED ANATOMY. 645

If the amount of urine is permanently increased, it is indicative
of some form of diabetes, the specific gravity test and character of
the solids, making the diagnosis clear. A lessening in the amount
of urine secreted, is suggestive of a contracted or non-developed kidney.
The writer has had several cases in which the kidney was imperfectly
developed, the patient having a pasty complexion, general weakness,
headaches and backache due to the toxemia, indigestion, constipation,
and in fact, everything that has for its cause toxemia, the symptoms
varying with the degree and amount of toxic matter retained in the
body. In such cases I have invariably found a marked separation or
break in the spine ranging from the eighth, to the twelfth dorsal vertebra,
the articulation between the tenth and eleventh being most commonly
affected. In some cases of scanty elimination of urine, hysteria should
be considered as a factor. The condition of the nervous system also
has a great deal to do with the amount as well as the quality of urine
excreted. If the urine is watery in appearance, suspect diabetes in-
sipidus or nervousness. If of a light amber color, diabetes mellitus may
be present. If red, suspect blood or an excess of urates. Heating the
urine will clear it up if the red color is not due to the presence of blood.
Albumen in persistent quantities in the urine is almost diagnostic of
organic disease of the kidney as in Bright 's disease. Pus is suggestive
of cystitis; phosphates, of some disturbance of the nervous system and
is usually present in the pregnant. Casts in the urine are usually diag-
nostic of nephritis and should be looked on with alarm. Sugar found in
quantity and from time to time, is diagnostic of diabetes mellitus. The
absence of urea leads to uremic poisoning and in the pregnant will often
lead to eclampsia. Liver disorder is more often to blame for the absence
of urea than is kidney disturbances, since the urea is formed in the liver
and this formation is affected by diseases of the organ.

In all affections of the kidneys characterized by urinary changes
and practically all are, the spinal lesions are the predisposing causes and
if a cure is secured, these must be corrected. In all cases it is advisable
to make a test of the urine since the urine is a pretty reliable indicator
of the condition of the body as well as that of the kidney itself. This
examination should include the microscopic as well as the chemical test
since by it, casts are discovered if they are present, spermatozoa, crystals,
bacteria, and pus.

The ureter is the excretory tube or duct of the kidney connecting

646 APPLIED ANATOMY.

the pelvis with the bladder. The pelvis of the kidney is really the ex-
panded portion of the ureter, which in turn divides into three infundi-
bula and these into the calices. The size of the ureter varies but on an
average is about that of a goose-quill. Its length is about thirteen
inches. In its course it is in relation with the psoas magnus muscle, external
iliac artery, spermatic vessels and on the right with the inferior vena
cava and on the left, the sigmoid flexure of the colon. They pass down
behind the bladder which they enter, at the lower part or near the trigone.
Enlargement of the uterus as in pregnancy or tumor, may cause pressure
on the ureter and thus produce hydronephrosis. Contracture of the
muscles in relation with it sometimes affects its function. Inflammation
of the pelvic tissues occasionally reaches to the ureter.

It has three coats, a fibrous, which seems to be continuous with the
capsule of the kidney, a muscular composed of a circular and longitu-
dinal layers, and the mucous coat in which the epithelium is loose and
arranged in folds.

The ureter is capable of great, though painful, distension as is dem-
onstrated by the passing of large calculi. These calculi are most
likely to lodge in the upper part because it is the largest. Care should
be taken in manipulating over the ureter if a calculus is lodged in it be-
cause pressure or manipulation directly on the calculus, will increase
the pain because the sharp corners of it are forced into the wall of the
ureter. Gentle inhibition applied to the ureter sometimes causes relax-
ation and consequently dilatation so that the stone is passed the easier
along the tube. The external landmarks of the ureter should be borne
in mind on account of the treatment and the help in the differential
diagnosis of calculi and colic in that part of the body.

The arteries supplying the ureters are derived from the renal, sper-
matic, internal iliac, and vesical arteries. The innervation of these
arteries comes from the plexus that surrounds the arteries of which
they are branches. The veins empty into the corresponding trunks.
The nerve supply is derived from the spermatic, hypogastric and renal
plexuses. The ureter is highly sensitive as is evidenced by the severe
pain accompanying the passage of a renal calculus. On account of the
number of nerves and plexuses that contribute to the innervation of the
ureter, a calculus in it will cause the pain to be referred to the testicle,
kidney, bladder, down the inner side of the thigh and to the abdominal
wall in relation with the ureter. In the palliative treatment for renal cal-

APPLIED ANATOMY. 647

culi, inhibition .applied to the spine from the eleventh thoracic to the
second lumbar vertebra will ordinarily relieve or lessen the pain or colic.
Lesions in this region will affect the innervation of the kidney and
ureter and produce effects that are similar in character to the passing
of renal calculi. According to Head, the sensory impulses for the ureter
are derived from the tenth thoracic, for the upper part, and from the first
lumbar, for the lower part. Clinically, it seems that the sensory impulses
reach the spinal cord through the spermatic and renal plexuses and that
lesions affecting these will produce pains that will be referred to the
ureter.

THE BLADDER.

The urinary bladder is a hollow, musculo-membranous receptacle
for the urine. Its average capacity is about one pint when moderately
distended but is capable of great distension especially in the female, so
that it may contain a half-gallon or more. The size, position and shape
of the bladder, vary with the amount of urine in it, sex and the condi-
tion of the surrounding structures. In the infant, the bladder extends
above the pubic bone and on this account, in distension of it, can be manip-
ulated and micturition be brought about in most cases of distension,
without the use of a catheter. In the adult, it is entirely in the true
pelvis except when markedly distended with urine. It is broader and
larger in the female than in the male.

The bladder has been divided into the summit, body, trigone and
neck for the sake of convenience in its description. The summit is round-
ed and connected with the umbilicus by the urachus, the obliterated intra-
abdominal portion of the allantoic stalk of fetal life. In some cases this
tube or stalk does not become obliterated and consequently, a connection
exists between the bladder and the umbilicus and urine escapes from the
latter point. The body comprises the greater part of the bladder and
when distended is in relation with the anterior abdominal wall and all
the pelvic viscera. The trigone is the most sensitive portion and con-
sists of the area between the entrance of the ureters. Any irritation of
this part will produce micturition and if kept up, frequent and perhaps
painful micturition. The neck is that part which is constricted and is
continuous with the urethra.

The ligaments of the bladder are divided into true and false-five of
each — the false consisting of folds of peritoneum. The true ligaments

648 APPLIED ANATOMY.

are formed principally from the fascia in relation, the recto-vesical, ex-
cept the superior one which is the remains of the urachus. Some of them
contain muscle fibers and consequently are subject to considerable re-
laxation and contraction. The false, are simply folds of peritoneum
derived from that which covers and dips down on all sides but particularly
the front and back.

In structure the bladder is composed mainly of unstriped muscle
fibers covered with fascia and peritoneum and lined with a mucous mem-
brane. The walls are quite thick ranging from an eighth to a half of
an inch. The mucous membrane is continuous with that lining
the ureters and urethra which thing permits inflammation to travel the
easier from one part to the other, especially from the urethra to the
bladder as in cystitis from urethritis.

The relations of the bladder are of interest in that diseases of it are
most frequently secondary to disease, displacement or enlargement of
structures or viscera in relation. Anteriorly, it is in relation with the
anterior ligament, symphysis pubis, and in the female, with the anterior
vaginal wall. As a result of these relations, the bladder when distended,
will produce a rounded, symmetrical enlargement of the abdomen im-
mediately above the pubis, a bulging of the anterior vaginal wall as in
cystocele, and is subject to injury from operations on the symphysis as
in symphysiotomy an operation resorted to by some in cases of parturi-
tion in which normal delivery is impossible on account of deformity or
a lessening in size of the pelvis.

The bladder can be reached by a local vaginal examination and in
calculi or prolapsus of it, the condition is better diagnosed and possibly
remedied, by the local treatment. Superiorly and posteriorly, the bladder
is covered with peritoneum thus permitting of the development of per-
itonitis from inflammatory disturbances of the organ. In the male the
rectum, sigmoid flexure, and small intestines, the vesical seminales and
the prostate gland are in posterior relation. Disease of the bowel or
any of these organs may affect the bladder. If there is enlargement or
if the disease is an irritative one, frequent micturition is a sequel as in
enlargement of the prostate. In the female, the uterus is in posterior
relation and in forward displacements or inflammation of the uterus, the
bladder is affected, frequent and painful micturition being the most
common of the effects. The explanation is that pressure on the bladder
sets up impulses that are carried to the micturition center 'and thus

APPLIED ANATOMY. 649

it is kept in a state of continual activity. The effect is the more marked
if the uterus is inflamed and antedeviated at the same time. The hypo-
gastric arteries, vasa deferent ia, and the pelvic nerves are also in rela-
tion but this is of little practical importance except that inflammation
of the bladder tends to produce disturbance of these structures.

The blood-supply of the bladder is derived from the vesical arteries,
the obturator and internal pudie, and in the female, some twigs of the
uterine and vaginal arteries go to the bladder. The superior and middle
vesical, usually come from the obliterated hypogastric arteries and the
inferior, from the anterior division of the internal iliac. The nerves
innervating these arteries are derived from the lumbar segments, the
impulses passing by way of the lumbar nervi efferentes through the hypo-
gastric and pelvic plexuses into the vesical. Some probably pass by
way of the sacral nerves but experimentally, little if any vaso-motor
effect follows stimulation of the pelvic nerve. Although it has not been
demonstrated experimentally that the vaso-motor impulses for the
bladder are derived from the lumbar or even the sacral nerves, yet there
are clinical evidences that most of the impulses are derived from the
lumbar nerves. The principal proof is that lesions affecting the lumbar
vertebra? are usually found to be present in all cases of vascular disturb-
ances of the urinary bladder, and by correcting the lesions, beneficial
effects were obtained.

The veins form into plexuses at the sides, base and neck of the
bladder and finally empty into the internal iliac. In disorders of this
vein, the venous circulation of the bladder is often quite seriously inter-
fered with. The lymphatic vessels follow a similar course and in cystitis,
the glands in the lumbar region are enlarged and tender. Manipulation
over them is fraught with clanger, irritation of them increasing the en-
gorgement and tenderness.

The nerve supply of the bladder is derived from the second, third
and fourth sacral nerves and from the hypogastric plexus. The impulses
that pass over the sacral nerves go directly to the pelvic plexus without
going through the gangliated cord. The fibers are small and medullated
and are called the pelvic splanchnics. The vesical branches of the
hypogastric plexus are non-medullated and are derived from the upper
lumbar nerves. They reach the hypogastric plexus by way of the aortic
23lexus and the inferior .mesenteric ganglion. They reach the bladder
by passing through the pelvic plexus and over the vesical plexus, a sub-
division of the pelvic.

650 APPLIED ANATOMT.

The sensory innervation of the bladder is derived from the upper
four sacral nerves and quite a "number of sensory fibers pass into the
spinal cord through the intermediation of the hypogastric plexus."

Contraction of the bladder is a reflex process and like other reflex
processes, there must be a stimulus, afferent pathway, center, efferent
nerve and muscles that receive the impulses. The above named sensory
nerves carry the impulses generated by the accumulation of urine in
the bladder, to the micturition center situated in the second lumbar seg-
ment of the spinal cord, while the efferent impulses are carried by
the lumbar nerves into the hypogastric and pelvic plexuses, thence to
the vesical. The sacral branches are supposed to be motor to the longi-
tudinal fibers and inhibitor}' to the circular, while the hypogastric branches
have just the opposite function. The bony or spinal lesions that are
important as etiological factors in the production of disease of the blad-
der are most "frequently found in the upper lumbar region. They dis-
turb the function of the bladder by interfering with the connection of
the bladder and the spinal cord and consequently there are sensory,
vaso-motor, trophic, secretory, and motor disturbances from these le-
sions. If the lesion is irritative, the sensibility of the bladder will be in-
creased and frequent and painful micturition occurs, since it is a reflex
process. If it is inhibitive, urine will accumulate in the bladder on ac-
count of the inhibition of the sensory and motor nerves as well, as the
micturition center. These lesions interfere with, or break the connec-
tions existing between the bladder and the spinal cord by lessening the
size of the intervertebral foramina and by direct pressure on the nerves
and on the blood-vessels supplying nutrition to the spinal centers. If
the center is irritable as in enuresis, inhibition applied at the exit of the
nerves from the intervertebral foramina, will quiet the center and tem-
porarily relieve the condition. Stimulation will have the opposite effect.
A lesion will have either, and thus to cure the condition, correction of the
lesion is imperative. The trophic, secretory and possibly the vaso-
motor impulses pass over the same nerves and are thus subject to derange-
ment from the same lesions. Since the function of the urinary bladder
is that of expelling as well as retaining the urine as it is secreted by the
kidneys, the motor nerves are important but since their action seems to
be under the control of the sensory, micturition being a reflex process,
the latter are the most important from a clinical point of view.

APPLIED ANATOMY. 651

THE SUPRA-RENAL CAPSULES.

The supra-renal bodies are two solid organs that cap eacn kidney.
They, like the thyroid gland are ductless. The right capsule is pyramidal
in shape. Its anterior surface rests on the posterior surface of the right
lobe of the liver, upon which it leaves an impression. Posteriorly it is
in relation with the right crus of the diaphragm while its inner aspect
presents a vertical furrow that is moulded against the inferior vena cava.
The left, is crescentic in shape and is in relation anteriorly with the
stomach, spleen, pancreas, and the splenic vessels. Posteriorly, it rests
against the crus of the diaphragm, and is near the aorta. Both are
in relation with the great splanchnic nerve and the semilunar ganglion.

The blood-vessels supplying the suprarenal capsules are derived
from suprarenal arteries and from branches of the renal and phrenic.
After reaching the hilum they break up into many minute twigs before
entering the substance of the organ. The vaso-motor nerves supplying
them follow the arteries into the capsule and are derived from about the
same source as those that supply the kidney, especially the tenth and
eleventh thoracic segments. The impulses pass from the spinal cord to
them by way of the splanchnic nerves, they containing vasodilator and
secretory fibers for the suprarenal capsules. The veins on the right
side empty into the vena cava and sometimes into the phrenic and renal
by means of a number of small branches. Those on the left, empty into
the renal on that side. From this it follows that diseases characterized
by congestion of the renal vein, will affect the circulation of the adrenal
body. The lymphatics, empty into the renal glands which contain a
great deal of pigment.

The nerve supply of the suprarenal capsules is very abundant as
well as the number of blood-vessels. They form a rich interlacement
and are derived from the renal and solar plexuses, filaments from the
splanchnics, phrenic and pneumogastric nerves. They are made up
principally of fine medullated fibers and most of them have small ganglia
on them before entering the organ.

The function of these capsules is practically unknown. After ex-
tirpation of one gland, the other doubles in size while removal of both
is followed by death with symptoms of poisoning. If only a small part
is left in, these symptoms are absent. "It appears, therefore, that the
suprarenal bodies are also designed to destroy a poisonous substance in

652 APPLIED ANATOMY.

the body, which exhibits its injurious effects after extirpation of the
glands."* He further states that Brown-Sequard believed that one of
the functions of the suprarenal bodies is to inhibit excessive pigment
formation. In agreement with this view, Tizzoni found, after extirpa-
tion of the organs (in rabbits), abnormal pigmentations, especially on
the lips, and Boinet in the blood and subcutaneous cellular tissues (of
rats). In the medullary layer a substance is formed that becomes
brown when exposed to the air or brought in contact with alkaline tis-
sues. In man, the skin often presents a bronzed pigmentation (bronzed
skin, Addison's disease) when the suprarenal bodies and their capsules
have undergone (tuberculous) degeneration. From experiments it is
to be concluded that the suprarenal body has an internal secretion that
has to do with the elaboration of the blood and which stimulates the
muscle fibers of the heart and arteries. That its function is an important
one is indicated by the great number of nerves and blood-vessels that
supply it. Clinically, we have not had enough cases in which it was
positively known that the gland was affected, to draw any definite con-
clusions as to the effects of a lesion on its function, but judging from the
source and course of the nerves and vessels that supply it, lesions of the
lower thoracic vertebrae and ribs will undoubtedly affect its function.

THE OVARIES.

The ovaries are two almond-shaped bodies, varying in size in differ-
ent people and at different times in the same individual, which are at-
tached to the posterior layer of the broad ligaments, uterus and pelvic wall.
They are about one and one-half inches in length, about three quarters
of an inch in width and one-half an inch in thickness, and are located
within an inch to an inch and a half of the uterus. The application of
this fact is, that uterine displacements are accompanied by displacement
of the ovaries, a condition quite common. The ovaries are regarded as
the most important of the pelvic viscera, since without them there would
be no menstruation, absence, or imperfect development of the uterus
and mammary glands, and the function of the internal generative organs
would be lost.

They are held in position by the broad, the infundibulo-pelvic and
ovarian ligaments which attach them to the uterus and pelvic wall.
The infundibulo-pelvic ligament is that part of the upper portion of the

*Landois' Physiology, p. 198.

APPLIED ANATOMY. 653

broad ligament that is in relation with the Fallopian tubes and attaches
the ovary to the innominate bone. The ovarian, is a longitudinal fold
of peritoneum attaching the ovary to the uterus, into which unstripecl
muscle fibers are prolonged from the uterus. Relaxation of the uterine
muscle fibers would be accompanied or followed by relaxation of this
ligament and this by displacement of the ovary, prolapsus being the
most frequent form of displacement. During fetal life, the ovaries are
in the abdominal cavity, descent not being complete until the tenth
year. They remain small until puberty at which time they become en-
larged and assume activity.

The external landmarks are the anterior superior spines of the ilia,
the ovaries being located about two inches internal and one and one-half
inches inferior to this, spine. The size varies with the age of the indi-
vidual, and according to the state of sexual activity. After cessation
of the sexual function the ovaries atrophy, diminishing in size from one-
half to one-third. In old women they are often as small as peas, the
atrophy being gradual after the menopause.

They consist of two parts, the stroma or frame-work and the par-
enchyma. They are covered by columnar epithelium, sometimes called
germinal epithelium. Immediately beneath this epithelial layer, is the
tunica albuginea which is composed of fibrous tissue which contains a
few muscle' fibers. The Graafian follicles, in all stages of development,
are imbedded in the connective tissue or stroma and contain the ova.
The younger and smaller lie in the cortical area. Their number is im-
mense, it being estimated from 40,000 to 70,000. During menstruation, one
or more of these follicles ruptures, permitting the ovum to escape. After
rupture, the ovum is caught by the fimbriated extremity of the tube,
carried or drawn into the tube and transmitted to the uterus, partly by
the action of the cilise and partly by the peristaltic action of the tube.
In young women, the surface of the ovary is smooth and glistening in
appearance, but as the woman continues to menstruate, and the Graafian
follicles rupture, it begins to appear scarred and corrugated; in the aged
it resembling the convolutions of the brain. In diseased conditions,
such as inflammation and congestion, there is some interference with
the rupture of the Graafian follicle and the ovarian form of dysmenor-
rhea results. This form is best diagnosed by the time of the appearance
of the pain in reference to the beginning of the flow,it preceding the
flow from four to six days. As soon as the follicle ruptures, it is filled

654 APPLIED ANATOMY.

with a yellowish fluid which is gradually absorbed, leaving a scar which
is called a corpus luteum. If impregnation does not follow the rupture
of the follicle, it is called a false corpus luteum, but if impregnation does
take place, it is called a true corpus luteum and is not readily obliterated.

The function of the ovary is that of maturing and expelling the ovum
and of regulating menstruation, therefore, any disturbance of the func-
tion of the ovary will result in sterility or menstrual disturbances. The
ovary is supposed to have an internal secretion that has to do with the
elaboration of the blood. "From the time that Brown-Sequard pub-
lished his studies upon the secretion of the testicles, it has been more
or less generally believed that the ovaries likewise elaborate a somewhat
analogous product, which plays an important part in the female econ-
omy. Indeed, Knauer's recent work renders it probable that this se-
cretion is directly concerned in maintaining the integrity of the other
generative organs; inasmuch as he has shown that atrophy of the uterus
and vagina rapidly follows the removal of the ovaries, whereas this does
not occur when the ovaries are removed from their normal position and
transplanted to other portions of the body. Knauer therefore concludes
that in such cases the absence of atrophy must be attributed to the
action of the internal secretion of the transplanted ovaries, since all
nerve connections were severed at the time of operation. "*

The blood-supply, comes from branches of the ovarian artery, some
six or eight in number, which enter the ovary at the hilum. The veins
correspond to the arteries and enter the pampiniform plexus in the
broad ligament, from which the blood is carried by the ovarian veins to
the renal on the left side, and to the inferior vena cava on the right.
On account of the presence of the rectum on the left side, constipation
being so common, and the left ovarian vein entering the renal at a right
angle and also because the left has no valves, the left ovary is more
commonly diseased than is the right. The nerves that control the size
of the ovarian vessels, pass from the spinal cord over the lesser and least
splanchnics, the white rami connecting them with the anterior division
of the lower three or four thoracic nerves, and reach the ovary by way
of the renal, aortic and ovarian plexuses. Consequently lesions in this
region will affect the vaso-motor innervation of the ovaries.

The nerves of the ovary are derived from the inferior hypogastric

♦Williams' Obstetrics, p. 58.

APPLIED ANATOMY. 655

plexus, by way of the uterine, and from the ovarian, which is formed
from the renal and aortic plexuses. The nerves supplying the iliac
fossae, the tenth and eleventh intercostal, connect with the above plex-
uses; in fact, the source of nearly all the nerve force for all the above
named nerves and plexuses that supply the ovary, is in the tenth and
eleventh segments of the spinal cord. In most all ovarian affections,
especially congestion and inflammation, the pain is felt is the abdom-
inal wall in the area corresponding to the distribution of the tenth and
eleventh intercostal nerves, which is that part of the iliac fossa on a
level with the anterior superior spines of the ilia. The source of the
nerve supply to the ovary furnishes an explanation of lower thoracic
lesions affecting the ovary, which has been demonstrated beyond a rea-v
sonable doubt.

The lesions that affect the function of the ovary are most frequently
found in the lower thoracic region, the ninth, tenth and eleventh thor-
acic vertebrae and the corresponding ribs. The reason that such lesions
affect the ovary is that they lessen the size of the intervertebral foramina,
and consequently the connection existing between the spinal cord and
the ovary, is broken. Such lesions also produce contracture of the mus-
cles in relation and this interferes with the function of the nerves and
blood-vessels in relation which supply the ovary. Disease of the kid-
ney is often associated with ovarian affections, especially the contracted
or non-developed kidney.

THE TESTES.

The testes, the homologues of the ovaries, lie in a pouch called the
scrotum. They are suspended and largely supported by, the spermatic
cords. The testicle is somewhat larger than the ovary but in other
repects resembles it. In the process of development, the testicle descends
and consequently its vessels and nerves are elongated. It is covered
by a reflection of a portion of the peritoneum which is carried down
with it in its descent from the abdominal cavity. The connection be-
tween this cavity and the peritoneal cavity is usually obliterated but in
some cases remains, this resulting in the congenital form of hydrocele.
The acquired form of hydrocele is the result of accumulation of a serous
fluid in this cavity formed by the tunica vaginalis and most commonly
is the result of an injury to the covering.

The arteries supplying the testes are derived from the abdominal

656 APPLIED ANATOMY.

aorta and are quite long. Their innervation is the same as that of the
ovarian vessels that is, it is derived from the lower thoracic spinal seg^
ments, and the impulses reach the testicle by way of the spermatic
plexus of nerves. The veins empty into the renal on the left, and the
inferior vena cava on the right. Stagnation of the blood in them occurs
often and is made worse by the long distance from their origin to where
they empty, the absence of valves in them and the upright posture.
This is particularly true of the veins of the left side on account of the
angle formed by the spermatic and renal, it being a right angle. Stag-
nation of the blood in the spermatic and pampiniform plexuses of veins
produces varicosities that are called varicocele. Lesions along the
lumbar spine affect the innervation of these veins and thus predispose to
varicocele. The lifting of heavy weights, occupations that involve stand-
ing on the feet for many consecutive hours, and abuses of the sexual
function are common and important causes of varicosities of these veins.
The most important of all exciting causes is ungratifiecl sexual desire or
repeated sexual excitement. Relaxation of the cremaster muscle per-
mitting of descent of the testicle, assists in the formation of varicocele.
Lesions of the upper lumbar region that affect the genito-crural nerve,
produce weakening of this muscle.

The nerves supplying the testes are analogous to those supplying the
ovaries. Lesions in the lower thoracic region affect the innervation of
the testes because the impulses pass from the spinal cord at that place.
This accounts for atrophy, congestion, tenderness and in fact nearly all
affections of the testicle not directly traceable to trauma, excesses and
infection. Head gives in his chart the sensory innervation of the testes
including the epididymis, as coming from the tenth, eleventh and twelfth
thoracic and first lumbar spinal nerves. This applied clinically means
that painful affections of the testes can be temporarily relieved by inhi-
bition at these points and also that lesions of these vertebra? will affect
the sensory innervation of the testes and thus cause disorders of sensa-
tion. The testicle like the ovary, is supposed to have an internal secre-
tion. Brown-Sequard observed that extracts of the fresh testes when
injected under the skin or into the blood, may have a remarkable in-
fluence on the nervous system. The general mental and physical vigor
and especially the activity of the centers, are greatly improved not only
in cases of general prostration and neurasthenia, but also in the case of
the aged. The same observer admits that some of this same' substance

APPLIED ANATOMY

657

is found in the external secretion that is, the spermatic fluid. This
accounts for the effects on the individual if there is masturbation or
excessive venerv. This is particularly true of the young, this indicating
that this secretion has to do with the growth and development of the
organism.

URETER

SEMINAL VESICLE

PROSTATE
COwPER'S GLAND

Fig. 161. — The prostate gland, seminal vesicles, bladder, vas deferens, ureter
and Cowper's gland. Note the relation of the prostate and seminal vesicles to the
bladder. The rectum is in posterior relation. (After Spalteholz.)

During early fetal life the testicle lies in the abdominal cavity in
relation with the posterior abdominal wall and the kidney. By the
seventh month, it has reached the internal abdominal ring carrying with

658

APPLIED ANATOMY.

LUMBAR ART

fNF MESENTERIC

SUP HEMORRHOIDAL

LEFT COMMON ILIAC

LEFT EXT. ILIAC

LEFT INT ILIAC.

GLUTEAL A

OBTURATOR A

SPINAL BRANCF

DORSAL BRANCH

ILIOLUMBAR ART

LAT SACRAL ART

INT PUDIC ART

,/ ^ART. OFTHE

VAS DEFERENS

INT PUDIC ART

PROSTATE GLAND

SEMINAL VESICAL

Fig. 162. — The arteries of the male pelvic organs.

APPLIED ANATOMY.

659

it its vessels and nerves and a portion of the peritoneum. This peri-
toneal sac grows downward and passes through the ring carrying the
testicle with it. In some cases there is failure of descent and the testicle
remains in the abdominal cavity or in the groin. The writer saw a case

LEFT EXT. ILIAC ART.

LEFT UTERINE ART

OVARIAN ART

-SUPERIOR
EMORRHOIOAL
ARTERY

UTERUS

UTERO-SACRAL
LIGAMFNT

VAGINALART'S

VAGINA

INT. PUDIC

VAGINAL BULB

BARTHOLIN'S GLAND

Fig. 163.— -The arteries of the female pelvic organs. Note the tortuous course
of the uterine and ovarian arteries.

SIXTH INTERCOSTAL ART.

FOURTH
LUMBAR ART.

LUMBAR OH

ASCENDING

BRANCH

SPINAL BRA. ANT. OFFSET
POST OFFSET

ANT. SPINAL

FIRST LUMBAR

^POST.OHDORSAL
BRANCH

FIRST SACRAl
VERTEBRA

INT. ILIAC ART.

LATERAL SACRAL
ARTERIES

FIRST COCCYGEAL VERTEBRA

Fig. 164. — A view of the blood-vessels of the spinal cord and canal. The arches
of the vertebras have been removed.

APPLIED ANATOMY.

661

of incomplete descent in which the right testicle had remained in the
inguinal canal and had given rise to an error in diagnosis, it being treated
as a case of inguinal hernia.

THE SPERMATIC CORD.

The spermatic cord passes through the inguinal canal and can be
plainly palpated as a hard, round cord. When tender on mild pressure,

SCIATIC

UTERINE

VA6INAL ART.

UTERINE

INF VESICAL

BLADDER

VAGINAL ART'S.

INF. HEMORRHOIDAL

Fig. 165. — Posterior view of the arteries of the female pelvic organs.

it is indicative of congestion of its blood-vessels. This results from
excessive venery and from lesions that affect the muscles of the lower
part of the abdomen and the innervation of the vessels. If the muscles
of the abdomen are sprained, tenderness of the spermatic cord often
follows. Sprains of the hips such as would result from jumping or
forced and marked abduction, will usually cause enlargement of the
inguinal glands and tenderness of the spermatic cord.

662

APPLIED ANATOMY.

SUP. MESENTERIC ART.

MID.COLIC
ART.

ART.0F7H

APPENDIX

ILIAC ART'S.

Fig. 166. — Showing the arteries of the intestines. Displacement of the bowel as
in enteroptcsis, materially disturbs these vessels.

APPLIED ANATOMY. 663

THE VESICLE SEMINALES.

The vesicle seminales are attached to the posterior and lower part
of the bladder and are thus subjected to pressure in constipation and
distension of the lower bowel with hard fecal matter. Lesions of the
lumbar region affect the irritability of these vessels and evacuation of
their contents takes place on the least provocation. The vasa deferentia
carry the testicular secretion from the testes to the seminal vesicles into
which they empty at the lowest part.

THE PROSTATE GLAND.

The prostate gland is a firm musculo-glandular body situated at the
neck of the bladder, and surrounds the prostatic portion of the urethra.
Some claim that it is composed almost entirely of muscle fibers with
few glandular elements. It is in relation with the bladder, triangular
ligament, prostatic vessels, the levator ani muscle which is called the
levator of the prostate, and the rectum.

The relation of the rectum is the most important on account of the
frequency of constipation and its effect on the prostate. Straining at
stool in case in which the bowel is engorged, results in pressure of the
fecal contents on the prostate accompanied by a mucus discharge from
the penis often mistaken for spermatorrhea, but in reality prostator-
rhea. The gland is surrounded by a dense fibrous capsule which serves
to regulate the blood pressure and the size of the gland. On account
of the small amount of elasticity of the capsule, congestion and inflam-
mation are the more painful.

The gland is divided by an antero-posterior median furrow, into
two lobes, while some describe as a third lobe, the bulging of the front
part between the neck of the bladder and the lateral lobes. This lobe
is especially prominent in old people. The enlargement of the third
lobe affects the urethra more than does that of the lateral, on account of
its relation to the prostatic urethra. In the introduction of a catheter
in patients suffering with prostatic hypertrophy, it is advisable to guide
the instrument through this part of the urethra by means of the finger
inserted in the rectum. On rectal examination the different lobes
can be clearly outlined especially if there is any enlargement of them.

The function of the prostate is that of secreting a viscid, opalescent
fluid that serves to form a part of, and thin the semen. "It contributes

664

APPLIED ANATOMY.

pectus A bd

^tij-uLrolI riy^g

, A.S.S.

Fid. • I

us- I

£tt

\ v-^

4 .

nerve
""" Ovarian vessels

Ext. iliac art.
Ext. iliac vein

153^

-'Ve.

Fig. 167. — Showing the internal inguinal and femoral rings and the round liga-
ment as viewed from within the body. (Kelly).

Al'PLlED ANATOMY.

665

Sup. ves.

Hypogastric

Fig. 168. — A view of the important vascular trunks of the uterus. (Kelly).

666

APPLIED ANATOMY.

the substance of Charcot's crystals to the semen, and their partial de-
composition is said to be responsible for the characteristic odor of the
seminal fluid." (Howell). It is a genital rather than a urinary organ.
Its principal function is that of contraction on the semen at orgasm, by
which it is forcibly expelled. By contraction at the completion of the
act of micturition the remaining drops of urine are expelled. In the aged,
this power is often lost and the urine dribbles from the urethra for some

Fig. 169. — The normal position of the uterus viewed from the left side.

time after urinating. It seems also to be the seat of voluptuous sen-
sation. "The seat of the venereal orgasm is in the nerves of the mucous
membrane lining the prostatis sinus, as proved by the fact that it is
sometimes excited by the passage of a sound through the prostate, and
is not destroyed by amputation of the glans penis. "*

*Keyes' Geni to-urinary dis. p. 169.

APPLIED ANATOMY.

667

The arteries that supply the prostate are derived from the middle
hemorrhoidal, internal pudic and the inferior vesical. The innervation
of these arteries comes from the plexus that surrounds the anterior divi-
sion of the internal iliac which is a prolongation downward of the aortic
plexus and is called by Spalteholz, the iliac plexus. This plexus like
the rest, is reinforced by branches from the eangliated cord that are, in

«fvf<f :.'.-

Fig. 170. — The pelvic viscera of a woman seen from above,
tube have been drawn up into the left iliac fossa. (Testut).

The left ovary and

this case, derived from the lumbar spinal cord and pass to, and on through
without much alteration, the lumbar gangliated cord. Lesions in the
lumbar region tend to interfere with this connection and consequently

668

APPLIED ANATOMY.

are important factors in the production of diseases of viscera innervated
by this part of the spinal cord, the prostate gland amongst other organs
being affected.

The innervation of the prostate comes from the prostatic plexus, a'
subdivision of the pelvic plexus. Since the pelvic is made up of branches
from the sacral and from the hypogastric plexus, the prostatic plexus
derives its impulses from the sacral and lumbar nerves. Those from
the lumbar are the more important from a practical point of view in that
they are affected more frequently by lesions than are the sacral.

Fig. 171. — Sagittal section through adult woman. (Kelly).

The veins that drain the prostate are in free communication with
those that drain the other pelvic structures and organs. This free
connection between the pelvic organs permits of a congestion of one, dis-
turbing the circulation of others.

The principal disorders of the prostate are hypertrophy and inflam-
mation. These conditions may in part be due to lesions of the spinal
column which act as predisposing causes, but sexual excesses and gonor-

APPLIED ANATOMY. 669

rheal infection are the exciting causes. Such affections interfere with
micturition and urination, and with the expulsion of the semen at orgasm.
There is frequent micturition and painful and incomplete urination and
imperfect ejaculation. If the hypertrophy is very great, it may so ob-
struct the prostatic urethra that retention of urine with uremia results,
this resulting fatally if it continues for even a short while.

THE UTERUS.

The uterus which is the homologue of the prostate gland, is a pear-
shaped body situated in the true pelvis with the larger end or fundus
directed anteriorly when the patient assumes the erect posture. It is
divided into the fundus which comprises that part above the Fallopian
tubes, a body or corpus and a neck or cervix. It varies more in size than
any other organ, even in the same individual. In the average multi-
parous subject, it is about three and one-half inches in length and two
inches in breadth at the widest place. These dimensions are a fourth
larger than those for a nulliparous subject. In the young and in those
that have an infantile uterus, the cervix forms the largest part of the
uterus, it comprising more than one-half. The cervix is the lower round-
ed part that projects into the vagina, at least the greater part of it does.
It is of importance in that by its condition and position, many disorders
of the body and fundus of the uterus that are not visible and scarcely
palpable, can be diagnosed.

The walls of the body are formed of three layers of muscle fibers;
a serous or peritoneal coat; and a mucous layer. The arrangement of
the muscle fibers is peculiar, there being a circular, longitudinal and an
oblique layer. By contraction of the circular, the ora are lessened in
size and consequently this layer acts as a protection against the expul-
sion of the uterine contents as in pregnancy. The contraction of the
longitudinal, acts as an expellant force, and is the important one in men-
struation and parturition. By contraction of the oblique layer, the
blood-vessels are temporarily ligated and is nature's method of prevent-
ing or stopping a uterine hemorrhage. This layer is especially devel-
oped at a time when its function is most needed, viz., during pregnancy
and parturition.

The ligaments of the uterus are formed principally from the peri-
toneum in relation and serve to anchor and support the uterus. The
broad, prevent lateral and downward displacement of the uterus and

670 APLLIED ANATOMY.

act as a carrier of the blood-and lymph- vessels, and the nerves, gives
attachment to the ovary, and contains the tubes, and round ligaments.
The round- ligaments prevent retro-displacement if they are in a normal
condition. They are artificially shortened in Alexander's operation.
The utero-sacral, are the most important of the uterine ligaments so far
as the support of the uterus is concerned. Its fibers are almost in a
vertical position when the body is in the erect posture and when relax-
ation of them takes place, the uterus descends into a position of retro-
version and prolapsus.

The blood-supply of the uterus is derived from the uterine and
ovarian arteries, branches respectively of the anterior division of the
internal iliac and the abdominal aorta. They pass downward to the
edge of the broad ligaments and thence between the two layers of this
ligament into the uterus. The vaso-motor nerves that supply the uterine
artery are derived from the lumbar spinal cord, the impulses passing
from it into the gangliated cord, thence over the branches that go to
form the hypogastric plexus. The vaso-motor nerves of the ovarian
artery come from a point higher in the cord, viz., the ninth to the twelfth
thoracic segments. The imprdses pass by way of the splanchnics, renal
and ovarian plexuses. Lesions affecting that part of the spinal column
from which these nerves emerge that supply the uterus, affect the func-
tion of the uterus. The important lesions are in the lumbar vertebral
articulations and in the innominata. The reason that such lesions af-
fect the vaso-motor nerves that supply the uterus is that the nerve im-
pulses come from the spinal cord and pass out from the spinal canal
through the intervertebral foramina which are lessened in size by the
subluxation of the vertebra?. The arteries of the uterus anastomose
freely and are very tortuous thus permitting of movement and enlarge-
ment of the organ.

The veins form into plexuses around the arteries and most of the
blood passes into and through the pampiniform plexus of veins located in
the broad ligament. The veins are large and traverse the uterus in
every direction. Although in every organ the capacity of the veins is
greater than that of the arteries, the disproportion between their size
and capacity in the uterus, is especially of interest. Mayrhofer says:
"When the vessels of the uterus are injected, the veins and arteries
with different colored injection, one is struck by the great preponderance
of veins over arteries."

APPLIED ANATOMY.

671

The circulation of the blood through the uterus is influenced by
many tilings. Respiration when normal, assists in the circulation of the
blood through the uterus. If the breathing is shallow, spasmodic or
irregular, the blood tends to become stagnant in the uterus as well as in
other organs of the body. Deep breathing is of great value in the treat-
ment of disorders of the uterus because it assists in the establishment of
a normal circulation through the uterus, a thing absolutely necessary if
the disorder is to be cured. The contraction of the muscles of the ab-
domen and back, the heart beat, the condition of the vaso-motor nerves,
and of the vessels themselves, the condition of the uterus that is, its tone

v\\ - \t t / iflSfe*

auLB OF

VAGINA '";WI?/~

LVO-VA3INAL

GLAND

Fig. 172. — The vulvovaginal gland or gland of Bartholin,
indicates the limits of the bulbs of the vagina. (Testut).

The dotted line

and size, the position of the organ and the posture of the patient all are
to be considered as important factors in the circulation of the blood
through the uterus. If the muscles are poorly developed or atrophied, if
the heart is weak, the vaso-motor impulses lessened in amount and num-
ber, the vessels diseased, the uterus relaxed and out of normal position,
or if the patient keeps the erect posture too long, the circulation of the
blood through the uterus will be impaired.

The lymphatic vessels of the uterus empty into the hypogastric and
lumbar glands, those from the lower part emptying into the hypogastric.

672 APPLIED ANATOMY.

This is of importance in the explanation of certain abdominal tenderness
since the tenderness is often clue to enlargement of these lymph glands
from an inflammation or injury of the uterus. Care should be exercised
in the abdominal treatment of such cases since the glands, enlarged and
tender, may be injured by injudicious manipulation of them.

The nerve supply of the uterus is derived from the cerebro-spinal
and sympathetic systems. The lower part is supplied mostly by the
anterior division of the second, third and fourth sacral nerves, the fibers
passing through the pelvic plexus into the uterine. The sympathetic
nerves are derived from the uterine and ovarian plexuses and are pri-
marily derived from the lower thoracic and lumbar segments of the
spinal cord. Langley states that in experiments on animals it has not
been demonstrated that any impulses from the sacral nerves reach the
uterus at all, that is, stimulation of these nerves produces no apparent
effect on the uterus. Starling says: "The internal organs, i. e., the
uterus and vagina in the female and vasa "deferentia, seminal vesicles,
and uterus masculinus in the male, differ from the external organs in
receiving no efferent nerve fibers from the sacral nerves, as has been
pointed out by Langley and Anderson. They are supplied with fibers
which pass out through the anterior roots of the third, fourth and fifth
lumbar nerves (in the rabbit and cat), and run through the sympathetic
to the inferior mesenteric ganglia, whence they proceed by the hypo-
gastric nerves. On stimulating these fibers, two effects are produced on
the uterus and vagina, namely, a contraction of the small arteries, lead-
ing to pallor of the organs and a strong contraction of the muscular
• coats."* This in the main, coincides with the experiments and ob-
servations in the human and helps to substantiate the claim that lesions
in the lumbar region affect the function of the internal generative organs.
Stimulation over the posterior divisions of the sacral nerves will undobt-
edly cause contraction of the uterus, this having been demonstrated by
the writer in hundred of cases, especially during parturition. This
would indicate that the sacral nerves supply the uterus with motor and
perhaps other impulses.

"According to most authorities there is a center for uterine move-
ment situated in the lumbar region of the spinal cord. The fibers from
this center emerge by the third, fourth, and fifth, lumbar nerves and
possibly from some sacral nerves and communicate with the pelvic
*8chafer's Physiology, Vol. II, p. 349.

APPLIED ANATOMY.

673

plexuses of the sympathetic. Many of the nerve fibers are destined
for the supply of the blood-vessels, but without doubt some control the
uterine contractions, for if the lumbar center be destroyed all power of
parturition is abolished. Stimulation of the nerves, moreover, produces
powerful uterine and vaginal contractions."

Clinically, it is well known that lesions of the lumbar articulations
produce uterine disorder, this being the result, as stated before, of dis-
turbance of the innervation, it being, according to the above citation,
from the lumbar spinal nerves.

The function of the uterus is that of menstruation and parturition.
These functions are controlled by centers located in the lumbar spinal
cord. The character and amount of blood that passes through the uterus

Fig. 173. — The lymphatic vessels of the vagina and uterus

are the most important of all factors that have to do with its function.
Lesions of the innominata, sacrum, lumbar and lower thoracic vertebrae
affect the function of the uterus, that is, make menstruation abnormal
or interfere with pregnancy and parturition. They do this by affecting
the blood supply, the nerve supply, the spinal center and by affecting
the nutrition of the uterus. These lesions are characterized by irregu-
*Manual of Midwifery, p. 50. 906. Jellett.

674 APPLIED ANATOMY.

larity and tenderness over and around the articulation, and in the case of
the vertebra?, over the spinous processes.

THE EXTERNAL GENITALIA.

The external genitalia are subject to disturbances from spinal and
other lesions. The vaso-motor centers controlling their blood-supply
are located in the lumbar spinal cord and any lesion that breaks the
connection between them and the parts supplied, will cause disturbance
or disease in the parts. The sacral nerves seem to be motor but partly
vaso-motor to the external genitalia. Starling says: "The external
generative organs like the bladder, are supplied from two sets of nerve
fibers — from the lumbar nerves through the sympathetic, and from the
sacral nerves. The fibers from the lumbar nerves arise in the cat from
the second, third, and fourth, or the third, fourth and fifth lumbar nerve
roots, and in the dog from the thirteenth thoracic and the first to the
fourth lumbar roots. They run in the white rami communicantes to
the sympathetic chain, whence they may take two paths.

(a) The great majority of the fibers run down the sympathetic
chain to the sacral ganglia, whence fibers are given off in the grey rami
communicantes to the sacral nerves: their further course is by the pudic
nerves, none running in the nervi erigentes.

(b) A few fibers go by the hypogastric nerves to the pelvic plexus.
Excitation of these fibers causes strong contraction of the arteries of
the penis, and of the unstriated muscles of the tunica dartos of the
scrotum."* These nerves are vaso-motor, secretory, motor, sensory
and trophic and consequently any form of disorder of the external
genitalia may be produced by or predisposed to, by lesions that affect
these nerves. These lesions are similar in character and location, to those
that affect the internal generative organs.

THE MAMMAE.

The mammary gland in the female, consists of an aggregation of
compound racemose glands, the ducts of which open separately at the
nipple. In the male, the gland is rudimentary and the nipple marks
the location of the fourth rib. In the female they extend from the third
to the sixth or seventh ribs and are enveloped with the superficial fascia
which seems to split to receive them. They vary in shape and size in

*Schafer's Physiology, p. 34S, Vol. II.

APPLIED ANATOMY.

675

different individuals and in the same person at different times. They
are not exactly symmetrical, the left is usually the larger and they are
pendulous in the average case and especially so in multiparas. In struc-
ture they are regarded as modified sebaceous glands and consequently
appendages of the skin.

The arteries are derived from the long thoracic, the external mammary
and from the intercostals in relation and from the internal mammary.

Fig. 174. — Anterior wall of vagina, showing columnar. (Savage.) 1, 2, anterior
columns of the vagina; n, urethral orifice; m, cervix.

The branches of the[ internal mammary perforate the intercostal spaces,
the second, third, fourth and sometimes the fifth, and are thus subject
to pressure from subluxations of the corresponding ribs. The inner-
vation of these arteries is from the lower cervical but particularly from
the upper thoracic region. Lesions in this region, especially affect the
function of the breast.

676

APPLIED ANATOMY.

The veins correspond to the arteries and empty into corresponding
trunks. The superficial veins become markedly engorged in enlarge-
ment of the breast as during pregnancy. On account of the relation of
these veins to the ribs and the clavicles, displacement of these bones will
obstruct to a greater ox lesser degree the passing of the blood from the
gland to the heart and thus cause disorder of function of the breast.

The nerves are exceedingly numerous and important. McLachlin
says: "We have (1) twigs from the fourth and fifth cervical nerves;
(2) twigs from the anterior cutaneous branches of the second, third,

Fat.
Lobule unravelled.

Lobule'

•> Lactiferous duct.

Ampulla.

Loculi in connective tissue.

Fig. 175. — Dissection of the lower half of the female breast during the period of
lactation. (Luscka).

fourth and fifth intercostal nerves, and of the lateral cutaneous of the
third, fourth and fifth. Now, from the second, is given off the inter-
costo-humeral, supplying the skin of the inside of the arm and axilla;
from the third a branch to the same parts, and also the skin about the
shoulder; and from the fourth and fifth, the skin near the scapula. These
communications explain the widely diffused pain in cases of inflammatory

APPLIED ANATOMY. 677

affections, especially of the breast."* Lesions of the ribs in relation
with the nerves innervating the mammary glands are common and im-
portant causes of affections of the breast.

It is claimed by some, that there are no secretory nerves to the
breast that is, section of all the mammary nerves does not lessen the
secretion of milk. This has been doubted by others and clinically it
seems that the secretion of milk is controlled to a great extent by the
nerves, especially the vaso-motor nerves.

The acini and ducts of the gland are surrounded by a net -work of
lymph vessels. The axillary glands drain most of the lymph vessels of
the breast. This is well demonstrated about the time of the establish-
ment of lactation after parturition. At this time the axillary glands
become very much swollen and tender, making movements of the arm
painful.

The appearance and condition of the breast furnish indications of
certain disorders that are fairly reliable. If the nipple is short and
retracted it is suggestive of ovarian affection on the same side or the
schirrous form of carcinoma. A pendulous breast indicates multiparity.
A large mammary gland may be the result of deposit of fat or of irrita-
tion of the sexual organs. If at or near puberty, it is suggestive of pre-
mature development of the ovaries and a state of sexual excitement.
Tenderness of the breast usually occurs at menstruation and in certain
forms of uterine and ovarian disease. If localized and the tissues
hard and retracted, it indicates cancer. Pigmentation occurs dur-
ing pregnancy and in some cases of polypi of the uterus. The breasts
undergo atrophy at the menopause and the glandular elements are re-
placed by adipose tissue if the size is retained. Many disorders of the
breast result from direct trauma on account of the exposed position of
the gland but most of the affections are due to lesions of the third, fourth
and fifth ribs plus some exciting cause such as ovarian or uterine disorder.

*Applied Anatomy, p. 226, Vol. II.

APPLIED ANATOMY.

679

I NDEX

ABDOMEN, The, 435.

regions of, 439.

blood-vessels of, 443.

lymphatics of, 444.

nerves of, 444.

vaso-motor supply of, 184.
Abdominal ring, external, 443.
Abscess of ear, 45.
Agraphia, 548.
Anemia, 49.
Angina pectoris, 137, 145, 166, 397, 400,

597.
Anosmia, 47.
Anus, the, 634.
Aphasia, 548.
Aphonia, 64, 115,451,575.
Apoplexy, 47, 538, 544, 546.
Appendicitis, 239, 628.

pseudo, 416, 448.
Appendix, veriform, 230, 442, 628.
Arachnoid, the, 535.
Arm, the lesions affecting, 394.

as a region, 461.

lymphatics of, 462.
Arryhthmia, 402.
Artery or arteries,

aorta, abdominal, 240, 439.
arch of, 425.

axillary, 150.

brachial, 92.

carotid, 120, 149.
internal, 537.

cerebellar, anterior, 539.
posterior inferior, 539.
superior, 539
superior, 539.

cerebral, anterior, 537.
middle, 537, 540.
posterior, 539.

choroid, anterior, 538.

eceliac axis, 439

communicating, posterior, 537.

coronary, 150.

Artery or arteries, femoral, 254, 265

gastric, 224.

gluteal, 308.

hepatic, 224.

Oiac, 240, 439.

ilio-lumbar, 308.

intercostal, 149, 240, 407.

mesenteric, superior, 224, 240.

ophthalmic, 552.

ovarian, 223, 240.

renal, 223, 240.

sacral lateral, 30S.

spermatic, 240.

spinal, lateral, 130, 149.

splenic, 224.

thyroid, inferior, 112.

vertebral, 149, 539.
Arthritis deformans, 463.
Arthritis, rheumatoid, 490.
Articulations or articulations (See Joints)

aeromio-clavicular, 89, 453

atlanto-axoidean, lesions of, 22, 28,
35, 56, 64.
ligaments of, 22, 54.
movements of, 53, 55, 56.
nerves in relation, 64.

atlanto-occipital, lesions of, 17, 18,
20, 21, 22, 26, 28, 35.
ligaments of, 21, 22.
movements of, 19

costo-chondral, 382.

costo-vertebral, 374, 382.

sacro-iliac, 280, 296, 299, 305, 324,
328.

sacro-coccygeal, 330.

sterno-clavicular, 452.

temporo-maxillary, 448.

Fibio-fibular, 483.
Asthma, 144, 517, 589.
Astigmatism, 39
Ataxia, 547.
Atlas, the, 17.

arteries in relation with. 25

680

APPLIED ANATOMY.

Atlas, muscles in relation with, 22.

nerves in relation with, 28.

veins in relation with, 24.

summary of, 51.
Atrophy of arms, 178.

deltoid muscle, 90.
lower limb, 283.
shoulder, 45S.

muscular, 356.

progressive muscular, 99, 109, 464.

of spinal muscles, 196.
Axis, the, 53.

blood-vessels in relation with, 59.

muscles in relation with, 56.

nerves in relation with, 61.

summary of, 66.

BACK, the, as a re'gion, 332.

Biliousness, 191, 200.

Bladder, the, 234, 239, 256, 270, 278, 647.

blood supply of, 649.

ligaments of, 647.

nerves of, 647.
Blepharospasm, 41, 135, 508, 551,
Blood, the diseases of, 192.
Blotches of the skin, 49.
Blushing, pathological, 49.
Bone or bones — Hyoid, 64, 115, 451.

sesamoid, 486.

turbinate, 560.
Bradycardia, 166.
Brain, the, 522.

arteries of, 47, 537.

fissurei of, 522.

lobes of, 522.

veins of, 540.
Bright's disease, (See nephritis).
Bronchi, The, 144, 426, 580.
Bronchitis, 392.
Broncho-pneumonia, 391.

CECUM, The, 232, 442, 62S.
Cancer of stomach, 200.
Capsules, suprarenal, 651.
Carcinoma, 71.
Caries, 71, 151.

Cartilage or cartilages, costal, 413.

cricoid, 571.

semilunar, 479.

thyroid, 571.
Cataract, 42, 553.
Catarrh, nasal, 46, 562.

post-nasal, 113.
Centers (in medulla),

cardiac, 529.

coughing, 528.

deglutition, 530.

hiccough, 530.

kidneys, 644.

mastication, 531.

pupilo-dilation, 531.

respiration, 528.

salivary secretion, 528.

sneezing, 527

spasm, 531.

sweat, 531.

sucking, 531.

vaso-motor, 529.

winking, 531.
Centers (in spinal cord), cilio-spinal, 153.

defecation, 256.

ejaculation, 27S.

emotional, 153.

erection, 285.

heart acceleration, 155.

liver, 176.

lungs, 155.

mammarj- gland, 161.

menstruation, 259.

micturition, 256, 25S

nutritional, 153, 176.

parturition, 256, 259.

stomach, 176.

sweat, 155, 177.
Cerebellum, The, 532.

arteries of, 539.

veins of, 542.
Cerebral softening, 47.
Cerebrum, The, 522.

crura of, 525.
Cerumen, 513, 556.

APPLIED ANATOMY.

6S1

Chest, barrel-shaped, 429.

blood-vessels of, 426.

funnel-shaped, 430.

nerves of, 426.

surface markings of, 424.

tubercular, 42S.
Chorea, 51.

Clavicle, The subluxation of, 101.
Coceydynia, 332.
Coccyx^ The, 332.

muscles in relation to, 331.

nerves in relation to, 331.
Cold, (See coryza), 331.
Colon, The, ascending, 629.

descending, 632.

transverse, 630.
Column, spinal (See Spine),
Coma, 545.

Congestion of spinal cord, 145.
Conjunctivitis, 41, 135, 550.
Constipation, 200, 216, 232, 256.
Convulsions, 545.
Co-ordination, 532.
Cord, spermatic, 661.

spinal, 367.

blood supply, 65, 113, 369.
congestion of, 375.
drainage, venous, 398.

spinal segments, (See respective spinal
nerves,
Cords, The vocal, 572.
Corpora quadrigemina, The, 525.
Corpus collosum, The, 523.

striatum, The, 524.
Coryza, 72, 123, 503.
Cough, 113, 515, 528.
Cretinism, 119, 578.
Cyst, meibomian, 550.
Cystitis, 258.

DACTYLITIS, 463.
Deafness, 45, 509, 557.
Defecation, 256.
Deglutition, 530.
Delirium, 545.

Dementia, 545.
Diabetes mellitus, 191.
Diaphragm, The, 78, 205, 426.

disease of, 192
Diarrhoea, 216, 257.
Diplopia, 555.

Discs, intervertebral, 68, 242, 374.
Dislocation of the hip, 472, 476.
knee, 480.

cartilage, semilunar, 4S1.
Douglas, pouch of, 634.
Duodenum, The, 441, 622.

hernia of, internal, 623.
Dura mater, 535.
Dysmenorrhcea, 260.
Dyspepsia, 174, 177, 192
Dysphagia, 50, 199, 517.

EAR, The, 42, 556.

abscess of, 45.

catarrh of, 45.

ossicles of, 559.

summary of, 45.
Earache, 63.
Elephantiasis, 490.
Emission, nocturnal, 270.
Endocarditis, 592.
Endocardium, 592.
Enteroptosis, 601, 625.
Enuresis, 258, 650.
Epididymus, 234.
Epiglottis, 571.
Epilepsy, 51, 113.
Epistaxis, 47.
Eruptions, 49.
Erysipelas, 451.
Extremit}', The upper as a region, 461.

lower as a region, 486.
Eye, The, 36, 73, 550.

nutritional disorders of, 42.

summary of, 42.

FACE, The, 48, 135, 146, 149.
Fatigue, 143.
Feet, sweating of, 494.
Fever, typhoid, 233.

682

APPLIED ANATOMY.

Flexure, hepatic, 630.

sigmoid, 632.

splenic, 631.
Fluid, cerebrospinal, 374.
Follicle, Graafian, 653.
Fossa, infra-clavicular, 116.

supra-clavicular, 116.

supra-sternal, 116.

GAIT, as a symptom, 491.
Gall-bladder, 182, 203, 206, 220, 441, 614.
Gall-stones, 192, 199, 206, 618.
Ganglion or ganglia, Gasserian, 536.
Ganglion or ganglia, inferior cervical, 110.

middle cervical, 94, 95, 103

stellate, 132.

superior cervical, 28, 65, 73.
Gastralgia, 192, 200.'
Gastric crises, 218.
Gastritis, 200.
Gastroptosis 200.
Genitalia, The external, 674.
Gland, The cervical lymphatic, 120.

mammary, 149, 160, 178, 398, 402,
674.

blood supply of, 675.
nerve supply of, 676.

parotid, 451.

prostate, 220, 234, 271, 277, 663.
blood supply of, 667.
nerve supply of, 320, 668.

salivary, 503.

submaxillary, 142.
Gland, The thyroid, 117, 388, 575.

blood supply of, 576.

nerve supply of, 577.
Goitre, 94, 103, 119, 578.

exophthalmic, 554.
Gums, The, 563.

The Heart, accelerator nerves of, 135,
144, 177, 178.

blood supply of, 593.

nerve supply of, 594.

palpitation of, 16.5, 400.
Heartburn, 174.
Hemianesthesia, 547.
Hemianopsia, 548, 555.
Hemidrosis, 49, 504.
Hemiplegia, 491, 547.
Hemorrhoids, 270.
Herpes, 71.

zoster, 179, 198.
Hiccough, 80, 122, 195, 410, 418, 530.
Hip, The dislocation of, 266.
Hoarseness, 574.
Hordeolum, 551.
Humerus, The, 92.
Hydrocephalus, 543.
Hyperacusis, 509.
Hyoidbone, 64, 115, 451.

ILEUM, The, 624.
Ilium, The, 302.
Impotence, 285.
Indigestion, 191, 200.
Innominate bone, 301, 305.
Insanity 543.

Intestines 176, 192, 199, 205, 216, 218
230, 417,
catarrh of, 209.
large, 442, 628.

blood supply of, 636.
nerve supply of, 637.
small, 441, 622.

blood supplj' of, 625.
nerve supply of, 626.
vaso-motor supply of, 174.
Intussusception, 216.

HAND, The, 461. JAUNDICE, 190, 192, 200, 553.

Hay fever, 46, 144. Jenunum, The, 624.

Headache, 47, 63, 66, 105, 122, 393, 500, Joint or joints (See also "Articulations")

545. ankle, 280, 483.

Head's Law, 136. elbow, 110, 459.

Heart, The, 113, 167, 398, 424, 589. knee, 280, 477.

APPLIED ANATOMY.

683

Joint or joints, hip, 280, 283, 320, 469.
ligaments of, 470.
shoulder, 87, 90, 98, 454.
wrist, 110. 459.

KERATITIS, 42.

Kidney, The, 213, 220, 426, 443, 639.

blood supply of, 641.

diseases of, 192, 233, 417,

nerve supply of, 641.

vaso-motor center for, 644.
Kyphosis, 348

LACRYMATION, 42.
Laryngisimus stridulous, 574.
Larynx, The 50, 571.
Leg, The, as a region, 486.
Lesions, innominate, 326.
Lesions, spinal 67, 104, 114, 122, 128, 13S,
168, 179, 187, 194, 273, 296, 304,
326, 334.
Lesions, spinal, effects of, 378.
Ligaments, The, atlanto-axoidean, 22, 54.

atanto-occipital, 21. 22.

costo-vertebral, 382.

ilio-femoral, 470.

ilio-lumbar, 289.

lumbo-sacral, 289.

occipito-axoidean, 55.

sacro-sciatic, 298.

spinal, 242.

effects of lesion on, 68, 76.
Ligamentum nucha?, 105.

patella?, 478.
Liver/The, 178, 182, 199, 220, 406, 439,
608.

blood supply of, 611.

diseases of, 189, 196, 200, 216.

nerve supply of, 611.

vaso-motor supply of 174.
Locomotor ataxia, 153, 184.
Lordosis, 352.
Lumbago, 230, 261, 291.
Lungs, The, 171, 425, 582.

MALARIA, 191.
Mastication, center for, 531.

Mastoid cells, 51, 559.

Medulla oblongata, 527, 542.

Membrane, Schneiderian, 561.

Meningitis, 66.

Menstruation, 260, 653.

Mesentery, The, 624.

Microcephalus, 542.

Micturition, 239, 258.

Monoplegia, 465, 547.

Mouth, The, 563.

Musca? volitantes, 42.

Muscle or muscles, abdominal, 417.

biceps, 101.

complexion, 64.

cremaster, 254.

deltoid, 90.

diaphragm, 78.

erector spina?, 205.

genio-hyoid, 64.

hyoid, 50.

infra-hyoid, 64.

intercostal, 204.

interspinales, 57, 59.

levator anguli scapula?, 59.

levator costa?, 128, 204.

longus colli, 57.

multifidus spina?, 57, 205.

oblique, external, 180.
inferior, 57.

omo-hyoid, 64.

platysma myoides, 116.

psoas magnus, 262.

quadratus lumborum, 240, 276.
femoris, 292, 317.

rectus capitis anticus major, 63.
posticus major, 57.

rotatores spina?. 129, 205.

scalenus anticus, 68
medius, 59.
posticus, 84.

semispinalis colli, 54.

splenius, 57.

sterno-hyoid, 64.

sterno-mastoid, 63.

sterno-thyroid, 64.

tensor tympani, 558.

6S4

APPLIED ANATOMY

Muscle or muscles, thyrohyoid, 64.

trapezius, 72.
Mydriasis, 40.
Myelitis, anterior plioo, 464.

transverse, 114, 151, 375.
Myopia, 39, 552.
Myosis 40.
Myxedema, 119, 578.

NAILS, The, 462.
Neck, The, as a region, 115.
blood-vessels of, 120.
bony landmarks of, 123.
lymphatic glands of, 120.
nerves of, 122.
Nephritis, 240, 415.
Nerve or nerves, The,
Ansa subclavia, 94.
anterior crural,
anterior thoracic, external, 91.

internal. 110, 131.
arnold, 513.

cardiac accelerator, 170, 595.
cardiacus magnus, 94.
chorda tympani, 507.
ciliary, 135.
circumflex, 88.
clunei, superior, 267.
cervical, first (suboccipital), 20, 28.
cervical,

second, 61, 64, 65.

third, 72.

fourth, 77.

fifth, 85.

sixth, 97.

seventh, 107.
cranial, 494.

olfactory, 494.

optic, 495.

motor-oculi, 496.

trochlear, 498.

trifacial, 49, 498.
cranial, abducens, 505.

facial, 48, 49, 506.

auditory, 45, 508.

glossopharyngeal, 50, 65, 75, 510.

Nerve or nerves, pneumogastric, 75, 512.

spinal accessor}'-, 64, 73, 75, 519.

hypoglossal, 65, 520.
depressor, 518.
external cutaneous, 254.
genito-crural , 24S, 252.
great auricular, 51, 61, 63.
gluteal, inferior, 292.

superior, 292.
hemorrhoidal, inferior, 311.
ilio-hypogastric, 246.
ilio-inguinal, 246.
internal cutaneous, 110, 131.

internal cutaneous, lesser, (Wris-

berg), 131.
laryngeal, inferior, 50, 516.

recurrent, 50, 112.

superior, 50, 514.
long saphenous, 263.
lumbar, first, 248.

second, 252.

third, 262.
median, 9S.

musculo-cutaneous, 98.
musculo-spiral, 99, 462.
obturator, 255, 265, 324.
occipital, great, 61.

small, 61.

third, 72.
phrenic, 73, 79, 80.
popliteal, external, (peroneal), 321.

internal, (popliteal), 321.
posterior thoracic, 85.
pudic, 310.
pupillo-dilator, 142.
sacral, 317.
sciatic, great, 293, 320.

small, 314.
splanchnic, great, 144, 174, 206.

lesser, 225.
subscapular, first (short), 91.

middle (long), 98.

third, 98.
superficial cervical, 63.
supraclavicular, 71.
suprascapular, 87.

APPLIED ANATOMY.

6S5

Nerve or nerves, thoracic, first, 131.

second, 140.

fourth, 159.

fifth, 169.

sixth, ISO.

seventh, 194.

eighth, 203.

eleventh, 226.
ulnar, 109, 461.
vagus, (See Pneumogastric, cranial

nerves).

OESOPHAGUS, 203, 206.

Osteitis, articular, 475.

Otalgia, 42.

Otitis media, 45.

Ovary, The, 216, 234, 239, 241, 652.

blood supply of, 654.

disease of, 211, 221, 415, 417.

infantile, 223.

ligaments of, 652.

nerve supply of, 654.

PALATE, The, 56S.

Pancreas, The, 199, 202, 221, 442, 616.

blood supply of, 618.

nerve supply of, 619
Paralysis agitans, 464.
Paralysis, Bell's, 49, 507.

Erb's, 126.

infantile, 283, 491.
Paraplegia, 376, 273, 491.
Penis, The, 313.
Pericardium, The, 425, 591.
Peritoneum, The, 176, 200, 203, 435.
Peritonitis, 192, 435.
Phalangitis, 50.
Pia mater, The, 535.
Pharynx, The, 49, 569.
Pituitary body, The, 29.
Pleura, The, 143, 178, 209, 425, 585.
Pleurisy, 192, 392.
Plexus, aortic, 244, 249, 255, 268, 293.

cardiac, 595.

carotid, 29.

cavernous, 29.

coronary, 144.

Plexus, hemorrhoidal, 270.

hypogastric, 255, 269, 293.

mesenteric, inferior, 255.

ovarian, 255.

pharyngeal, 50, 514.

prostatic, 271.

renal, 236.

tympanic, 29, 511.

vertebral, 31, 65, 113.

vesical, 270.

uterine, 271.
Pneumonia, 391, 588.
Polypi, nasal, 563.
Pons, Varolii, The, 5W.
Pott's disease 157, 187.
Pouch of Douglas, 634.
Prostatorrhcea, 320.
Pterygium, 41, 552.
Ptosis, 40, 548, 551.
Pubes, The, 303,
Pulse, The, 546.
Pupil, The, 553.
Pupillo-dilation, center of, 531.

RAMI, gray, 74, 103, 110, 136, 161, 172,

198.

white, 134, 141, 162, 172, 199, 268.
Receptaculum chyli, The, 626.
Rectum, The, 256, 278, 633.
Respiration, center for, 528.

Cheyne-Stokes, S4, 546.
Rheumatism, 92.

sciatic, 322.
Rib or ribs, The, 378, 584.

first, 103, 384.

second, 390, 395.

third, 395.

fourth, 398.

fifth, 403.

sixth, 405.

seventh, 408.

eighth, 410.

ninth, 413.

tenth, 414.

eleventh, 415.

twelfth, 418.

686

Rib, movements of, 422.
Rickets, (Rachitis), 420.

SACRUM, The, 303, 327,
Salivary, gland, The, 51.
Scapula, The, 360.

"winged", 87.
Sciatica, 322.
Sclerosis, multiple, 547.
Scoliosis, 354.
Seasickness, 510.-
Shingles, (See "Herpes Zoster")
Sneezing, center for, 527.
Spasms, 49, 51.

center for, 531.
Spermatorrhea, 270.
Spine, The, 336.

curvature of, 347.

fracture of, 367.

mobility of, 167, 192, 242, 289, 362,

372.

muscles in relation to, 336.

tenderness along, 367.
Spina bifida, 364.
Spleen, The, 177, 426, 620.
Squint, convergent, 37.
Stammering, 521.
Sterility, 234.
Sternum, 420.
Stomach, The, 176, 179, 199, 205, 216,

406, 426, 441, 598.

blood supply of, 602.

cancer of, 200.

catarrh of, 209.

disease of, diagnosis, 182, 196.

nerves of, 603.

ulcer of, 200.

vaso-motor innervation, 174, 606.
Strabismus, 37, 135, 554.
Stuttering, 574.
Sty, 551.

Succus entericus, 241, 638.
Sucking, center of, 531.
Sweat secretion, center of, 531.
Synovitis, 481.

TACHYCARDIA, 166.

APPLIED ANATOMY.

Talipes, 490.

Teeth, The, 564.

Testicle, The, 216, 220, 234, 239, 655.

blood supply of, 655.

nerve supply of, 656.
Thalamus, optic, 525.
Thorax, The, 420, 433.
Tic douloureux, 49.
Tinnitus aurium, 44, 509.
Tonsils, The, 50, 566.
Tongue, The, 564.
Toothache, 49, 502.
Torticollis, 6.3, 115, 520.
Toxemia, 376.
Trachea, The, 119, 426, 579.
Tube, Fallopian, 234, 277.

Eustachian, 559.
Tuberculosis of hip, 475.
Tuberculosis, pulmonary, 87, 392, 395, 589.
Tympanum, The, 557.

UMBILICUS, The, 437.

Ureter, The, 220, 645.

Urinalysis, 645.

Uterus, The, 221, 234, 225, 271, 277, 669.

blood supply of, 670.

inertia of, 259.

ligaments of, 669.

nerves of, 319, 672.

tumor of, 271.
Uvula, The, 568.

VAGINA, The, 277.

Varicocele, 234.

Varicose veins, 281, 493.

Vas deferens, 278, 320, 663.

Vaso-motor supply of abdomen, 171, 184.

arm, 142, 146.

back muscles, 149.

brain, 47.

bronchi, 150.

ear, 142.

eye, 503.

face, 48, 135, 146, 149.

general, 376.

heart, 146, 149.

lungs, 142, 146, 149, 170.

APPLIED ANATOMY.

687

Vaso-motor supply of nasal tract, 144.
spinal cord, 149.
stomach, 174.
centers, (See "Vaso-motor supply"
and "Centers" in cord and medulla).
Vein or veins, azygos, 240, 407.
pampiniform plexus, 670.
portal, 174, 207, 611.
renal, 207,

vena cava, inferior, 240.
vertebral, 20, 113.
Vertebra, cervical, first (See "Atlas")
second, (See "Axis').
third, 67.

summary of, 76.
fourth, 76 .

summary of, 82.
fifth,- 84.

summary of, 95.
sixth, 97.

summary, 101.
seventh, 104.

summary of, 114.
lumbar, first, 241.
summary of, 251.
second, 251.

summary of, 261.
third, 261.

summary of, 274.
fourth, 274.

summary of, 287.
summary of, 211.

Vertebra, fifth, 287.
thoracic, first, 127.
summary of, 137.
second, 13S.
third, 146.

summary of, 156.
fourth, 156.

summary of, 167.
fifth, 167.

summary of, 179.
sixth, 179.

summary of, 192.
seventh, 192.

summary of, 200.
eighth, 202.
ninth, 211.

summary of, 217.
tenth, 217.

summary of, 225.
eleventh, 225.

summary of, 234.
twelfth, 234.

summary of, 240.
Vertigo, 545.

Vesicles, seminal, 278, 294, 320, 663.
Vision, disturbances of, 548.
Vomiting, 177, 530.

WINKING, center for, 531.
Wrist-drop, 110.
Wryneck, 58.

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Full text of "Applied Anatomy: Designed for the Use of Osteopathic Students and Practitioners as an Aid in the Anatomical Exploration of Disease from an Osteopathic Viewpoint"

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